Aneurysmal Bone Cysts of Spine: An Enigmatic Entity

Aims

The study was done to review the literature about the intriguing aspects of the aneurysmal bone cyst and to describe our experience with these cases.

Design

Retrospective.

Material and Method

We reviewed the records of all patients with primary spinal tumours whom we managed over last 8 years. We selected the patients with biopsy proven aneurysmal bone cyst (ABC) for our study.

Results

Four patients (two males and two females) were included. The age ranged from 15-18 years. Three of them had neurological deficits and one had only pain. All of them were operated and three required instrumentation for stabilization. Neurological deficits improved in all the cases. However we had to re- operate one of the cases for recurrence and that patient was administered adjuvant radiotherapy.

Conclusions

ABC is not a tumour in real sense but due to destructive nature that are classified as tumours. The patients have an excellent outcome as the disease is benign and has very low recurrence rates if surgical excision is complete. Best treatment modality is complete excision. Aneurysmal bone cyst is one of the uncommon tumors of the spine, and many of its features continue to be unclear even today. There is ambiguity about the definition, etiopathogenesis, radiological characteristics, histopathology and treatment modalities. They are common in young age and etiology is not clear. The presentation is varied with pain being the common symptom and neurological deficit depends on extent of cord involvement. The best treatment is controversial although surgery is believed to be curative in the majority of cases. We here describe our experience with four such cases who had varied clinical presentation and outcome.

The description of urodynamic study for bladder dysfunction in compressive myelo- or radiculo-pathy: A prospective study in an institutional setup

Purpose:

To study the significance of filling cystometry with pressure flow studies and bladder electromyography (EMG) in assessment and management of neurogenic bladder with myelopathies and evaluated neurological recovery in the follow-up period.

Methods:

The study was a 3-year prospective urodynamic study in 63 patients, with traumatic and nontraumatic myelopathy. Bladder management was advised based on the cystometric findings. Neurological recovery and mode of bladder management were evaluated during follow-up after a minimum of 6 months.

Results:

Mean age was 44.6 years (range 10–80 years). Thoracolumbar area was most commonly involved. Cystometry revealed overactive detrusor in 46 patients, (17 had detrusor sphincter dyssynergia [DSD], 29 without DSD) and areflexic/underactive detrusor in 9 patients. Postvoid residual (>15% of voided urine) was significant in 27 patients. Neurological recovery was seen in 60.3%, whereas 22.2% showed no improvement (partial improvement in 4.8%) and 12.6% had normal bladder function both initially and at follow-up. Correlation between neurological recovery and bladder management was found to be insignificant (P > 0.05) using spearman's correlation coefficient.

Conclusion:

Filling cystometry with pressure flow studies and EMG study is valuable for the assessment and management of neurogenic bladder in patients with myelopathy. In neurogenic bladder management and follow-up, pressure flow studies help to prevent complications and upper urinary tract complications.

Endoscopic Third Ventriculostomy in Noncommunicating Hydrocephalus: Report on a Short Series of 53 Children

Introduction:

Endoscopoic third ventriculostomy (ETV) is currently considered the best alternative to cerebrospinal fluid (CSF) shunt systems in the treatment of obstructive hydrocephalus. The aim of ETV is to communicate the third ventricle with the interpendicular cistern and create CSF flow which bypasses an obstruction to the circulation of the CSF.

Aims and Objectives:

The purpose of this study was to elucidate the indications, efficacy, safety and outcome Of ETV pediatric patients of noncommunicating hydrocephalus.

Material and Methods:

This study is a 3 year prospective study from June 2012 to May 2015. Records were kept for age, gender, etilogical factors, symptoms, signs, previous use of shunt or external ventricular device, imaging findings, and surgical complications (intraoperative and postoperative). Only those patients with age between 6months and 18 years with symptoms of intracranial hypertension and radiographic evidence of noncommunicating hydrocephalus were included in the study.

Results:

A total of 53 patients were studied, out of these 29 were boys and 24 were girls. The mean age of the patients was 6.6 years. Overall a total of 50 successful ETVs were done in 53 patients. The success rate is estimated to be 94%. There was no mortality. The average postoperative hospital stay was 4 days. The followup ranged from 6 to 16 months (mean, 12 months).

Conclusion:

ETV in children is a safe, simple and effective treatment and a logical alternative to shunting procedure for patients of noncommunicating hydrocephalus.

Utility of Computed Tomography-guided Biopsy in Evaluation of Metastatic Spinal Lesions

INTRODUCTION

Computed tomography (CT)-guided biopsy of spine is currently a valuable diagnostic tool and effective technique for diagnosing and planning a proper therapeutic strategy for certain spinal lesions. The reported diagnostic accuracy of core biopsy ranges from 77% to 97%.

MATERIALS AND METHODS

We included all patients with spinal lesions suspicious of metastasis on magnetic resonance imaging, who presented between May 2012 and April 2014 and underwent CT-guided biopsy in our study. A total of thirty patients with spinal lesions were evaluated.

RESULTS

Majority presented in the seventh decade of their life (average age = 53.93; age range = 10-72 years). Male:female ratio was 1.5:1. Pain was the most common presenting symptom (100%). Lumbar spine was the most common site of lesion followed by dorsal spine. Biopsy is the gold standard in histopathological evaluation of spinal lesions. Metastatic lesion was diagnosed in 12 (40%) cases, plasmacytoma in 12 (40%) cases, non-Hodgkin's lymphoma in 2 (6.66%) cases, small round cell tumor in 1 (3.33%) case, nonspecific chronic inflammation in two patients, and necrosis with no viable cells in one patient. The most common malignancy to metastasize to spine was adenocarcinoma. The most common primary tumor of spine was plasmacytoma - multiple myeloma.

CONCLUSION

CCT-guided biopsy is a safe procedure, and no procedure-related complication was seen in any patient.

Spinal epidural abscess: Report on 27 cases

BACKGROUND

Spinal epidural abscess, although an uncommon disease, often correlates with a high morbidity owing to significant delay in diagnosis.

METHODS

In a prospective 5-year study, the clinical and magnetic resonance (MR) findings, treatment protocols, microbiology, and neurological outcomes were analyzed for 27 patients with spinal epidural abscess.

RESULTS

Patients were typically middle-aged with underlying diabetes and presented with lumbar abscesses. Those undergoing surgical intervention >36 h after the onset of symptoms had poor neurological outcomes.

CONCLUSION

Early recognition and timely evacuation of spinal abscesses minimized neurological morbidity and potential mortality.

Compressive Myelopathy due to Osteochondroma of the Atlas and Review of the Literature

We report a case of vertebral osteochondroma arising from the posterior C1 arch that presented with features of compressive myelopathy. Osteochondromas are usually found in extremities and are rarely seen in the spine. They are most commonly found in posterior elements in the spine, and intraspinal extension is uncommon. The most common presentation is incidental finding during routine imaging followed by palpation of painless swelling. Compressive myelopathy as a presentation of vertebral osteochondroma in a child is a rare entity. Surgical excision is the treatment of choice. Spinal osteochondromas should also be kept in mind as a cause of spinal cord or nerve root compression in children.

Clinicopathological characteristics of chordoma: an institutional experience and a review of the literature

AIM

To study the clinicopathologic characteristics of chordomas from a single institution.

MATERIAL AND METHODS

This study is a retrospective analysis of 18 cases of chordomas diagnosed over a period of 5-years at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, from 2006 to 2010.

RESULTS

The overall mean age of the patients was 46.72 years. Males outnumbered females. Sacrum was the commonest site involved. Histopathologically, the majority of cases were conventional chordoma with four cases of chondroid variety. There was a single case of dedifferentiated chordoma that presented with bone metastasis. Most patients did well after surgery and radiotherapy. One patient had a local recurrence and one patient with dedifferentiated variant died on follow-up.

CONCLUSION

Though locally aggressive, chordomas are effectively treated with resection and postoperative radiotherapy.

Post-traumatic sagittal sinus thrombosis: case report

Post-traumatic superior sagittal sinus thrombosis is rare. The usual presentation is raised intracranial pressure symptoms. We report a case of post-traumatic superior sagittal sinus thrombosis in which the computed tomography (CT) scan revealed depressed fracture of the vertex with parasagittal contusions. Despite surgical elevation of the fracture and repair of the superior sagittal sinus, the patient developed thrombosis of the anterior half of the superior sagittal sinus with bilateral hemorrhagic infarcts in the motor strip. This case is reported for its rarity and to highlight the importance of careful postoperative observation of such patients. In such settings, timely diagnosis and anticoagulant therapy are rewarding.

Is hypothyroidism and hypogonadism an issue after aneurysmal subarachnoid hemorrhage-an institutional experience?

BACKGROUND

The incidence of hypopituitarism in aneurysmal subarachnoid hemorrhage ranges from 0% to 45%. Also the screening for hypopituitarism in survivors of aneurysmal SAH is not a routine. This has led to a controversy in the management of such patients.

OBJECTIVES

The aim of the study was to evaluate the endocrine profile of our patients who had presented with aneurysmal SAH.

PATIENTS AND METHODS

This was a prospective study conducted over a period of three years in patients of aneurysmal subarachnoid hemorrhage. The serum samples for levels of free T4, free T3, TSH, prolactin, FSH, LH and testosterone were analyzed at the time of admission and at a follow-up period between 9-12 months. Patients with known endocrine abnormalities, liver or kidney disease and patients with hemodynamic abnormalities were excluded from the study. Abnormalities in levels were noted and a comparative analysis of the hormone levels between the 2-time periods was done. A total of 73 patients were enrolled in the study.

RESULTS

Serum prolactin was raised in 17.80% (13/73) and FSH, LH and testosterone levels were reduced in 12.32% (9/73) of patients in the acute phase at admission. After 9 months follow-up, serum prolactin normalized in all except one patient and in all the males, testosterone level increased significantly. Two patients (3%) developed central hypothyroidism on follow-up.

CONCLUSIONS

Chronic hypothyroidism and hypogonadism is not an issue in aneurysmal SAH patients.

Congenital intraosseous cavernous hemangioma of the skull: an unusual case

Intraosseous hemangiomas are benign vascular malformations mostly seen in the spine. They rarely occur in the skull. The usual age-group involved is the 2nd to 4th decades, and females outnumber males. We hereby report a rare case of congenital intraosseous cavernous hemangioma of the skull bone in a male infant. The patient underwent total excision of the lesion.

Spinal epidural hematomas in fast bowlers: report of two unusual cases

We report 2 cases of spinal epidural hematomas (SEDH) after a spell of fast bowling in 2 young boys. Both patients presented with spinal pain followed by weakness in both lower limbs. MRI of the spine revealed cervical SEDH in 1 patient and thoracic SEDH in the other. The authors want to highlight this peculiar mode of sports-related spinal injury. This type of injury has not been reported before.

Congenital occipital encephalocele with Dabska tumor: report of an unusual case

Encephaloceles arise from developmental defects in neural tube formation. These lesions contain brain and meninges which herniate through a defect in the skull. These may present as isolated malformations or rarely be associated with brain tumors. We hereby discuss a case of an unusual association of an occipital encephalocele with papillary intralymphatic angioendothelioma or Dabska tumor arising from the sac itself. The patient underwent resection of the herniated brain tissue with repair and closure of the dural defect. Histopathological examination revealed evidence of Dabska tumor from the sac. This is the first case report of the association of an occipital encephalocele with a rare vascular tumor, i.e. papillary intralymphatic angioendothelioma.

Posterior fossa dermoid with Klippel-Feil syndrome in a child

Intracranial dermoid tumors constitute a rare entity. Their association with Klippel-Feil anomaly is all the more rare. These lesions, if associated with dermal sinuses, receive attention when a patient presents with features of central nervous system infection. We describe a 5-year-old girl who presented with purulent discharge from an occipital dermal sinus with an infected posterior fossa dermoid associated with cerebellar abscesses and characteristic Klippel-Feil anomaly.

Pediatric epidural tumors of the spine--experience of a decade from the Kashmir Valley

We present our experience after analyzing retrospectively the clinicopathological characteristics, surgical approaches, immediate and long-term postoperative complications and survival outcome of pediatric spinal epidural tumors treated over a period of 10 years from 2000 to 2009 in a tertiary-care hospital. Our study included benign and malignant tumors. The majority of our patients were boys (14:8). The duration of symptoms was longer in benign lesions. Non-Hodgkin's lymphoma was the commonest malignant tumor and aneurysmal bone cyst was the commonest benign tumor. The mean duration of follow-up was 19 months (range 3-48 months). Most of the patients improved in their neurological grade after surgery; however, the degree of excision had no bearing on the length of survival for malignant lesions.

Primary spinal paragangliomas: a clinicopathological and immunohistochemical study of six cases

Spinal paragangliomas are uncommon neoplasms and subject of much debate regarding the factors governing their biological behaviour. We describe the clinicopathological and immunohistochemical (IHC) features of six cases of spinal paraganglioma. The mean age of patients was 40 years (range 20-60 years) with a male to female ratio of (2:1). Majority presented with low backache, sphincter disturbances and sensory symptoms. All tumors were intradural in the cauda region one of them extending to the filum. Only one showed focal extradural extension on microscopy. Gross total resection of tumors was possible in all cases. Histologically four showed classical 'zell-ballen' pattern and two revealed an ependymal morphology. On immunohistochemistry, in all the six cases the chief cells were intensely labeled by antibody to chromogranin but not for GFAP while staining for synaptophysin was less intense and variable in five. Sustentacular cells in all cases showed strong expression for S-100 protein and chief cells were stained light in three cases. Low MIB-1 labeling index of 0.01-2% was noted in five cases and in the sixth it was 5%. None of the tumours recurred. Immunohistochemistry assisted in differentiating these relatively benign neural crest tumours from the more aggressive spinal ependymomas.