[Endoscopic treatment of mine-explosive spine injuries: 3 clinical cases and literature review]

Modern warfare is characterized by common mine-explosive injuries. The last ones are accompanied by multiple injuries, large area of damage and severe clinical status of victims.

OBJECTIVE

To demonstrate treatment of mine-explosive spinal injuries using modern minimally invasive endoscopic techniques.

MATERIAL AND METHODS

The authors present 3 victims with various mine-explosive injuries. Endoscopic removal of fragments from the lumbar and cervical spine was successful in all cases.

DISCUSSION

Most of victims with injuries of the spine and spinal cord do not require urgent surgery and can underwent surgical treatment after clinical stabilization. At the same time, minimally invasive techniques provide surgical treatment with minimal risk and earlier rehabilitation, as well as reduce the risk of infectious complications associated with foreign bodies.

CONCLUSION

Careful selection of patients for spinal video endoscopy will ensure positive outcomes. Minimization of iatrogenic postoperative injuries is especially important in patients with combined trauma. However, well-experienced surgeons should perform these procedures at the stage of specialized medical care.

[Hemangioblastomas of the filum terminale and cauda equina]

Hemangioblastoma of the filum terminale and cauda equina is a rare tumor of nervous system. There are only few case reports in the literature. In this manuscript, the authors analyze the diagnosis and treatment of patients with this disease. MRI data and intraoperative images of stage-by-stage resection allow one to get an idea about radiological characteristics of hemangioblastoma of the filum terminale and surgical intervention. The authors discuss the world experience of surgical treatment and consider intraoperative complications.

Surgical Treatment of Intramedullary Hemangioblastomas: Current State of Problem (Review)

Intramedullary hemangioblastomas (HAB) refer to very rare highly vascularized vascular spinal cord tumors associated with various neurological disorders. Effective HAB therapy to a greater extent depends on diagnostic accuracy and the absence of intra- and postoperative complications.

The present study is a review of publications concerned with modern diagnostic and therapeutic techniques to control spinal HAB. The authors showed that perfusion computed tomography, computed tomographic angiography, and magnetic resonance angiography can be reasonably used for diagnosis and differentiation in a number of HAB due to their high vascularization. Preoperative embolization significantly reducing intraoperative bleeding risks is highly efficient. Some authors recommend this procedure in case of large lesions and high risks of intraoperative bleeding. The review also considered intraoperative imaging of a tumor and its feeding vessels using indocyanine green providing inspectability over the total tumor resection and clear imaging of tumor vascular architecture. The advantages and restrictions of the mentioned procedures were described.

[Visual fluorescence combined with laser spectroscopy in surgery for intramedullary spinal cord tumors]

BACKGROUND

Surgical treatment of intramedullary spinal cord tumors is aimed at total resection of tumor with maximum preservation of neurological and functional status. In some cases, intramedullary tumors have unclear dissection plane or gliosis zone. This area is not a tumor and does not require resection. However, it is difficult to distinguish visually intact spinal cord tissue and tumor at the last surgical stages. Thus, we evaluated the effectiveness of fluorescence combined with laser spectroscopy in surgical treatment of intramedullary spinal cord tumors.

OBJECTIVE

To determine the effectiveness of visual fluorescence combined with laser spectroscopy in surgery for intramedullary spinal cord tumors.

MATERIAL AND METHODS

There were 850 patients with intramedullary spinal cord tumors for the period 2001-2019. In 35 cases, intraoperative fluoroscopy with laser spectroscopy were used. All patients underwent a comprehensive pre- and postoperative clinical and instrumental examination (general and neurological status, McCormick grade, spinal cord MRI). Carl Zeiss OPMI Pentero microscope with a fluorescent module was used for intraoperative fluorescence diagnosis. A domestic preparation 5-ALA «ALASENS» (State Research Center NIOPIK, Moscow, Russia) was used for induction of visible fluorescence. Laser spectroscopy was carried out using a LESA-01-BIOSPEK spectrum analyzer. Morphological analysis of intramedullary spinal cord tumors was performed in the neuromorphology laboratory of the Burdenko Neurosurgery Center.

RESULTS

Intramedullary anaplastic ependymoma and astrocytoma, as well as conventional ependymoma were characterized by the highest index of 5-ALA accumulation. Intramedullary hemangioblastoma and cavernoma do not accumulate 5-aminolevulinic acid due to morphological structure of these tumors. In particular, there are no cells capable of capturing and processing 5-ALA in these tumors. Sensitivity of visual fluorescence combined with laser spectroscopy varies from 0% to 100% depending on the histological type of tumor: hemangiogblastoma and cavernoma - 0%, low-grade astrocytoma - 70%, high-grade astrocytoma - 80%, ependymoma - 92%, anaplastic ependymoma 100%. Dissection plane is absent in anaplastic ependymoma, high-grade astrocytoma. We often observed gliosis during resection of ependymoma. This tissue is not a part of tumor. Intraoperative metabolic navigation with neurophysiological monitoring are advisable for total tumor resection in case of unclear dissection plane and peritumoral gliosis.

CONCLUSION

Visual fluorescence combined with laser spectroscopy is a perspective method for intraoperative imaging of tumor remnants and total resection of intramedullary spinal cord tumors with minimum risk of neurological impairment.

[Intraoperative video-angiography in surgery for spinal intramedullary cavernous malformations: first experience of its application at the Burdenko Neurosurgical Center]

Spinal intramedullary cavernous malformations are a rare vascular pathology of the central nervous system. They account for 3-5% of spinal cord diseases. The clinical picture in patients with cavernous malformations varies from an asymptomatic course to gross neurological deficit in the case of bleeding from a malformation. Due to the lack of reliable methods for predicting the development of bleeding, the need for surgical treatment of asymptomatic patients remains a relevant and open topic for discussion. The goal of surgical treatment of cavernous malformations is to minimize the risk of repeated hemorrhages and gross neurological deficits in patients. Intraoperative indocyanine green video angiography is a promising technique for intraoperative visualization of the size and adherence area of a cavernous malformation to the spinal cord tissue. This increases the radicality of cavernous malformation resection and minimizes intraoperative risks for the patient.

[Spinal cord metastasis of anaplastic oligodendroglioma of the brain without recurrence of primary tumor. Ccase report and literature review]

Spinal cord metastases of brain gliomas are rare. However, incidence of these tumors has been increasing recently. The vast majority of neurosurgeons and oncologists recognize spinal cord metastasis of malignant brain glioma followed by symptoms of transverse spinal cord lesion as non-curable terminal stage of malignant process. In this paper, we report a rare clinical case of metastatic spinal cord lesion in a patient after previous surgery for anaplastic oligodendroglioma of the right frontal lobe. There were no signs of local recurrence of the primary tumor. Active surgical strategy followed by radio- and chemotherapy significantly improved the patient's quality of life. Postoperative follow-up is 6 months by the moment of writing the manuscript, no clinical signs of progression are observed.

[Treatment of malignant peripheral nerve sheath tumors: case reports and a literature review]

Malignant peripheral nerve sheath tumors (MPNSTs) are soft tissue sarcomas that develop from peripheral nerve sheath cells (T. Hirose, B.W. Scheithauer). These tumors are characterized by aggressive growth with an unfavorable outcome and may develop de novo or through malignant transformation of schwannomas, neurofibromas, or ganglioneuromas. MPNSTs are characterized by a rapid course and a poor prognosis. In this article, we reported cases of patients with malignant peripheral nerve tumors of the brachial plexus trunks and spinal localization.

[Complications of surgical treatment of sacral tumors]

Sacral tumors are a group of neoplasms heterogeneous in the histological type, malignancy, and growth pattern, but with common localization. Surgical treatment of these tumors is associated with the risk of major and minor complications, both during and after surgery. Usually, any surgery aimed at removing tumors in the sacrum or sacral region is associated with the need for reconstruction of bones and/or soft tissues to provide conditions for normal wound healing and the possibility of activating the patient.

AIM

The study aim was to analyze complications associated with surgery for sacral tumors.

MATERIAL AND METHODS

The study is based on the experience of surgical treatment of 57 patients with the diagnosis of sacral tumor. The patients underwent 60 surgical interventions related to treatment of the underlying pathology and complications of surgical treatment. Major and minor complications developed in 37 (68%) operated patients. A total of 47 different complications were recorded. In 6 patients, complications in the early postoperative period required additional surgery.

CONCLUSION

Surgical treatment of sacral tumors is associated with a high risk of complications. Despite the potential risk of major complications, sacrectomy for primary, or potentially aggressive, or malignant neurogenic tumors of the sacrum is necessary to improve local control and survival of patients.

[Management of neurogenic tumors of the sacrum and sacral area]

Tumors of the sacrum rarely occur in routine practice. Due to the absence of pathognomonic symptoms, the diagnosis often becomes apparent at a late disease stage. In this case, the treatment approach depends on the degree of tumor malignancy, growth pattern and location, and relationship between the tumor and the nervous structures, major vessels, and pelvic bones.

OBJECTIVE

Analysis of the overall and relapse-free survival of patients with neurogenic tumors of the sacrum.

MATERIAL AND METHODS

In this study, we analyzed the treatment outcomes in 27 patients with neurogenic sacral tumors who underwent surgery at the Burdenko Neurosurgical Institute.

RESULTS

The median survival time of patients with neurogenic tumors was 72 months; the shortest survival time was observed in a group of neurogenic sarcomas, with the mean survival time being 30 months. Malignant tumors of the peripheral nerves recurred in 100% of cases.

CONCLUSION

Surgical treatment of neurogenic tumors of the sacrum reduces pain, but does not lead to regression of the neurological symptoms caused by compression of the sacral plexus roots. Patients with malignant tumors of the sacrum should undergo partial or complete sacrectomy. In this case, the choice of treatment strategy should be based on assessment of the functional status, tumor histology, and somatic features of the patient.

[Resection of a giant sacral schwannoma: case report and literature review]

Neurogenic sacral tumors are extremely rare. In most reported cases, this pathology was associated with neurofibromatosis. Sacral tumors manifest themselves at the stage when the neoplasm volume becomes giant, but these manifestations usually go unnoticed for the patient. Surgical approach to the sacral region is extremely challenging; intimate proximity of tumor capsule to vital organs, vessels, and nerves makes radical surgical treatment of these neoplasms rather difficult. A case report of radical resection of a schwannoma that was destroying the sacrum and continued to grow after radiotherapy is presented in this article.

[Surgical treatment of intramedullary-extramedullary ependymomas. Two clinical cases and a literature review]

Ependymoma is a central nervous system tumor that grows from ependymal cells lining the cerebral ventricles, central canal of the spinal cord, and filum terminale. Regardless of the histological type of ependymomas, they rarely have exophytic growth. Because of an extremely low occurrence rate of this phenomenon, we present two clinical cases of patients with classical intramedullary ependymomas (Grade II) having an extramedullary component.

MATERIAL AND METHODS

The paper presents two clinical cases of patients with intramedullary-extramedullary ependymomas of the spinal cord. The surgical technique is described. After surgical treatment, the performance status of patients remained unchanged.

CONCLUSION

Radical removal of complex ependymomas provides conditions for long-term disease-free survival and further neurological recovery.

[Comprehensive assessment of the outcomes of surgical treatment of patients with metastatic spinal cord injuries]

INTRODUCTION

Every year the number of cancer patients increases due to increased life expectancy. According to various sources, metastases in the spine are found during autopsy in 30-90% of patients with a history of cancer. So far, there have been no full-scale studies of the quality of life of patients with various metastatic tumors of the spine who underwent surgical treatment in Russian literature. The main objective of this study was to demonstrate the need for implementing the comprehensive treatment of patients with metastases in the spine and target setting as the main tool to identify the factors that adversely affect the patients' quality of life.

MATERIAL AND METHODS

The quality of life of 56 patients aged 16 to 81 years was assessed, including 26 males and 30 females. Twenty-six patients underwent surgical treatment between 2002 and 2009, and thirty patients underwent surgical treatment between 2009 and 2014. Kidney cancer was a primary disease in 30.3% of patients, multiple myeloma was a primary disease in 23.1% of cases, and the primary source of a tumor was not identified in cancer screening in 10.5% of cases. There were also isolated cases of melanoma, thymoma, metastases of tumors of the gastrointestinal tract, uterus, ovary, lung, prostate, pancreas, and the thyroid gland, which on the average amounted to 3.5% (1.8 to 7.14%). The quality of life of patients was studied using the EORTC QLQ C30 scale. The patients were surveyed prior to the surgery and then 1, 3, 6 and 12 months after surgical treatment during 1 year or until death. Preoperative and postoperative contrast-enhanced SCT and MRI examinations were used to control the extent of decompression of neural structures.

RESULTS

On the basis of these findings, the authors identified the main factors affecting the quality of life of patients and formulated a range of treatment goals for patients with metastases in the spine.

CONCLUSION

Surgical treatment has a positive effect on the quality of life of patients with metastases in the spine. However, it is not a key factor in the context of survival rate of these patients. Therefore, a decision on the possibility and necessity of surgical treatment should be taken in cooperation with the patient and oncologists of different specialties.

The use of intraoperative neuroimaging tools and a navigation system in surgical treatment of primary and metastatic tumors of the spine

INTRODUCTION

Surgical treatment of spinal tumors is associated with a high risk of intraoperative complications, including injury to the spinal cord, its roots, and large vessels both during tumor resection and at the stabilization stage during implantation of pedicular or corporal screws. The use of intraoperative neuroimaging tools and a navigation system in surgical treatment of oncological diseases of the spine enables identifying the location and extension of a tumor lesion directly in the operating room, which provides control of the resection area and the possibility of the spine stabilization under disturbed anatomy conditions when bone density is altered by the osteolytic process or systemic changes. Also, the risk of injury to the major blood vessels is reduced.

MATERIAL AND METHODS

Surgical treatment of 156 patients with primary and metastatic tumors of the spine was performed at the Burdenko Neurosurgical Institute in the period from 2002 to December 2014. Twelve patients underwent diagnostic intervention (transcutaneous biopsy), and 35 patients underwent surgery using intraoperative CT and a navigation systems. The indication for biopsy using both CT and the navigation system was the presence of a spinal tumor not verified by a pathomorphological examination. An O-arm intraoperative computed tomography scanner and a Medtronic's StealthStation S7 Navigation System were used in all cases.

CONCLUSION

The use of both CT and the navigation system provides high quality treatment and significantly reduces radiation exposure to the medical personnel and patient. The possibility of intraoperative identification of the location and extension of a tumor in bone tissue facilitates adequate tumor resection within the intact surgical margin, with the surrounding vessels and neurological structures being under real-time control.

Extradural spinal cord hemangioblastoma (a case report and literature review)

Hemangioblastoma is a rare CNS vascular tumor that develops sporadically and can also be associated with von Hippel-Lindau disease. Hemangioblastomas account for 2-6% of all spinal cord tumors and are ranked third in the structure of intramedullary space-occupying lesions of the spinal cord. For the first time in our practice, we observed a dumbbell paravertebral hemangioblastoma. The international literature reports only 3 cases of the tumor with this growth type.

Multiple primary liponeurocytoma of the central nervous system

We report a unique case of primary multiple liponeurocytoma. Liponeurocytoma is a rare benign tumor (Grade II) of the posterior cranial fossa with neural- or probably astrocytic-lineage cells; the tumor stroma contains mature adipocytes. This case is the thirty-eighth case of this pathology reported in the world literature and the first case of multiple form of this disease. We have provided a sufficiently thorough neuroradiological and histological picture that allows one to differentiate between a liponeurocytoma and other histological variants. Recommendations for the tactics for managing patients with this rare disease are proposed based on the analysis of treatment of this pathology reported in the world literature.