Manejo quirúrgico de ependimomas en médula cervical: A propósito de un caso clínico / Surgical management of ependymomas in the cervical spine: Apropos of a clinical case

Introducción: los ependimomas son tumores cerebrales que surgen de células ependimarias, células de soporte en el cerebro y la médula espinal. Representan entre el 2 y el 3% de todos los tumores cerebrales primarios. Son el cuarto tumor cerebral más común en los niños, donde el 90% de los mismos se localizan en la fosa posterior. En adultos, el 60% de estos tumores se encuentran en la médula espinal pudiendo presentarse a cualquier nivel de ésta; el caso a continuación reporta un ependimoma cervical. Objetivo: reportar un caso de ependimoma medular de ubicación poco frecuente, con resección total, sin recidiva porterior a 2 años de seguimiento.Descripción del caso: se reporta el caso de un paciente adulto, 44 años, masculino, con un síndrome medular cervical completo, progresivo, provocado por un ependimoma cervical. Intervención: se realizó laminectomía de dos espacios [C7 a T1], apertura dural, mielotomía posterior logrando exéresis total de la lesión con durorrafia a sello de agua y posterior cierre por planos sin complicaciones, con seguimiento de 2 años de sobrevida. Conclusiones: la resección total macroscópica de este tipo de tumores es muy importante para poder evitar residiva. El ependimoma cervical puede recidivar, sobre todo cuando existen residuales de la lesión. El manejo oportuno depende de gran manera de que los pacientes acudan tempranamente a valoración especializada; la resección guiada con monitorización neurofisiológica transoperatoria provee mayor oportunidad a los pacientes a no presentar secuelas permanentes y permite asimismo, mejores resultados de la rehabilitación neurológica postoperatoria

Introduction: ependymomas are brain tumors that arise from ependymal cells, supporting cells in the brain and spinal cord. They represent between 2 and 3% of all primary brain tumors. They are the fourth most common brain tumor in children, where 90% of them are located in the posterior fossa. In adults, 60% of these tumors are found in the spinal cord and can occur at any level of the spinal cord; the case below reports a cervical ependymoma. Objective: to report a case of medullary ependymoma of rare location, with total resection, without recurrence after 2 years of follow-up. Case description: a 44-year-old male adult patient with a progressive, complete cervical spinal cord syndrome, caused by a cervical ependymoma, is reported.Intervention: two-space laminectomy [C7 to T1], dural opening and posterior myelotomy were performed, achieving total excision of the lesion with water-seal durorrhaphy and subsequent closure by planes without complications, with a 2-year survival follow-up. Conclusions: macroscopic total resection of this type of tumor is very important to avoid residual. Cervical ependymoma can recur, especially when there is residual lesion. Timely management depends to a great extent on the patients attending early for a specialized evaluation; guided resection with intraoperative neurophysiological monitoring provides a greater opportunity for patients to not present permanent sequelae and also allows better results of postoperative neurological rehabilitation.

Intradural extramedullary tumor causing compression of the thoracic and lumbar vertebrae in a 22-year-old male with Acute Myeloid Leukemia

@#Myeloid sarcoma, characterized by the presence of immature myeloid cells occurring at an extramedullary site, is a rare manifestation of acute myelogenous leukemia (AML). Spinal cord compression as an initial presentation of AML is very rare with only a few reported cases. We discuss a case of a 22-year-old male who presented with bicytopenia and paraplegia. Workups were consistent with AML with monocytic differentiation. Chromosomal analysis revealed loss of Y and t (8;21). Spinal cord MRI showed intradural extramedullary-enhancing soft tissue lesions at levels T2 to T7 and L5 to S1, suspected to be myeloid sarcoma. Patient, however, succumbed to severe nosocomial infection prior to initiation of chemotherapy and radiotherapy.

Intradural Extramedullary Spinal Metastasis of a Kidney Cancer: Case Report

Objective To report a case of intradural extramedullary metastasis originated from a kidney neoplasm. Metastases in this topography occur in a low frequency, especially considering that the primary tumor was located along the urinary system. Case Report Amale adult begins to present with pain in the lower limbs and develops flaccid paraparesis of the pelvic limbs, also attacking the control of the sphincter. The patient had a previous history of right nephrectomy due to a kidney neoplasm. After investigation with imaging exams, ametastatic lesion was found to be the source of the symptoms. The patient was surgically treated by the neurosurgery team of the hospital. Conclusion Cases like this are not common, and considering the low incidence of these cases and the nonspecific symptoms, such as pain, we do not always come up with the hypothesis of a metastasis in this topography. The surgical treatment, although it is a palliative feature, has an important part inmaintaining the performance and the quality of life of the patient.

Intratumoral Hemorrhage of the Cervical Spinal Schwannoma Presenting: Acute Quadriparesis

Schwannomas are the most common extramedullary spinal tumors, with chronic progressive symptoms being the most common presenting features. The acute hemorrhagic onset of a spinal schwannoma is a rare occurrence. Here, we report the case of a 37-year-old male who presented with complaint of neck pain and an acute onset of quadriparesis. MRI of his cervical spine revealed an intradural extramedullary lesion in the C2 to C3 cervical segment, with features of acute hemorrhage but mild enhancement. He was operated in emergency and complete microsurgical resection of tumor was achieved. Histopathology revealed features of an ancient schwannoma with hemorrhage. Postoperatively, the patient showed significant improvement.

Clinoidectomía anterior intradural para clipado de aneurisma paraclinoideo izquierdo: video quirúrgico / Anterior intradural clinoidectomy for clipping left paraclinoid aneurysm: surgical video

Introducción: Los aneurismas paraclinoideos representan un verdadero desafío microquirúrgico para su resolución. Objetivo: Presentamos el caso de una mujer de 43 años de edad con cefalea, detectando en angiografía aneurisma paraclinoideo izquierdo. Material y métodos: Se realizó abordaje pterional izquierdo y exposición de carótida interna a nivel cervical, durotomía arciforme con apertura de cisterna silviana hacia cisterna carotídea. Se expone la apófisis clinoides anterior, observándose en el video, el aneurisma naciendo del segmento clinoideo de la arteria carótida interna, siendo imposible el clipado de la misma sin clinoidectomía anterior. Se secciona la duramadre desde medial respecto al conducto óptico hasta la apófisis clinoides. Se realiza fresado en la base de la apófisis clinoides para exponer el anillo dural distal. Se libera la carótida en el segmento clinoideo a través de la sección del anillo dural distal para poder movilizarla. Identificado el cuello distal y proximal del aneurisma, se comienza la reconstrucción colocando un clip a 90° en dirección anteroposterior, un segundo clip en dirección posteroanterior y al punzar el aneurisma se constata flujo aneurismático presente. Se coloca un tercer y cuarto clip en tándem desde la proximidad a la carótida interna hacia el domo del aneurisma. Finalmente se posiciona un quinto clip curvo sobre los anteriores para darles mayor presión de cierre. Resultados: Se observa angiografía postoperatoria con exclusión completa el aneurisma con adecuada permeabilidad carotidea. El período postoperatorio fue excelente, sin déficit neurológico. La paciente brindo consentimiento para publicar sus imágenes y videos.

Introduction: Paraclinoid aneurysms represent a true microsurgical challenge. Objective: We present the case of a 43-year-old woman with headache, in whom a left paraclinoid aneurysm was detected by angiography. Methods and Materials: A left pterional approach was adopted, combined with exposing the internal carotid artery at the cervical level, and an arciform durotomy with the opening of the sylvian fissure to the carotid cistern. The anterior clinoid process was exposed, revealing the aneurysm originating from the clinoid segment of the carotid artery; consequently, clipping was impossible without an anterior clinoidectomy. The dura was cut medially from the optic canal to the clinoid process. Drilling was performed at the base of the clinoid process to expose the distal carotid dural ring. The carotid was released in the clinoid segment by sectioning the distal dural ring to mobilize it. After identifying the distal and proximal neck of the aneurysm, reconstruction was initiated by placing a 90-degree clip in the anteroposterior direction; then, a second clip in the posteroanterior direction and puncturing the aneurysm, demonstrating that aneurysmal flow was present. Third and fourth clips were placed in tandem, one proximal to the internal carotid and the other at the dome of the aneurysm. Finally, a fifth curved clip was placed over the previous clips to increase their closure pressure. Results: Postoperative angiography revealed complete exclusion of the aneurysm with adequate carotid permeability. The postoperative period lacked any complications or neurological deficits. The patient consented to have her images and videos published. Conclusions: Combining a left pterional approach with exposing the internal carotid artery at the cervical level and performing an arciform durotomy at the sylvian fissure's opening into the carotid cistern, an angiographically-detected left paraclinoid aneurysm was treated successfully with an excellent outcome.

Resultados neurológicos en pacientes con diagnóstico de tumores raquídeos intradurales extramedulares / Neurological results in patients diagnosed with intradural spinal tumors

Se presentan a continuación los resultados neurológicos de 10 pacientes con diagnóstico de tumor intramedular extradural que fueron intervenidos quirúrgicamente en el Hospital Teodoro Maldonado Carbo durante el periodo enero 2015 a junio 2017. Se encontraron ocho hombres (80 %) y dos mujeres (20 %) con un promedio de edad de 44,4 años. El periodo de seguimiento posoperatorio fue de seis meses. La clínica neurológica,localización axial y sagital de los tumores, resultados histopatológicos fueron analizados. Los resultados neurológicos encontrados en el preoperatorio y en el periodo posoperatorio a los seis meses de seguimiento fueron evaluados de acuerdo con la clasificación ASIA (American Spinal Injury Association); y, el Score de Rankin modificado. Los resultados histopatológicos fueron los siguientes: cuatro casos (40 %) de schwannoma, tres casos (30 %) de meningioma, un caso (10 %) de plasmocitoma, un caso (10 %) de ependimoma y un caso (10 %) de metástasis de otros tumores. Se presentaron complicaciones en el 20 % de casos: un caso (10 %) de infección de herida quirúrgica; y, otro caso (10 %) de fístula de líquido cefalorraquídeo. En el 70 % de casos, al seguimiento seis meses luego de la cirugía se encontró mejoría en la clínica neurológica; y, en 30 % de los casos no hubo cambios neurológicos. Al valorar la Escala de Rankin modificada se encontró que tres pacientes (30 %) se recuperaron completamente, evolucionando desde un grado 2 (incapacidad leve) a un grado 1 (sin incapacidad); por otro lado, cuatro casos (40 %) mejoraron su grado de incapacidad funcional; y, tres casos (30 %) no mostraron cambios en cuanto a suincapacidad funcional, es decir, sin variaciones en su clínica neurológica. Podemos concluir que el diagnóstico oportuno y el tratamiento precoz mejoran la morbilidad y el grado de discapacidad, puesto que, ante un mayor déficit neurológico menor es el resultado pronóstico neurológico. Los resultados dependerán, por lo tanto, del momento oportuno de la intervención quirúrgica raquídea descompresiva.

We present the neurological results of 10 patients diagnosed with Extradural Intramedullary Tumor who underwent surgery at Teodoro Maldonado Carbo Hospital during the period January 2015 to June 2017. Eight men (80 %) and two women (20 %) were found with an average age of 44,4 years. The postoperative follow-up period was six months. Neurological symptoms, axial and sagittal localization of the tumors, histopathological results were analyzed. The neurological results found in the preoperative period and in the postoperative period at six months of follow-up were evaluated according to the ASIA (American Spinal Injury Association) classification; and, the modified Rankin Score. The histopathological results were the following: four cases (40 %) of schwannoma, three cases (30 %) of meningioma, one case (10 %) of plasmacytoma, one case (10 %) of ependymoma and one case (10 %) of metastasis of other tumors. Complications occurred in 20 % of cases: one case (10 %) surgical wound infection, and in anothercase (10 %) cerebrospinal fluid fistula. In 70 % of cases, at follow-up six months after surgery, improvement was found in the neurological clinic; and, in 30 % of the cases there were not neurological changes. When assessing the modified Rankin scale, it was found that three patients (30 %) recovered completely, evolving from a grade 2 (mild disability) to a grade 1 (without disability); On the other hand, four cases (40 %) improved their degree of functional disability; and, three cases (30 %) did not show changes in their functional disability, that is, without variations in their neurological clinic. We can conclude that timely diagnosis and early treatment improves morbidity and the degree of disability, since, in the face of a greater neurological deficit, the neurological outcome is lower. The results will therefore depend on the opportune moment of the decompression spinal surgery.

Treatment of Intradural Spinal Arteriovenous Fistula: Technical Case Report

Introduction Although rare, arteriovenous fistula (AVF) is the most common vascular malformation of the spine, and it is mainly located in the thoracic region. The fistula is identified by arteriography, which enables the treatment by embolization or guides the microsurgical therapy. Clinical Presentation We describe the case of a 61-year-old woman with neurogenic claudication evolving to paraparesis. A dorsal intradural AVF was identified by magnetic resonance imaging (MRI) and arteriography, and it was submitted to an embolization, but the procedure was unsuccessful. The patient was then referred for neurosurgery, and the AVF was obliterated using a microsurgical technique guided by multimodal intraoperative monitoring. We identified the AVF in the intraoperative moment and we then cut and coagulated the extradural portion of the nerve root. Discussion Arteriovenous fistulas occur in the dura mater of the nerve roots with the arterialization of the venous plexus. The treatment prevents the progression of the deficits. While performing diagnostic arteriography, attempts of embolization are possible. Conclusion Although the initial attempt of embolization at the moment of the diagnostic arteriography is achievable, it has failure rates of 50%, unlike the surgical treatment, which is definitive in all cases, as reported in this article.

Introdução Apesar de raras, as fístulas arteriovenosas (FAV) são as malformações vasculares mais comuns na coluna, localizadas essencialmente na região torácica. A fístula é identificada por arteriografia, a qual permite o tratamento da embolização ou guia a terapia microcirúrgica. Apresentação Clínica Descrevemos o caso de uma mulher de 61 anos com claudicação neurogênica evoluindo para paraparesia. Uma FAV intradural dorsal foi identificada por meio de ressonância magnética (RM) e arteriografia, e foi submetida a uma embolização, mas o procedimento não obteve sucesso. A paciente foi então encaminhada para tratamento neurocirúrgico, e a FAV foi eliminada por técnica microcirúrgica guiada por monitoração multimodal intraoperatória. Identificamos a FAV durante o período intraoperatório, e em seguida cortamos e coagulamos a porção extradural da raiz do nervo. Discussão As AVFs ocorrem na dura-máter das raízes neurais com a arterialização do plexo venoso. O tratamento evita o progresso de déficits. Durante a arteriografia diagnóstica, tentativas de embolização são possíveis. Conclusão Apesar de a tentativa inicial de embolização durante a arteriografia ser possível, ela tem probabilidades de 50% de sucesso, enquanto o tratamento cirúrgico é definitivo em todos os casos, como relatado neste artigo.

Inyección subdural: complicación en la técnica peridural lumbar: revisión bibliográfica / Subdural injection: complication in lumbar epidural block: review of the literature

Se realiza una revisión bibliográfica sobre inyección subdural en la técnica peridural lumbar. se analizan los aspectos anatómicos, se describen las diferentes formas de presentación y su imagen radiológica, se discuten los criterios diagnósticos, los posibles efectos de la inyección en dicho espacio y la conducta a tomar, una vez detectada la complicación.

A bibliographic review about lumbar epidural subdural injection is done. the anatomic aspects, the different forms of presentation, and the radiological image are described. the diagnostic criteria, the effects of injection in this space and the management of the complication are discussed.

Intradural Schwannoma Exacerbating the Symptoms of Degenerative Lumbar Stenosis: Case Report

Introduction Schwannoma is a common intradural slow-growing, benign and encapsulated tumor that originates from the myelin sheaths of the nerve fibers. However, a lumbar schwannoma complicating the symptoms of spinal stenosis is an extremely rare association. Aim To describe the case of a woman presenting a lumbar schwannoma in association with spinal stenosis. Case Report A 53 year-old female was referred to neurosurgical evaluation due to the worsening of a lumbar pain that was irradiating to the left inferior leg along the anterolateral surface. A neurological examination revealed motor deficits for extension of the left leg and attenuation of the left patellar reflex. Magnetic resonance imaging (MRI) showed lumbar spinal stenosis due to flavum ligament hypertrophy and disc herniation in the L3L4 and L4L5 segments, and an expansive lesion with homogeneous contrast enhancement occupying the left neuroforamen of the L3L4 segment. The patient underwent surgical resection of the tumor and decompression of the stenotic segments with posterior screw instrumentation from L3 to L5. She presented an uneventful recovery and significant improvement of the lumbar pain, and was still free of symptoms 6 months after surgery. An anatomopathological examination defined the tumor as a schwannoma (Grade I ­ World Health Organization [WHO]). Conclusion The present study highlights that lumbar schwannoma is a possible etiology complicating the symptoms of patients with previous lumbar spinal stenosis. It is important to treat both pathologies to improve the patients' symptoms.

Introdução O schwannoma é um tumor intradural comum, benigno, de crescimento lento e encapsulado que se origina da bainha de myelina das fibras nervosas. No entanto, a presença de um schwannoma lombar complicando os sintomas de estenose do canal medular é uma associação extremamente rara. Objetivos Descrever o caso de uma paciente portadora de schwannoma lombar exacerbando os sintomas de estenose do canal lombar. Relato de Caso Uma mulher de 53 anos de idade foi encaminhada para avaliação neurocirúrgica devido a relato de piora dos sintomas de dor lombar que irradiavam preferencialmente para o membro inferior esquerdo na sua face antero-lateral. O exame físico neurológico revelou a presença de déficit motor para a extensão do membro inferior esquerdo e redução do reflexo patelar esquerdo. A imagem de ressonância magnética mostrou a presença de estenose do canal lombar devido à hipertrofia do ligamento amarelo e herniações discais nos segmentos L3L4 e L4L5. Além disso, o estudo radiológico também evidenciou a presença de uma lesão expansiva ocupando o neuroforamen de L3L4 com captação homogênea do meio de contraste. A paciente foi submetida à ressecção cirúrgica do processo neoplásico e descompressão do canal medular com artrodese através de instrumentação dos segmentos L3L4L5 via posterior em um único ato operatório. A paciente apresentou uma recuperação pós-operatória adequada e mantém-se assintomática em segmento clínico seis meses após o procedimento cirúrgico. O estudo anatomo-patológico e imuno-histoquímico definiu o processo expansivo como schwannoma (Grau I da OMS). Conclusão O presente estudo destaca que o schwannoma lombar é uma possibilidade etiológica para os pacientes portadores de estenose do canal lombar que apresentam piora progressiva dos sintomas ou novos déficits neurológicos. É importante tratar as duas patologias para que o paciente obtenha melhor resultado clínico no controle dos sintomas.

Giant Ganglioneuroma of Thoracic Spine: A Case Report and Review of Literature

Ganglioneuroma (GN) is a rare benign tumor of neural crest origin usually found in the abdomen, but may occasionally present at uncommon sites including the cervical, lumbar, or sacral spine. However, GNs of thoracic spine are extremely rare. In this report, we describe a 12-year-old girl with giant GN in the thoracic spine, who underwent successful resection (T1–4 level) of the tumor. Histopathological examination confirmed the diagnosis. GN should be considered in the differential diagnosis of any paraspinal mass. A high index of suspicion and correlation of clinico-radiological findings is necessary in differentiating a large benign tumor from a malignant growth. Complete surgical excision is the treatment of choice; however tumor size and location need to be considered for the surgical approach (one-step or multiple surgeries). Close follow-up after surgery is mandatory.

Intradural Extramedullary Capillary Hemangioma In the Upper Thoracic Spine with Simultaneous Extensive Arachnoiditis

Capillary hemangiomas are common benign vascular tumors on skin and soft tissues, but developing as an intradural and extramedullary (IDEM) tumor in spine is extremely rare. In this report, we present IDEM tumor compressing thoracic cord in T2–3 level with extensive arachnoiditis below the tumor level in a 60-year-old man. The lesion was removed and histological diagnosis was capillary hemangioma. Prompt diagnosis and resection are important to avoid neurological deterioration from acute hemorrhagic condition. Simultaneous arachnoiditis may be originated from old subarachnoid hemorrhage associated tumor before diagnosis, and we suggest it as a helpful diagnostic feature to suspect vascular tumors such as capillary hemangioma.

Quiste aracnoidal cervical anterior en edad pediátrica / Anterior cervical arachnoid cyst in pediatric age

Los quistes aracnoidales espinales son lesiones poco comunes en la población pediátrica. La mayor parte de ellos, se ubican en los segmentos dorsales y la posición anterior respecto a la médula es rara en todos los casos. Si bien su patogenia no está aclarada, se han asociado a defectos del tubo neural y traumas previos. Clínicamente, pueden presentarse con síndrome medular que en ocasiones pueden empeorar con cambios posturales. El tratamiento, puede ser conservador o quirúrgico, el que está indicado en presencia de síntomas neurológicos secundarios a compresión medular, siendo el abordaje posterior el más frecuentemente utilizado. El propósito de la cirugía es la resección total o en su defecto, la fenestración del quiste para comunicarlo al espacio subaracnoídeo. Una potencial complicación de la vía posterior, es la herniación medular durante la durotomía, secundaria al efecto compresivo del quiste, la cual podría aumentar la morbilidad neurológica en el período postoperatorio. Se presentan 2 casos consecutivos en edad pediátrica con quistes intradurales espinales anteriores, el primero en la región cervico-dorsal cuya cirugía se vio dificultada por la presencia de herniación medular transdural y un segundo caso con un quiste exclusivamente cervical, en que mediante una punción lateral del quiste guiada por ecografía previo a la durotomía, se logró resecar la lesión sin esta complicación.

Spinal arachnoid cysts are rare lesions in pediatric population. Most of them are located posteriorly in dorsal segments ananterior position is rare. Although its pathogenesis has not been elucidated, they have been associated with neural tube defects and the presence of previous spinal traumas. Clinically, they present with a spinal cord syndrome which can sometimes worsen with postural changes. Treatment may be conservative or surgical, the latter indicated by the presence of neurological symptoms secondary to spinal cord compression, with the posterior approach being the most frequently used. The purpose of surgery is total or partial resection, or fenestration of the cyst to subarachnoid space. A potential intra-surgical complication of posterior approach in anterior cyst is spinal cord herniation during durotomy, secondary to the compressive effect of the cyst, which could increase neurological morbidity in the postoperative period (1 case with mortality is described in the literature). We present 2 consecutive cases in pediatric patients with previous spinal intradural cysts. The first in the cervico-dorsal region whose surgery was hampered by the presence of medullary transdural herniation and second case with an exclusively cervical cyst that through a side puncture cyst guided by ultrasound prior to durotomy, it was possible to resect the lesion without this complication.

Total Excision of a Giant Ventral Midline Cervical Spinal Intradural Schwannoma via Posterior Approach

Schwannomas are the most common intradural extramedullary tumors of the spine. They usually occupy a posterolateral or lateral position in relation to the cord. The ventral midline is a very rare location for the origin of a spinal schwannoma. A giant one in such a location causes technical difficulties in excision. Here, we present a giant cervical spinal schwannoma, located ventral to the cord, in a 38-year-old lady who presented with features of myelopathy and bladder involvement. Magnetic resonance imaging was suggestive of an intradural extramedullary lesion extending from cervico-medullary junction to the third dorsal vertebral level with severe cord compression. The same was excised totally via a posterior approach after midline suboccipital craniectomy and C2-C6 laminoplasty. Postoperatively, she made a good recovery and was ambulant without support. Postoperative magnetic resonance imaging showed complete excision of the tumor. Histopathology was suggestive of schwannoma.

Extensive Intradural Epidermoid Cysts with Cauda Equina Syndrome in the Lumbosacral Spine: Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare case of extensive epidermoid cysts in the lumbosacral spine. SUMMARY OF LITERATURE REVIEW: The intradural epidermoid cyst with extensive involvement is rare, and previous reports have reported only extensive intramedullary epidermoid cysts. MATERIALS AND METHODS: A 75-year-old male presented with progressive motor weakness of both extremities beginning 3 days prior. MRI showed extensive intradural extramedullary epidermoid cysts in the lumbosacral region. We performed total laminectomy from the L1 to the L5 level, and the cystic mass was removed. RESULTS: We confirmed the epidermoid cyst on histopathologic examination. CONCLUSIONS: Extensive extramedullary epidermoid cysts are difficult to remove completely. Attempting complete removal may result in neurological deficit. Therefore, when surgical intervention is planned, the poor postoperative prognosis should be taken into consideration.

Huge Intradural Lumbar Disc Herniation Mimicking an Intradural Spinal Tumor: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a case of cauda equine syndrome due to a lumbar intradural disc herniation. SUMMARY OF LITERATURE REVIEW: IDH is rare but there is a higher incidence of neurologic deficit in IDH. Therefore, it should be treated immediately. MATERIALS AND METHODS: A 34-year-old male patient was presented with cauda equina syndrome due to a lumbar intradural mass and underwent surgical excision. RESULTS: Operative findings and the histologic study revealed an intradural disc herniation. CONCLUSIONS: IDH is very rare lesion but should be considered in a differential diagnosis if preoperative MRI demonstrates an intradural lesion.

Utility of Discography as a Preoperative Diagnostic Tool for Intradural Lumbar Disc Herniation

Preoperative definitive diagnosis of intradural lumbar disc herniation (ILDH) is difficult despite the availability of various neuroradiological investigative tools. We present a case of ILDH diagnosed preoperatively by discography and computed tomography-discography (disco-CT).The patient was a 63-year-old man with acute excruciating right leg pain. Discography and disco-CT demonstrated leakage of the contrast medium into the intradural space. Based on these findings, a right L5 nerve root disturbance caused by ILDH was diagnosed. A right L5 hemi-laminectomy and a dorsal durotomy were performed. The herniated disc was carefully dissected and then completely removed. Three months after surgery, the patient had fully recovered. This report highlights the importance of making a definitive diagnosis of ILDH preoperatively for better surgical planning and improved clinical outcomes. Furthermore, discography and disco-CT are both useful preoperative diagnostic tools for the diagnosis of ILDH.

Magnetic resonance evaluation of intra dural spinal tumors with histopathology correlation.

Background: Tumors of the spinal cord or canal constitute approximately 15% to 20% of central nervous system tumors. The differential diagnosis of spinal neoplasms is primarily based on location of the lesion relative to the spinal cord and the age, sex and clinical presentation. The aim and objective of the study was to determine the sensitivity of magnetic resonance imaging (MRI) in diagnosing intra spinal tumors and to correlate findings on MRI with histopathological diagnosis. Methods: This is a retrospective study. The study group included all the patients who presented to our hospital with progressive sensory or motor deficits, para or quadriperesis with or without bladder/bowel Involvement. Only patients with Intra dural lesions such as intradural extra medullary and Intra medullary lesions were included in the study. All the extra dural lesion cases such as vertebral tumors, degenerative/osteoporotic compressions and Trauma related cord compressions were excluded from the study. Results: Of the forty intradural tumors, 28 were extramedullary and 12 were intramedullary. Most of the tumors were located in the cervical and the dorsolumbar spine accounting for more than 50%. The most common tumor encountered in our study was schwannoma (22/40), followed by ependymoma (7/40), meningioma (4/40), astrocytoma (4/40), one each of Hemangioblastoma, Neuroentericcyst and Dermoid cyst. Ependymomas, Astrocytomas and hemangioblastoma were intramedullary lesions and the remaining lesions constituted Intra Dural extra medullary lesions. Conclusions: MRI was found to be a highly sensitive imaging procedure and the method of choice for intradural tumor evaluation and to differentiate extra medullary from Intra medullary lesions. It is not sensitive enough to differentiate the Intra medullary tumors. Nevertheless, definite diagnosis could be made by histopathology only.

INYECCIÓN SUBDURAL: COMPLICACIÓN EN UN PROCEDIMIENTO EPIDURAL TRANSFORAMINAL LUMBAR

Se comunica un caso de inyección subdural accidental en el contexto de una inyección epidural transforaminal lumbar, con una aparente ubicación apropiada de la aguja. Se describen las imágenes observadas, se analizan las posibles complicaciones de la inyección en dicho espacio, y se discute la conducta a tomar una vez instalada la complicación.

A case on unexpected subdural injection despite apparent proper placement of the needle is reported. The watched images are described, the possible complications of the injection in this space are analyzed, and the proper conduct is discussed.

Distinctive Characteristic Features of Intramedullary Hemangiopericytomas

STUDY DESIGN: The retrospective analysis of intramedullary hemangiopericytomas (HPCs) was performed, and the entity was discussed in accordance with the literature findings. PURPOSE: This study aimed at defining distinctive characteristic features of intramedullary HPC with respect to surgical approach and prognosis. OVERVIEW OF LITERATURE: Intramedullary HPCs are extremely rare tumors. They originate from capillary pericytes, supposedly follow the vessels over the spinal cord, and infiltrate deep into the spinal cord without a distinct plane. Their treatments and prognosis are not well-defined in the literature. METHODS: Our database was retrospectively reviewed for the cases of HPCs. Later on, a literature search was performed to reveal all reported cases of intramedullary HPCs. The following key words were searched in PubMed databases: "hemangiopericytoma and intramedullary," "hemangiopericytoma and spine (spinal) and intradural," and "hemangiopericytoma and spinal cord." The articles were reviewed for patients' demographics features, imaging characteristics, tumor-specific factors (surgical technique, pathological descriptions, and world health organization grades), and postoperative course and prognosis (adjuvant therapies, recurrences, complications, and mortalities). RESULTS: A total of seven patients (three male and four female) was reached, with their ages ranging from 15 to 80 years (mean, 32.5 years). The tumors were located majorly in thoracic region (5/7, 71.4%), and only two cases were in the cervical region (2/7, 28.6%). All tumors were completely removed, and only two cases received radiotherapy. No recurrence was reported. CONCLUSIONS: Complete resection of the intramedullary HPCs seems to be the best management strategy for long-term and recurrence-free survival and in alleviating further need for radiotherapy.

A Rare Intradural Extramedullary Calcifying Pseudoneoplasm of the Spine Presenting with Radiculopathy.

Aims: Calcifying pseudoneoplasms of the neuroaxis (CPN) are rare, poorly understood lesions of the central nervous system that pose a diagnostic challenge because they mimic the more common calcified lesions of the neuroaxis. We highlight the relevant clinical presentation as well as radiological and histopathological features unique to intraspinal CPNs. Presentation of Case: We present the case of a 44-year-old Hispanic male with lumbar radiculopathy, radiological features of an indolent, intradural extramedullary mass, and a histopathological evaluation consistent with CPN. The patient underwent successful surgical resection and remained neurologically intact at long-term follow-up. Discussion: Epidural CPNs have been described in the literature. However, intradural CPNs are exceedingly rare lesions, and as a result, are not routinely included in the differential diagnosis of calcified, intraspinal lesions. Although there are currently no consensus guidelines for the diagnosis and management of intraspinal CPNs, understanding the clinical presentation and radiological features of these lesions is crucial for spine surgeons and neurosurgeons because surgical resection may offer a cure. Conclusion: Calcifying pseudoneoplasms may present as intradural abnormalities that mimic more prevalent lesions such as meningiomas. Surgical resection should be considered as first-line treatment because it is associated with low morbidity and may be potentially curative.