Tratamiento quirúrgico de las metástasis espinales epidurales / Surgical Treatment for Epidural Spine Metastasis

Introducción:Los tumores metastásicos son los más comunes de la columna vertebral.Objetivo:Evaluar los resultados quirúrgicos de pacientes con metástasis espinales epidurales, según dolor pre-y posoperatorio, estado neurológico e índice de discapacidad.Métodos: Estudio descriptivo de tipo longitudinal retrospectivo en una muestra de 34 pacientes de 20 o más años de edad ‒universo conformado por 62 pacientes‒con metástasis espinal, atendidos en el hospital "Hermanos Ameijeiras" entre enero 2016-marzo 2018 y operados con técnica de descompresión por corpectomía y fijación de columna. Se comprobóla intensidad del dolor mediante la escala Denis;el estado neurológico mediante la escala de Frankel y el porcentaje de discapacidad a través de la escala Oswestry. Se aplicaron pruebas de significación estadística. La investigación cumplió con los principios de la Declaración de Helsinski.Resultados:predominaron los pacientes de 40 a 59 años (64,7 por ciento) y sexo masculino (67,6 por ciento). El tumor primario más frecuente fue el hematopoyético (41,2 por ciento), con afectación del segmento torácico (57,9 por ciento). La técnica criolla, la más empleada con el 44,1 por ciento. En el preoperatorio la mayoría se encontraban en Denis III, con Frankel D y 66,2 por ciento de discapacidad. En la evaluación posoperatoria la mayoría se encontraban en un Denis entre 0 y 1, Frankel E con conservación del estado neurológico y 31,4 por ciento de incapacidad (p= 0,000). Conclusiones:El tratamiento quirúrgico de los pacientes con metástasis vertebral por medio de instrumentación y descompresión tiene beneficios clínicos, sobre todo, la mejora del dolor y de la función neurológica(AU)

Introduction: Metastatic tumors are the most frequent in the spine. Objective: To evaluate surgical results in patients with epidural spine metastatic tumors, according to pain before and after surgery, their neurological status, and disability index. Methods: This is a retrospective longitudinal descriptive study in a sample of 34 patients older than 20 years- longitudinal descriptive study in a sample of 34 patients aged 20 or over from a universe made up of 62 patients. They had spinal metastases, they were treated at Hermanos Ameijeiras hospital from January 2016 to March 2018. They underwent surgery with a decompression technique by corpectomy and spinal fixation. Pain intensity was verified using Denis scale; neurological status using Frankel scale and the percentage of disability using Oswestry scale. Statistical significance tests were applied. The investigation complied with the principles of Declaration of Helsinki. Results: Patients aged 40 to 59 years (64.7percent) and male (67.6 percent) predominated. The most frequent primary tumor was hematopoietic (41.2 percent), with involvement of the thoracic segment (57.9 percent). The Cuban technique was the most used (44.1 percent). During the preoperative period, the majority were in Denis III, with Frankel D and 66.2 percent were disabled. At the postoperative evaluation, the majority were in Denis between 0 and 1, Frankel E with preservation of neurological status and 31.4 percent of disability (p= 0.000). Conclusions: Surgical treatment of patients with vertebral metastases by means of instrumentation and decompression has clinical benefits, above all, the improvement of pain and neurological function(AU)

A Thoracolumbar Pure Spinal Epidural Cavernous Hemangioma: A Case Report / 대한척추외과학회지

STUDY DESIGN: Case report. OBJECTIVES: We report a case of pure epidural cavernous hemangioma located at the thoracolumbar spine in a 53-year-old woman that mimicked a neurogenic tumor on magnetic resonance imaging (MRI). SUMMARY OF LITERATURE REVIEW: A pure spinal epidural cavernous hemangioma without bony involvement is a very rare lesion about which limited information is available in the literature. MATERIALS AND METHODS: A 53-year-old woman visited our clinic for hypoesthesia with a tingling sensation in the left anterolateral thigh that had begun a month ago. No other neurologic symptoms or signs were present upon a neurologic examination. MRI from an outside hospital showed a 2.0×0.5 cm elongated mass at the T11-12 left neural foramen. The tumor was completely removed in piecemeal fashion. RESULTS: The histopathologic examination revealed a cavernous hemangioma, which was the final diagnosis. The outcome was favorable in that only operation-related mild back pain remained, without any neurologic deficits, after a postoperative follow-up of 2 years and 3 months. No recurrence was observed on MRI at 2 years postoperatively. CONCLUSION: Pure epidural spinal cavernous hemangioma is very rare, and it is very difficult to differentiate from other epidural lesions. However, we believe that it should be included in the differential diagnosis of spinal epidural tumors due to its favorable prognosis.

Sarcoma de Ewing extraóseo en espacio epidural / Extraosseous Ewing's sarcoma in spinal epidural space

El sarcoma extraóseo de Ewing pertenece a la familia de tumores neuroectodérmicos que derivan de la cresta neural, característico por su agresividad. Varias localizaciones se han descrito, sin embargo, la presentación epidural es rara. El pronóstico ha mejorado por nuevos esquemas oncológicos y están en estudio otras dianas terapéuticas.

Extraosseous Ewing's sarcoma belongs to the family of neuroectodermal tumors that derive from the neural crest, characteristic of its aggressiveness. Several locations have been described, however,epidural presentation is rare. Prognosis has been improved by new oncological regimens and other therapeutic targets are being studied.

Survival score scales of patients operated with spinal metastases: retrospective application in a Brazilian population / Escalas de prognóstico em pacientes operados com metástases vertebrais: aplicação retrospectiva em população brasileira

ABSTRACT Spinal cord epidural metastasis (SEM) is a common complication of systemic cancer. Predicting these patient’s survival is a key factor to select the proper treatment modality, but the three most used score scales to predict their survival (Tokuhashi revised score, Tomita score and Bauer modified score) were designed in single institutions and their reliability to predict correctly the patient’s survival were first tested only in those specific populations. This prognostication issue is addressed in this article, evaluating retrospectively the survival of 17 patients with SEM from a Brazilian general hospital with these score scales. Our results show that the actual survival of those patients were worse than the predicted of all three score scales, suggesting that differences between the different populations might have affected their reliability and alert that their usage as a major factor to select the most appropriate treatment have to be done with caution.

RESUMO Metástases vertebrais são uma complicação comum em pacientes com câncer sistêmico. Avaliar o prognóstico e a sobrevida desses pacientes é um fator de grande importância para escolher o tratamento mais adequado, porém as três escalas mais usadas atualmente para prever a sobrevida deles (Tokuhashi revisada, Tomita e Bauer modificada) foram desenhadas em instituições isoladas, e sua habilidade em estimar corretamente a sobrevida desses pacientes foram testadas primeiramente apenas nessas populações específicas. Essa questão de estimar o prognóstico é abordada nesse artigo, analisando retrospectivamente a sobrevida de 17 pacientes com metástase vertebral provenientes de um hospital geral no Brasil com essas escalas. Nossos resultados apontam que a sobrevida real desses pacientes foi menor que a prevista pelas três escalas, sugerindo que as diferenças entres as diferentes populações podem ter afetado a aplicabilidade delas. Assim, alertamos que o uso dessas escalas em populações diferentes das estudadas originalmente deve ser feito com cuidado.

Epidural Capillary Hemangioma of the Thoracic Spine / Hemangioma capilar extradural da coluna torácica

Background Hemangiomas are congenital vascular malformations pathologically considered as harmatomas and classified as capillary, cavernous, arteriovenous or venous, and usually located at soft tissue or bone, mainly in the spinal column. Pure epidural capillary hemangiomas are extremely rare lesions that should be included in the differential diagnosis of spinal epidural lesions; only three patients with epidural capillary hemangiomas have been reported to date. Case Report We report a case of a 57-year-oldman that complained of dorsal and back pain. The neurological examination revealed back tenderness and crural paraparesis. His reflexes were exaggeratedand Babinski signwaspresenton both sides.Amagnetic resonance imaging showed an epidural lesion at the level of T10­12 that demonstrated extension with intense postgadolinium enhancement. These lesions were different from more common lesions, mainly schwanommas, mainly due to the foraminal extension, which sets them apart from cavernous hemangiomas. The surgical ressection was performed. After laminectomy, a reddish epiduralmass that extended intothe right T11­12 foraminawas revealed. Thefeeding vessels had to be identified and divided. In such cases, the surgeonmust carefully dissect the lesion circumferentially away from the dura and employ judicious hemostasis. The patient́s histopathological examination revealed a vascular tumor composed of vessels of several calibers. The imagery obtained from the exams led to the diagnosis of a capillary hemangioma. Conclusions Pure epidural capillary hemangiomas should be included in the differential diagnosis of spinal epidural lesions, mainly schwanommas, especially due to the foraminal extension, which may differentiates them from cavernous hemangiomas. Surgical excision is mandatory and intervertebral foraminal extension may preclude gross total resection.

Introdução Os hemangiomas são malformações vasculares congênitas patologicamente consideradas como hamartomas. Podem ser classificadas como capilar, cavernoso, arteriovenoso ou venoso, e são geralmente localizadas em tecidos moles ou ossos, principalmente na coluna vertebral. Hemangioma capilar epidural puro é uma lesão extremamente rara que deve ser incluída no diagnóstico diferencial das lesões espinais epidurais, foram relatados casos de apenas três pacientes com hemangiomas capilares epidurais. Relato de Caso Relatamos o caso de um homem de 57 anos de idade com queixa de dorsalgia. Ao exame neurológico, paraparesia crural, com hiperreflexia e sinal de Babinski bilateral. A ressonância magnética mostrou uma lesão epidural no nível de T10­12 com intenso realce pós-gadolíneo. Hemangioma capilar deve ser diferenciado de lesões mais comuns, principalmente schwannomas, devido à extensão foraminal. A ressecção cirúrgica foi realizada. Um processo expansivo epidural avermelhado, se estendendo para o forâmen direito de T11­12, tornou-se evidente após a laminectomia. Os vasos que o irrigavam foram identificados e adequadamente separados. A lesão foi cuidadosamente dissecada circunferencialmente e uma hemostasia criteriosa foi realizada. O exame histopatológico revelou um tumor vascular composto por vasos de vários calibres. Exames de imagem corroboraram com a hipótese de um hemangioma capilar. Conclusões Hemangiomas capilares epidurais puros devem ser incluídos no diagnóstico diferencial das lesões da coluna vertebral epidural, principalmente schwanommas, especialmente devido à extensão foraminal. A excisão cirúrgica é obrigatória e a extensão para o forame intervertebral pode impossibilitar a ressecção total.

Thoracic Epidural Cavernous Hemangioma / 대한정형외과학회잡지

A 31-year-old male presented with severe back pain and paraparesis. Imaging studies demonstrated an extraosseous, extradural mass without bone invasion at the T11-T12 vertebral level, located dorsal to the thecal sac. The spinal cord was compressed ventrally. The lesion was completely excised after a T11-T12 laminectomy. Histopathological examination revealed a cavernous hemangioma. The patient's symptoms improved after excision of the lesion.

A Rare Case of Malignant Lymphoma Occurred at Spinal Epidural Space: A Case Report

The sacral spinal epidural space is an uncommon site for primary malignant lymphomas, presenting with symptoms associated with cauda equina compression. Especially, lumbo-sacral epidural lymphoma has been reported to be very rare. We present a rare case of 29-year-old male with sacral spinal epidural malignant lymphoma. The patient complained of tingling sensation in his buttocks that was radiating to his calf. The neurological examination was normal. Magnetic resonance imaging (MRI) with contrast showed a well-defined extradural mass lesion at the mid L5 to mid S2 level. The lesion was iso- to hypointense on T1 and T2 weighted images and showed homogenous enhancement and a focal enhancement in the L5 vertebral body on post-contrast images. The patient underwent a L5-S2 laminectomy and subtotal excision of the lesion. Intra-operatively, the lesion was extradural and not densely adherent to the dura; the lesion was friable, not firm, fleshy, brownish and hypervascular. The histologic diagnosis was grade 2 non-Hodgkin's follicular lymphoma. Even though the primary spinal epidural non-Hodgkin's lymphoma is a very rare disease, clinicians should take it into consideration in the differential diagnosis of patients with spinal epidural tumor.

Pure Spinal Epidural Cavernous Hemangioma with Intralesional Hemorrhage: A Rare Cause of Thoracic Myelopathy

Although cavernous hemangiomas occur frequently in the intracranial structures, they are rare in the spine. Most of spinal hemangiomas are vertebral origin and "pure" epidural hemangiomas not originating from the vertebral bone are very rare. Our spinal hemangioma case is extremely rare because of its "pure" epidural involvement and intralesional hemorrhage. A 64-year-old man presented with progressive paraparesis from two months ago. His motor weakness was rated as grade 4/5 in bilateral lower extremities. He also complained of decreased sensation below the T4 sensory dermatome, which continuously progressed to the higher dermatome level. Magnetic resonance imaging demonstrated thoracic spinal tumor at T3-T4 level. The tumor was located epidural space compressing thoracic spinal cord ventrally. The tumor was not involved with the thoracic vertebral bone. We performed T3-5 laminectomy and removed the tumor completely. The tumor was not infiltrating into intradural space or vertebral bone. The histopathologic study confirmed the epidural tumor as cavernous hemangioma. Postoperatively, his weakness improved gradually. Four months later, his paraparesis recovered completely. Here, we present a case of pure spinal epidural cavernous hemangioma, which has intralesional hemorrhage. We believe cavernous hemangioma should be included in the differential diagnosis of the spinal epidural tumors.

Epidural Gas-containing Pseudocyst in Lumbar Spine: A Case Report

STUDY DESIGN: Case report. OBJECTIVES: We report two cases regarding epidural air pseudocyst at the lumbar spine. SUMMARY OF LITERATURE REVIEW: Epidural air pseudocyst at the lumbar spine that provokes radiating pain and neurologic symptoms can be misdiagnosed as an epidural tumor or HIVD. Consequently, proper diagnosis and treatment of the epidural air pseudocyst at the lumbar spine is necessary. MATERIALS AND METHODS: We report on two patients with radiculopathy and neurologic symptoms resulting from epidural air pseudocysts. In one patient, the epidural air pseudocyst was found within the epidural ligament flavum area on an MRI, and fluoroscopic-guided FNA (fine needle aspiration) was performed. In the other, the epidural air pseudocyst was found behind the posterior longitudinal ligament and was accompanied by spinal stenosis. In this patient, we conducted open cystectomy and posterior decompression surgery. Results: After treatment, all patients have showed symptom improvement and they are currently living without discomfort. RESULTS: After treatment, all patients have showed symptom improvement and they are currently living without discomfort. CONCLUSIONS: Due to frequent misdiagnosis, the careful diagnosis of lumbar epidural air pseudocyst is necessary. Physicians should select a proper treatment plan concerning the patient's condition and the location of the lesion.

MRI Features of Spinal Epidural Angiolipomas

OBJECTIVE: To describe the MRI findings in ten patients of spinal epidural angiolipoma for differentiated diagnosis presurgery. MATERIALS AND METHODS: Ten surgically proved cases of spinal epidural angiolipomas were retrospectively reviewed, and the lesion was classified according to the MR findings. RESULTS: Ten tumors were located in the superior (n = 4), middle (n = 2), or inferior (n = 4) thoracic level. The mass, with the spindle shape, was located in the posterior epidural space and extended parallel to the long axis of the spine. All lesions contained a fat and vascular element. The vascular content, correlating with the presence of hypointense regions on T1-weighted imaging (T1WI) and hyperintense signals on T2-weighted imaging, had marked enhancement. However, there were no flow void signs on MR images. All tumors were divided into two types based on the MR features. In type 1 (n = 3), the mass was predominantly composed of lipomatous tissue (> 50%) and contained only a few small angiomatous regions, which had a trabeculated or mottled appear. In type 2 (n = 7), the mass, however, was predominantly composed of vascular components (> 50%), which presented as large foci in the center of the mass. CONCLUSION: Most spinal epidural angiolipomas exhibit hyperintensity on T1WI while the hypointense region on the noncontrast T1WI indicates to be vascular, which manifests an obvious enhancement with gadolinium administration.

Thoracic spinal epidural mixed capillary-cavernous haemangioma: case report and review of literature

We describe a case of a patient with a thoracic spinal mixed capillary/ cavernous haemangioma, who was operated for decompression. The literature regarding spinal haemangiomas is reviewed and the symptomatotogy, neuro-radiotogy, pathology, management and prognosis of these lesions are discussed. The need to include cavernomas in the differential diagnosis of various spinal conditions is emphasized

Epidural angiopomatosis of the thoracic spine: Case report and literature review

Spinal epidural angiolipomatosis [SEA] is a rare benign neoplasm of adipose tissue with a prominent vascular component. Classified as either idiopathic or secondary to chronic steroid therapy it accounts for 0.14% of all spinal axis tumours. The clinical and radiological features and treatment of a case in a 24-year-old male are described and discussed together with a review of the literature and previous reports

Diretrizes no tratamento das metástases epidurais da coluna vertebral: atualização / Guidelines for treatment of epidural spinal metastases

Objetivo: Atualizar conceitos e recomendar condutas da prática médica nos aspectos de prognóstico,diagnóstico e tratamento das metástases epidurais da coluna vertebral. Método: O período de apuração das publicações situou-se entre janeiro de 1990 a janeiro de 2006, incluídas as referências relevantes prévias. A ausência de evidências de valor científico para determinar padrões ou diretrizes de conduta em temas médicos que geram incertezas da prática, permite usar do termo diretrizes para todas as recomendações. Resultados: A modalidade de tratamento a ser escolhido depende da análise dos fatores preditivos de prognóstico, tais como: o estado clínico do doente; a possibilidade de resgatar ou manter a capacidade de deambulação; grau de disseminação e transmissão da neoplasia primária.As informações obtidas com o diagnóstico de imagem da ressonância magnética efetuada em toda a extensão da coluna vertebral e o complemento das imagens ósseas pertinentes da tomografia axial computadorizada são necessárias na escolha e implementação do tratamento escolhido. O tratamento cirúrgico inclui a descompressão circunferencial da medula espinhal, a reconstrução do corpo vertebral e a estabilização segmentar da coluna vertebral. Conclusões: As recomendações conferem eficácia e eficiência nas condutas médicas. O prognóstico depende dos fatores preditivos de sobrevivência.Os exames complementares de imagem auxiliam no estadiamento e planejamento do tratamento.A modalidade de tratamento escolhida depende da previsão de sobrevivência e da capacidade de deambulação do doente.

Objective: Bring up-to-date concepts and conduct practice parameters recomendations concerningaspects in prognosis, diagnosis and treatment of spinal epidural metastases. Method: Pertinent publications between January, 1990 and January, 2006, including previous relevant medical articles were reviewed. The absence of scientific value for evidence to determine conduct standards or guidelines in uncertain medical practice allows to use as guideline all recomendations. Results: The choice of a treatment modality depends on predictive prognosis factors, such as: patient’s clinical state; preservation or salvage of walking capabilty; primary cancer spreading and transmission grade. Diagnostic information obtained by magnetic ressonance imaging of the spinal column complemented by pertinent computorized axial tomography bone images are necessary to choose and implement the treatment modality. Surgical treatment includes: circumferential spinal cord decompression; vertebral body reconstruction; segmental vertebral column stabilization. Conclusions: Recommendations bestow efficacy and efficiency of medical conducts. Complementary imaging studies are useful to determine the treatment, staging and planning. Treatment modality to be chosen depends on the patients’ survival expectancy and their capability to walk.

Pure Epidural Cavernous Hemangioma of the Cervical Spine that Presented with an Acute Sensory Deficit Caused by Hemorrhage

Pure epidural cavernous hemangioma of the spine without vertebral involvement is rare. Due to the slow growth of this lesion, the most common symptoms are chronic pain, myelopathy, and radiculopathy. In our case, the patient complained of an acute onset sensory deficit of the C4 dermatome. An MRI revealed an epidural mass with an acute hematoma. Here, we report a case of a pure epidural cavernous hemangioma that presented with acute neurologic symptoms caused by intralesional hemorrhage and an acute epidural hematoma, which were demonstrated on the patient's MRI.

Pure Epidural Cavernous Hemangioma of the Cervical Spine that Presented with an Acute Sensory Deficit Caused by Hemorrhage

Pure epidural cavernous hemangioma of the spine without vertebral involvement is rare. Due to the slow growth of this lesion, the most common symptoms are chronic pain, myelopathy, and radiculopathy. In our case, the patient complained of an acute onset sensory deficit of the C4 dermatome. An MRI revealed an epidural mass with an acute hematoma. Here, we report a case of a pure epidural cavernous hemangioma that presented with acute neurologic symptoms caused by intralesional hemorrhage and an acute epidural hematoma, which were demonstrated on the patient's MRI.

Primary epidural malignant hemangiopericytoma of thoracic spinal column causing cord compression: case report

CONTEXTO: Hemangiopericitoma é uma neoplasia mensequimal incomum que raramente afeta o canal espinhal. O hemangiopericitoma maligno primário da coluna vertebral é extremamente raro. RELATO DE CASO: Relatamos um caso de hemangiopericitoma maligno epidural primário da coluna vertebral torácica que invade o osso vertebral, causando a compressão do cordão espinhal em um homem de 21 anos. O paciente apresentou-se com dor progressiva nas costas durante quatro meses, que progrediu para paraparesia, parestesia bilateral do pé e incontinência urinária. A intervenção cirúrgica com laminectomia e ressecção do tumor e fixação posterior foi executada. A radioterapia pós-operatória no campo envolvido foi realizada. Marcante melhoria neurológica foi observada subseqüentemente. Descrevemos as características clínicas, radiológicas, e histológicas deste tumor e revemos a literatura.

Primary Epidural Meningioma in Adolescence

Meningioma arises from the arachnoid cap cell found in the arachnoid layer of the meninges. Most meningiomas are located in the subdural space. Meningiomas are mostly found in adulthood between 20 and 60 years of age. A case of intracranial epidural meningioma without involvement of the subdural space is reported.

Extraskeletal Ewing Sarcoma of Cervical Epidural Region: Cases Report

Extraskeletal Ewing sarcoma is a rare malignant tumor found in children and young adults. It commonly occurs in deep soft tissue of the trunk, especially in the paravertebral region and extremities. We report two cases of extraskeletal Ewing sarcoma occurring as a cervical epidural tumor in elderly patients. The MRI and CT findings showed that paravertebral epidural tumors had invaded the spinal canal through the intervertebral foramen. At T1-weighted MR imaging, the masses were isointense to muscle, and at T2* and T2-weighted images were hyperintense, and heterogeneous contrast enhancement was observed. Extraskeletal Ewing sarcoma, though quite rare, should be borne in mind in the differential diagnosis of paraspinal epidural tumors.

Epidural Meningioma of the Upper Thoracic Spine in a Child: Case Report

Meningioma is the second most common primary intraspinal tumor. Most spinal meningiomas are located in the intradural extramedullary space and extradural meningiomas are less common. It is quite rare for this tumor to be found in the spinal epidural space of a child. These tumors may be easily confused as a malignant neoplasm because a metastatic lesion commonly located in the epidural space. We report a case of spinal epidural meningioma in a 12-year-old girl. Magnetic resonance findings led to the preoperative diagnosis of a metastatic lesion. The patient underwent total resection of the mass lesion and laminoplasty. She showed an excellent neurological recovery.