Ewing's Sarcoma of the Thoracic Spine Associated with Paraplegia: Report of 1 case

Since Ewing has reported a primary malignant tumor as medullary origin in 1921, the Ewing's sarcomas have been reported more than 1,000 cases in the literatures. The Ewing's sarcoma has frequent incidence in the long tubular bone but very rare in the skull and spine for primary malignant tumor of the bone. The incidence of the Ewing's sarcoma in the spine is very rare than in the skull. We experienced a case of Ewing's sarcoma of the thoracic spine which has associated a paraplegia as neurological deficit. A 24 years old Korean female has admitted to our clinical because of paraplegia with incontinence for 2 days. On admission, the neurological examination revealed a paraparesis below T3 level with urinary and fecal incontinence, and then local tenderness on T2 level. No fever and leucocystosis were checked. Only the ESR has elevated up to 38 mm/hr. The simple X-ray film of the thoracic spine has showed a mottled destruction of the T2 vertebral body and abscence of the pedicle shadow, which were more similar to the picture of malignant tumor(primary or metastatic) than the bony change of ostemyelitis. We performed a myelography by pantopaque through the lumbar and cisternal puncture for accurate site of lesion. We found a complete block at T2 level by myelography. Then the immediate total laminectomy on T2-3 was applied. The operative finding was a extradural mass, which has compressed the spinal cord. We removed the tumor mass incompletely but the decompression was enough. The neurologic deficit has improved gradually for post-operative 2 weeks, but the improvement of neurologic deficit has stopped to T10 sensory recovery. We performed a radiation therapy as 4500 rads dose for 4 weeks, but not further improvement has been found. The post-operative pathological diagnosis was Ewing's sarcoma as a anaplastic small cell type.

Intradural Extramedullary Tuberculoma of the Spinal Cord: Report of 1 Case

Tuberculoma of the spinal cord is one of rare lesions and usually produced by secondary lesion of tuberculosis. The first tuberculoma of spinal cord was described in 1830 by E.R.A. Serre and the first operative removal was performed in 1909 by Krauss and Mcguire. The most common age of tuberculoma is younger age group, especially under 30 years old and male is more frequent. The clinical symptom is rapid course and symptomatic Traid are motor, sensory, and sphincter disturbance, but early involvement is shpincter dist urbance. The authors present a case of intradural extramedullary tuberculoma of the spinal cord which was located at the thoracic region. The 63 years old female patient has complained the upper back pain and paraplegia by spontaneous onset before 3 days. On admission, paraplegia, urinary incontinence and weakness of anal sphincter were found. There were revealed within normal limit on simple flims of chest and thoracic spine. The color of the C.S.F. was xanthochromic, the amount of the protein was increased, and Quecken sted test was not patent. The contrast media was obliterated at the lower margin of 8th thoracic level and upper margin of 10th thoracic level, on myelogram by puncture of cisterna magna and lumbar region. We performed total laminectomy from T8 to T10 and removed a ID EM tuberculoma. We found white yellowish extramedullary tumor at the right postebrane. The extramedullary tumor was intermingling with dorsal nerve root on T9. The right dentate ligament and dorsal nerve root were cut and tumor was completely removed. Macroscopically the gross feature were 1.5 by 2 cm in size, white-yellowish color, hard and irregular round shape. The microscopic finding were showing multifocal granulomas with caseous necrosis. The granuloma was composed of epitheloid cells, lymphocytes and Langhans' giant cell. Post-operative recovery was very satisfactory.

Atlantal Fracture and Dislocation with Transverse Ligament Rupture Associated with Quadriplegia

Since Jafferson has reported the atlantal fracture in 1920, and its mechanism and type of fracture in detail, a few authers have reported the cases in their literature because the atlantal fractures are one of rare case in cervical injuries. The clinical signs are sparse indeed after acute transection or contusion of medulla. One survived has had a minimal neurologic deficit on account of wide vertebral canal for the cervical cord. The patient has complained the occipital headache and limited motion of neck commonly, without any neurological disturbance. The cervical tracton has been applied for the case usually. Recently, we experienced a case of atlantal fracture with occipito-atlantal dislocation and atlanto-axial dislocation, associated-with quadriplegia for 2.5 years progressively after cervical injury. On simple films of lateral view of cervical spine, it revealed a separated posterior arch was anteriorly dislocated and impacted into the vertebral canal, and anterior arch was markedly displaced anteriorly and had a bony union with the axis in angulated form. The odontoid process of axis is upward translocation. No fracture was found in open mouth view for the axis. The occipito-atlantal and atlanto-axial dislocation were found. On myelogram, the contrast media was almost obliterated in the false occipito-axial joint level by the compression of the fragmented posterior arch of atlas. On vertebral angiogram, it revealed a reverse curve of 3rd. portion of vertebral artery, representing the anterior arch of atlas included the arch retracted the vertebral artery anteriorly. We performed the suboccipital craniectomy and lanimectomy on the atlas for removal of posterior arch of atlas without any spine fusion, Because of the dislocated atlanto-axial joint had a bony union alreadly. The post-operative recovery was very rapid and satisfactory.

A Case of Post-traumatic Leptomeningeal Cyst

The post-traumatic leptomeningeal cyst, so-called growing fracture, is one of the complication of the skull fracture in childhood especially under the 3 years old, but very rare in the adult. Since Taveras and Ranschoff proposed the mechanism for production of the expanding fracture post-traumatically in 1953, many authers have explained the mechanism clinically and experimentally. Now we proposed a additional mechanism for producing the brain herniation into the expanding fracture as a case of post-traumatic leptomeningeal cyst reported. A 25 years old male patient was admitted to the department of Neurosurgery, Seoul Red Cross Hospital, because of headache, convulsion, and growing the mass with skull defect. The patient has had a history of skull fracture at the age of 2 years old. The simple skull films revealed a scalloped and saucerized margin of skull defect on left parietal bone. On electroencephalogram, we found a moderated abnormalities in the left parietal area. The left carotid angiogram showed a stretching of middle cerebral artery and elevation of left Sylvian point. The small capillary branches of middle cerebral artery has pushed out through the skull defect, which indented brain herniation into the skull defect. No cystic picture was found. We operated this case with the dura repair and grafting, and then cranioplasty with resion. On operative finding, we found that one edge on torn dura has impacted into the opposite edge of fractured skull tightly, which suggested the pulling up the dura and brain into the skull defect by growing rate of the skull bone. By the craniectomy for the bone, impacted dura, was free from the impacted bone and the above continued procedure had completely successful . The post-operative course was very satisfactory. According to the operative finding, the skull fracture with dural tearing are essential factors in producing the post-traumatic leptomeningeal cyst in infancy(usually under the 3 years old). When the one edge of torn dura is impacted into the edge of same side of fractured bone, or was left free, it will produce the simple leptomeningeal cyst during the improportional growing the skull bone and brain. On the other hand, when one edge of torn dura is impacted into the opposite edge of fracture bone, the growing parietal bone pulled up the encircled brain into the skull defect aperture gradually, which produced the brain herniation, a type of post-traumatic leptomeningeal cyst. We reported a case of the post-traumatic leptomeningeal cyst in adult very rarely, and proposed a mechanism for producing a brain herniation into skull defect, a type of post-traumatic leptomeningeal cyst.

The Clinical Observation on the Acute Epidural Hematoma

Acute epidural hematoma is the one which neurosurgeons encounter commonly in severe head injuries and needs emergency operation. But the fact that the mortality of it is still very high(20-50%), is disheartening to all neurosurgeons. In my country, the acute epidural hematoma has been recognized and treated since the 1950th by neurosurgeons. Nevertheless, the report of the collected acute epidural hematoma is rarely seen. The reason is felt that the illness is quite common around us but the mortality is so high to make the report be delayed. The authors have treated 60 cases of surgically confirmed acute epidural hematoma during 24 months from April 1969 to March 1971 and have observed clinically. Following are the results: 1) Sex incidence showed male(50), female(10), and age incidence ranged 2 years of age to 60 yrs. But it was most common in 2nd decade to 4th decade. 2) Most common mode of injury was traffic accident(33 cases) and there were 15 cases of falling down accident and 12 cases of direct batting over the head by blunt materials. 3) There were lucid interval in 13 cases. Most common papillary change was ipsilateral mydriasis(23 cases). Bilateral mydriasis were in 4 cases & other showed miotic or normal pupils. Bilateral positive Babinski's sign were noted in 22 cases and there were 14 cases of unilateral Babinski's sign. 4) Site of hematoma;Most common site of the hematoma was temporoparietal region but there were 8 cases of confined frontal pole and 3 cases of posterior fossa region. In 42 cases of 60, the site of hematoma was confirmed by carotid angiography & on the rest, direct surgery was performed without carotid angiography. 5) Mortality; 47 cases of 60, have survived. The age, level of consciousness, other intracranial associated injuries, time of operation, bilateral positive Babinski's sign, volume of hematoma were felt to be the influencing factors to mortality. In 5 cases of 13 which expired, have died 4 weeks after surgery and the causes of death were pulmonary edema, pneumonia, septicemia, tracheal bleeding & renal shut down. In survivals, hemiplegia, hydrocephalus, oculomotor nerve palsy and mental confusion were observed which improved gradually except 4 cases, & 43 cases of 60 which have survived could remain to return to his usual daily activity.