Surgical options in thoracic disc herniation: Evaluating long-term outcomes of 21 cases based on a single-center 10-year experience.

Background: Symptomatic thoracic disc herniation (TDH) is a rare pathology that is addressed with relatively challenging surgical approaches, the choice and technical execution of which have been well described in the literature. Interestingly, long-term outcomes, including surgical site pain-related disability, the need for instrumentation, and commonly occurring complications such as cerebrospinal fluid (CSF)-pleural fistula have not been widely addressed. Here, we address the complication profiles and long-term outcomes of different surgical approaches for TDH. Methods: We conducted a retrospective review of 21 consecutive patients who underwent surgery for TDH between 2000 and 2010. We assessed post-operative complications such as CSF-pleural fistulas, as well as long-term outcomes using Frankel grades, the EQ-5D-3L, and the Visual Analog Scale. We also looked at the need for instrumentation postoperatively. Results: 21 consecutive patients (13 females, 8 males) with a mean age of 55.3 years (Standard deviation 8.1) underwent thoracic discectomy for symptomatic TDH. Surgical approaches included posterolateral thoracotomy (52%, n = 11), costotransversectomy (43%, n = 9), and transpedicular (5%, n = 1). Herniations were classified as soft (38%, n = 8), calcified (38%, n = 8), or calcified-transdural (24%, n = 5). Postoperatively, all patients with calcifiedtransdural herniations undergoing posterolateral thoracotomy (100%, n = 5) developed CSF-pleural fistulas, which resolved spontaneously without the need for surgical re-exploration. 89% (n = 16) of patients exhibited sustained improvement in Frankel scores. Persistent wound site pain was reported by 50% (n = 7) of patients. Conclusion: Despite favorable neurological outcomes, patients with symptomatic TDHs can experience long-term surgical site pain, and therefore, a move toward minimally invasive exposure in such cases should be considered. Postoperative complications such as CSF-pleural fistulas are unlikely to require surgical intervention and thus can be managed conservatively.

Performance of Computed Tomography-Guided Spine Biopsy for the Diagnosis of Malignancy and Infection.

BACKGROUND: Computed tomography (CT)-guided percutaneous biopsies are used to guide treatment in vertebral osteomyelitis and spinal malignancy, but the efficacy of this study remains unclear. OBJECTIVE: To investigate the performance of CT-guided spinal biopsy, and factors that may influence its success. METHODS: Retrospective study of all consecutive patients who underwent a CT-guided spine biopsy at a UK teaching hospital between April 2012 and February 2019. Biopsies were performed by 3 consultant neuroradiologists for a lesion suggestive of either malignancy or infection. Data collection included patient factors, biopsy factors, further investigations required, and diagnosis. Data were analyzed using contingency tables, analysis of variance, unpaired t-test, chi-squared test, and Fisher's exact test. RESULTS: A total of 124 percutaneous biopsies were performed on 109 patients with a mean follow-up of 34.5 mo (range 4-86 mo) and a mean age of 66 yr (range 27-93). Approximately 32.3% (n = 40) of the biopsies investigated possible infection, and 67.7% investigated malignancy. The sensitivity for infected cases was 37.0%, and for malignancy 72.7%. The diagnostic accuracy was 57.5% and 78.6%, respectively. Complication rate was 1.6%. In our study, neither needle gauge, anatomic level of the biopsy, or bone quality significantly affected the rate of positive biopsy. CONCLUSION: Both in our study and in the wider literature, CT-guided biopsy has a vastly superior sensitivity for malignancy compared with suspected infection. These procedures may be painful, poorly tolerated, and are not entirely risk free. As such we advocate judicious use of this modality particularly in cases of suspected infection.

Complex spinal fixation of a cervical vertebra Brown tumour: report of an unusual case.

Brown tumours affecting the cervical spine are a rare but recognised complication of renal failure-related secondary hyperparathyroidism. We present a case of a 26 year-old female with radiculopathy who was managed successfully with 360° cervical spine fixation and parathyroidectomy.

Swelling and enhancement of the cervical spinal cord: when is a tumour not a tumour?

OBJECTIVE: To describe the management of patients with co-existing cervical spondylotic compression and enhancing intramedullary swelling of uncertain aetiology. We describe the key features, suggest a management plan and review the literature. MATERIAL AND METHODS: A short series of six cases with cervical myelopathy and radiological features of spondylotic compression, swollen cervical cord and intramedullary enhancement is described. Detailed descriptions of clinical features, radiological findings, surgical approaches and outcomes are discussed. All patients underwent cervical decompression via an anterior approach, posterior approach or both. Despite initial concerns that the aetiology might be tumour, no biopsy of cervical cord was required in any of the cases. RESULTS: Symptoms improved in four cases whilst contrast enhancement only improved in two cases following decompression. One patient who failed to improve postoperatively was found to have neurosarcoidosis. No patient became worse after the cervical decompression. CONCLUSION: Swelling of the spinal cord with enhancement and co-existing spondylotic cord compression, in the first instance, should be treated by decompression only. Biopsy to diagnose intrinsic tumour or inflammatory conditions should not be performed unless there is radiological or clinical progression despite adequate decompression.

Paravertebral cervical chordoma--a case report.

Chordomas constitute <5% of vertebral column tumours and a third of these arise in the upper cervical spine and tend to be clival - usually midline, with occasional eccentric extension. We report a case of cervical chordoma presenting as a lateral neck mass and discuss its origin, diagnosis and management.

Giant extradural sacral meningioma.

We present the first case of primary benign fibrous meningioma restricted to the sacrum with no sign of recurrence after a long follow-up duration. This occurred in a 36-year-old man who initially presented with a 3-month history of right-sided sciatica. The tumour was successfully resected after three surgical procedures due to its high vascularity and technical difficulties. Sacroiliac joint stability was not disrupted, and he is still doing well clinically at 8 years follow-up.

Intradural calcifying fibroblastic proliferation associated with a nerve root: a reactive process mimicking a nerve sheath tumor.

STUDY DESIGN: Case Report. OBJECTIVE: To share our experience about the unique histological appearances of a calcified intradural, extramedullary lesion involving a nerve root. SUMMARY OF BACKGROUND DATA: A 53-year-old man presented with a long history of low back pain and a few months of occasional left groin pain with no neurological deficit. Imaging of the spine revealed a calcified intradural extramedullary lesion at L1, separate from vertebrae. Intraoperatively, the lesion was found to involve closely one of the roots and was heavily calcified but relatively easy to excise. The histology revealed calcifying fibroblastic proliferation associated with a nerve root. This is an unusual pathological entity, which appears distinct from the rare but occasionally reported reactive process known, as heterotopic bone formation in a nerve or "neuritis ossificans," and it is important to distinguish it from other calcified intradural neoplasms. METHODS: The histology of an excised calcified intradural extramedullary lesion was initially reviewed by our local neuropathologist. A second opinion was requested from Prof. Malcolm, who is a histopathologist and bone specialist. The unique histological features of the lesion were confirmed. The literature (no date limitations) was reviewed. RESULTS: A calcified intradural extramedullary lesion, closely related to nerve root was found to have unique histological features, not reported in the literature so far. CONCLUSION: The histological features of the calcified lesion that we report here have not been described before. It is highly likely they represent a reactive process. We think these features are useful to be added to the differential diagnosis of a calcified intradural extramedullary lesion involving a nerve root.

Delayed fibrotic obliteration of the spinal subarachnoid space after cerebral aneurysmal subarachnoid hemorrhage: case report.

OBJECTIVE: Widespread fibrotic obliteration of the spinal subarachnoid space after cerebral aneurysmal subarachnoid hemorrhage (SAH) is rare. CLINICAL PRESENTATION: A 57-year-old woman presented with the gradual development of a spastic paraparesis. Two years earlier, she experienced a cerebral aneurysmal SAH that was successfully managed with endovascular coiling. However, the SAH was complicated by transient aseptic meningitis and hydrocephalus. Magnetic resonance imaging and computed tomographic myelography at the time of admission 2 years after SAH revealed widespread cystic obliteration of the thoracic subarachnoid space. INTERVENTION: Through an extensive laminoplasty, multiple non-communicating fibrotic cysts, intimately adherent to the pia, were found to have obliterated the spinal subarachnoid space. A full communication between all cysts and the subarachnoid space was ultimately established using a Fogarty catheter. The cerebrospinal fluid was clear and colorless, with normal microscopy. Histopathological examination revealed non-specific fibrosis with scattered lymphocytes and uniform hemosiderosis. CONCLUSION: In addition to precipitating leptomeningeal fibrosis within the convexity subarachnoid space and/or arachnoid granulations (causing delayed hydrocephalus), cerebral aneurysmal SAH may also rarely elicit widespread symptomatic fibrotic obliteration of the spinal subarachnoid space. Such cases seem to be characterized by a posterior circulation, Fisher Grade 3 to 4, aneurysmal SAH, and, when circumscribed and cystic, seem amenable to surgical decompression.

Lumbar extradural arteriovenous malformation: case report and literature review.

BACKGROUND CONTEXT: Most spinal arteriovenous malformations (AVMs) are dural arteriovenous fistulas in which a singularly intradural venous drainage emanates from an extradural nidus. A pure extradural spinal arteriovenous malformation (E-AVM), in the absence of a vertebral body (cavernous) hemangioma, is extremely rare, and full clinical, radiological, and operative descriptions are scant. PURPOSE: To fully document the rare occurrence of a symptomatic E-AVM producing spinal claudication. STUDY DESIGN: Case report. PATIENT SAMPLE: One patient. OUTCOME MEASURES: Radiological and functional. METHODS: This 62-year-old man presented with 6-month progressive spinal claudication, leg weakness, and diminished sensation. Electromyography revealed bilateral acute and chronic partial degeneration of L3-S1 nerve roots. Magnetic resonance imaging revealed moderate canal stenosis between L2-L4, with prominent epidural veins on the left at L3-L4. Spinal angiography was unsuccessful, and computed tomographic myelography merely confirmed minimal lumbosacral root filling. At decompressive L2-L4 laminectomy, inadvertent hemorrhage from varicose epidural veins released arterialized blood under considerable pressure. Only minor clinical improvement was noted after this procedure. Spinal angiography 6 weeks later subsequently confirmed an E-AVM on the left at L3-L4 which was successfully embolized. RESULTS: Follow-up at 8 weeks after this procedure confirmed significantly increased walking distance, improved distal sensation, and normal power in both legs, with insignificant claudication. CONCLUSIONS: When associated with canal stenosis, E-AVMs may exacerbate claudication by both compressive and venous-hypertensive mechanisms. Treatment should be by embolization, with laminectomy deferred.

Benign fibrous histiocytoma of the thoracic spine: case report and review of the literature.

Benign fibrous histiocytoma (BFH) is a rare skeletal tumor, accounting for approximately 1% of all surgically managed benign bone tumors. Spinal location is very rare, and its management can be challenging, involving excision of tumor and spinal reconstruction and stabilization. The prognosis is good after treatment. The authors present the case of BFH involving the thoracic spine and a review of the literature concerning BFH of the spine.

Acute obstructive hydrocephalus associated with infratentorial subdural hygromas complicating Chiari malformation Type I decompression. Report of two cases and literature review.

Obstructive hydrocephalus complicating foramen magnum decompression (FMD) for a Chiari malformation (CM) Type I is rare. Two female patients (17 and 55 years old) presented with strain-related headaches. In both cases magnetic resonance (MR) imaging studies confirmed a CM Type I, which was accompanied by syringomyelia in one case. Both patients underwent uncomplicated FMD with good initial recovery. Unfortunately, conditions in both patients deteriorated, with severe headaches occurring between Days 5 and 6 post-FMD. Decreased consciousness occurred in one case. In both patients, computerized tomography scanning demonstrated an acute obstructive hydrocephalus associated with bilateral infratentorial extraaxial fluid collections (EAFCs). In addition, left parafalcine and convexity EAFCs were present in one case. An emergency external ventricular drain was required in one patient, with delayed conversion to a ventriculo-peritoneal shunt. Spontaneous resolution occurred in the other patient without neurosurgical intervention. In both cases, MR imaging confirmed that each EAFC was subdural, resembled cerebrospinal fluid (CSF), and had distorted the superior cerebellum anteroinferiorly. Despite upper fourth ventricle/aqueduct compromise in one case, normal aqueduct flow artifacts were apparent on examination. All EAFCs resolved spontaneously. Obstructive hydrocephalus complicating FMD is rare but invariably associated with infratentorial EAFCs, which were confirmed to be subdural hygromas in this report. The authors assert that hydrocephalus results from upper fourth ventricle/aqueduct compromise as a result of CSF subdural dissection following a pinhole arachnoid tear on durotomy. Because such hygromas spontaneously resolve, permanent shunt insertion should be avoided.

"Disc cysts" and "posterior longitudinal ligament ganglion cysts": synonymous entities? Report of three cases and literature review.

OBJECTIVE AND IMPORTANCE: Extradural cysts intimately associated with relatively normal lumbar discs have rarely been reported. Histologically nonspecific, most have been designated posterior longitudinal ligament (PLL) or annulus fibrosus (AF) "ganglion cysts." Recently, "disc cysts" have been distinguished as a separate entity, mostly on the grounds of cyst-disc communication. CLINICAL PRESENTATION: Three young male patients presented with unilateral sciatica. In all cases, magnetic resonance imaging demonstrated rounded, cystic lesions (i.e., hypointense on T1- but hyperintense on T2-weighted scans) adjacent to minimally dehydrated, nonherniated disc spaces. INTERVENTION: At surgery, each cyst was found intimately related to either the AF (Case 3) or the PLL (Cases 1 and 2) of the adjacent disc; and direct disc-space communication was evident in Case 3. After cystectomy, with or without discectomy, all patients achieved complete and long-lasting resolution of their sciatic symptoms. Histological appearances were typical of ganglion cysts in all three cases, with evidence of prior hemorrhage in Cases 1 and 3. CONCLUSION: Our results and those of others suggest that all such cysts are ganglion cysts that derive from either the AF or the PLL at the disc level. Although disc cysts might be AF ganglion cysts exhibiting disc communication, their separate distinction is probably unnecessary. Cystectomy alone affords complete symptomatic remission; discectomy is usually unnecessary. Although anticipated with ganglia in general, neither spontaneous resolution nor postoperative recurrences have been witnessed. Unlike ganglia in general or juxtafacet ganglion cysts, such cysts seem to be unusually restricted to young men.

Change in CT radiodensity of a colloid cyst of the third ventricle: case report and literature review.

A unique case is presented of a decrease in density on CT scans of a colloid cyst of the third ventricle with time. This occurred in the absence of any operative intervention in a 35-year-old woman.

Rare presentations of delayed radiation injury: a lobar hematoma and a cystic space-occupying lesion appearing more than 15 years after cranial radiotherapy: report of two cases.

OBJECTIVE AND IMPORTANCE: Radiation vasculopathy and radionecrosis, constituting delayed radiation injury, are rare but recognized complications of radiation therapy occurring at a peak incidence of 3 years after treatment. Little information is available about these complications occurring more than 15 years after radiotherapy and presenting as other than solid intracranial masses. CLINICAL PRESENTATION: We describe two patients who presented with space-occupying cerebral lesions. Patient 1 presented as an emergency with a sudden loss of consciousness. Computed tomography revealed a large left intracerebral hemorrhage; cerebral angiography disclosed nothing abnormal, and a primary spontaneous hemorrhage was presumed. Twenty-seven years earlier, this patient had received adjuvant whole-brain and spine radiotherapy and concomitant chemotherapy after excision of a vermis medulloblastoma. Patient 2 presented with a left frontal cystic lesion (presumed malignant glioma) as the cause of personality and behavioral changes for some months. She had previously received external beam radiation for a basal cell epithelioma, which had been excised from her left forehead 19 years earlier. INTERVENTION: Both patients recovered well after undergoing craniotomies and removal of their lesions; they were discharged home with no neurological deficit. CONCLUSION: Even after long intervals after radiotherapy, it is important to consider radiation vasculopathy and radionecrosis as differential diagnoses of more common conditions. Histological confirmation of a delayed radiation injury in the absence of any evidence of neoplasia or vascular abnormality has allowed appropriate prognosis and management to be formulated with confidence in each of these patients.

The dysmorphic cervical spine in Klippel-Feil syndrome: interpretations from developmental biology.

The authors conducted a study to identify radiological patterns of Klippel-Feil syndrome (KFS), and they present a new interpretation of the origin of these patterns based on recent advances in understanding of embryonic development of the spine and its molecular genetic control. The authors studied radiographs and computerized tomography (CT) scans as well as magnetic resonance images or CT myelograms obtained in 30 patients with KFS who were referred for treatment between 1982 and 1996; the patients had complained of various neuroorthopedic complications. Homeotic transformation due to mutations or disturbed expression of Hox genes is a possible mechanism responsible for C-1 assimilation, which was found to have occurred in 19 cases (63%). Notochordal defects and/or signaling problems, which result in reduced or impaired Pax-1 gene expression, may underlie vertebral fusions. This, together with asymmetrical distribution of paraxial mesoderm cells and a possible lack of communication across the embryonic midline, could cause asymmetrical fusion patterns, which were present in 17 cases (57%). The wide and flattened shape of the fused vertebral bodies and their resemblance to the embryonic cartilaginous vertebrae as well as the process of progressive bone fusion with age suggest that the fusions occur before or, at the latest, during chondrification of vertebrae. The authors suggest that the aforementioned mechanisms are likely to be, at least in part, responsible for the observed patterns in KFS that affect the craniovertebral junction and the cervical spine.