Giant sacrolumbar meningioma. Case report.

A case of giant sacral meningioma with presacral and lumbar extension is presented. The difficulties in diagnosis and management are emphasized including the staged multidisciplinary surgical approaches and preoperative tumor embolization.

Nuclear parameters as prognostic indicators in glioblastoma patients.

The objective of this study was to determine whether nuclear parameters were associated with prognosis in glioblastoma multiforme. DNA indices, cell cycle parameters, and nuclear population densities were compared with patient survival. Selection criteria included the pathologic diagnosis of a cerebral glioblastoma multiforme, absence of therapy before surgery, and adequate tissue to measure each nuclear parameter studied. Nine cases accrued over a two year period. The amount of DNA per nucleus was quantified in fresh tissue specimens by nuclear-isolation flow cytometry in Vindelov's solution. One particular association was significant when tested by Cox models: The percentage of nuclei with S-phase amounts of nuclear DNA was a significant predictor of decreased survival (regression coefficient = 0.20, p = 0.04). The percentage of nuclei in the G0/G1 peak was marginally associated with longer survival. These data are evidence of an association between nuclei in certain phases of the DNA cell cycle and postoperative survival.

Sacral and presacral tumors: problems in diagnosis and management.

We reviewed 9 cases of sacral tumors with presacral extension. These included 2 chordomas, 1 metastatic renal cell carcinoma, 2 schwannomas (1 malignant, 1 benign), 1 neurofibroma, 1 neurofibrosarcoma, 1 aneurysmal bone cyst, and an exceedingly rare meningioma. The sex of the patients was not significant. The age of the patients at diagnosis ranged from 13 to 68 years (mean, 47 years). Initial symptoms of low back and radiating leg pain were present in all but 1 patient. The duration of symptoms prior to diagnosis ranged from 1 month to 9 years (mean, 2.6 years). A delay in diagnosis of 2 years or more occurred in 6 of the 9 patients. Progressive perineal numbness and/or sphincter dysfunction were seen in 6 patients, and a palpable rectal mass was noted in 6 of 9 patients. The efficacy of various diagnostic tests is presented, as are the surgical options--needle biopsy and anterior and posterior approaches. Despite improved radiographic imaging techniques, these unusual tumors are often diagnosed at an advanced stage, and may masquerade as discogenic radiculopathy. Late diagnosis contributes to the difficulty of surgical extirpation. Anterior and posterior surgical approaches involving general, orthopedic, and urological surgeons may be required.

Anterior cervical osteophytes as a cause of progressive dysphagia.

An uncommon cause of progressive dysphagia may be large cervical osteophytes impinging upon the cervical esophagus. Dysphagia may be due to the mechanical mass effect of a large anterior osteophyte, trapping the esophagus opposite a fixed point such as the cricoid cartilage, or a local inflammatory reaction resulting in cricopharyngeal spasm. We report three patients with progressive dysphagia due to large anterior cervical osteophytes. All three patients were treated with anterior cervical approach with removal of the osteophytes without fusion. A review of the literature in addition to the specific case histories, video fluoroscopic and radiographic findings are presented.

Atlanto-axial rotational limitation secondary to osteoid osteoma of the axis. Case report.

An unusual case of atlanto-axial rotational limitation secondary to an osteoid osteoma of the axis is presented. Transoral microsurgical resection followed by physical therapy improved the clinical symptoms. This case illustrates several unique problems within the cervical spine as well as the efficacy of the transoral approach to the axis.

The pathogenesis of spinal epidural abscess: microangiographic studies in an experimental model.

An experimental model of spinal epidural abscess was developed in rabbits by injecting Staphylococcus aureus into the posterior thoracolumbar epidural space. This model has been shown to reproduce the neurological, bacteriological, and radiological aspects of the human disease. In this study, the effect of the infectious epidural mass on the vasculature of the spinal cord in paraplegic rabbits was studied using microangiographic techniques. The normal vascular anatomy of the rabbit spinal cord was defined in control experiments. Vascular proliferation was demonstrated in the epidural space surrounding the abscesses. Anterior and paired posterior spinal arteries remained patent in paraplegic rabbits with mild or moderate spinal cord compression and in some cases of severe compression. In animals with severe compression, the anterior epidural venous plexus remained patent, but the dorsal spinal vein was occluded. Occlusion of perforating arteries occurred only with extreme spinal cord compression. These data indicate that the initial neurological deficit associated with experimental spinal epidural abscess is not due to vascular thrombosis.

Experimental spinal epidural abscess: a pathophysiological model in the rabbit.

To define the pathophysiology of spinal cord dysfunction associated with spinal epidural abscess formation, we developed an experimental model. Spinal epidural abscesses were produced in rabbits by injecting Staphylococcus aureus into the posterior thoracolumbar epidural space under direct vision. Progressive neurological deficits were detected in 18 of 20 animals; severe paraparesis or paraplegia occurred in 75%, and sphincter dysfunction occurred in 55%. Clinical data, including the results of plain spine roentgenography, myelography, and biochemical and bacteriological examination of the cerebrospinal fluid, were recorded. Epidural abscesses with varying degrees of spinal cord compression were confirmed pathologically in 95% of the experimental group. Spinal cord white matter changes included vacuolization, loss of myelin, and axonal swelling. The gray matter of the spinal cords was relatively preserved. There was no microscopic evidence of thrombosis or vasculitis in the major blood vessels supplying the spinal cords. Histopathological changes detected in the spinal cords were more consistent with direct compression of neural tissue than with infarction. The progressive clinical course and the histopathological changes in the spinal cord after compression by abscess closely resembled those of experimental compression of the spinal cord by epidural neoplasm.

Superior sagittal sinus thrombosis with infarction in sickle cell trait.

An adolescent female with sickle cell trait presented with acute neurologic deterioration during treatment for pseudotumor cerebri. Cranial computed tomography, initially normal, subsequently revealed multiple hemorrhagic infarctions. Suspected superior sagittal sinus thrombosis was confirmed by cerebral angiography. Superior sagittal sinus thrombosis associated with sickle cell trait is exceedingly rare, and the accompanying increased intracranial pressure may require aggressive management.

Selective localization of gamma-enolase in stromal cells of cerebellar hemangioblastomas.

Three cases of cerebellar hemangioblastoma were studied using the immunoperoxidase technique to localize gamma-enolase, also known as neuron-specific enolase. The stromal cells demonstrated positive staining for gamma-enolase, while endothelial cells and pericytes showed no reactivity. Two vascular lesions, an angiosarcoma and a cutaneous angioma, were studied and found to be nonreactive for gamma-enolase. All tumors were also tested for factor VIII/von Willebrand factor, glial fibrillary acidic protein, and the S-100 protein. The lack of expression of gamma-enolase in endothelial cells of hemangioblastomas demonstrates a clear antigenic distinction from neighboring gamma-enolase-positive stromal cells. The significance of this finding and its implications for stromal cell histogenesis are discussed.

Anterior cervical epidural abscess: the use of intraoperative spinal sonography.

A case of acute cervical epidural abscess is presented. The use of intraoperative spinal sonography is discussed as a valuable adjunct in the evaluation and treatment of these uncommon lesions.