Surgical management of cerebellopontine angle epidermoid cysts: an institutional experience of 10 years.

BACKGROUND: Cerebellopontine angle (CPA) epidermoids, although of benign nature, are of considerable neurosurgical interest because of their close proximity and adherence to the cranial nerves and brain stem. In this paper, we describe our experience and attempt to correlate the final outcomes with the extent of surgical removal. The main objectives were to study various modes of surgical management of CPA epidermoids with regard to removal and preservation of the cranial nerves and also to evaluate the role of endoscopic assisted microsurgical excision thereby minimizing recurrences. This case series is one of the largest series reported so far worldwide. MATERIALS AND METHODS: From 2006 to 2016, 139 patients with CPA epidermoids were operated at Grant Medical College and J. J. Hospital, Mumbai. All patients underwent detailed magnetic resonance imaging (MRI) of brain. Lesions were classified according Rogelio Revuelta-Gutiérrez et al. with respect to their anatomic extent: grade I- within the boundaries of the CPA, grade II- extension to the suprasellar and perimesencephalic cisterns, and grade III-parasellar and temporomesial region involvement. Retrosigmoidal and sub temporal approaches were taken to excise the lesions. Endoscopic assisted microsurgical excision was done in cases with extensions beyond the CPA. Patient follow-up was based on outpatient repeated brain MRI studies. RESULTS: The mean duration of symptoms before surgery was 42 months (range, 2 months to 6 years). The mean follow-up period was 27 months (range, 2-60 months). The main presenting sympt om was headache in 69% (96/139) of the cases and trigeminal neuralgia in 30% cases was the second most common cause of consultation. Seventy-five percent of patients had some degree of cranial nerve (CN) involvement. Retrosigmoid approach was taken in 92% patients and 7 patients with supratentorial extension were operated by combined retrosigmoidal and subtemporal approach. Endoscopic assisted microsurgical excision was done in 40% cases. Use of angled views by an endoscope helped to excise residual tumor in 47 (83%) patients. Complete excision was achieved in 67% of cases. In 33% patients, small capsular remnants could not be removed completely because of their adherence to vessels, brainstem and cranial nerves. Compared with their preoperative clinical status, 74% improved and 20% had persistent cranial nerve deficits in the first year of follow up. CONCLUSIONS: Epidermoid cysts are challenging entities in current neurosurgery practice due to tumor adhesions to neurovascular structures. Meticulous surgical technique with the aid of neurophysiological monitoring is crucial to achieve safe and effective total or subtotal removal of these lesions. A conservative approach is indicated for patients in whom the fragments of capsule is adhered closely to blood vessels, nerves, or the brainstem, in order to avoid risk of serious neurological deficits related to an inadvertent damage of these structures. Use of angled views by endoscope at the conclusion of the surgery may assure the surgeon of total removal of the tumor.

Ruptured Conus Medullaris Dermoid Cyst with Fat Droplets in the Central

Spinal dermoid tumors are rare, benign, slow growing tumors. These tumors may become acutely symptomatic after rupture or infection. Excision of the lesion with long term close follow-up studies is required for the management of these lesions. We present a very rare case of ruptured conus medullaris dermoid cyst in a 22-year-old male presented with urinary retention and low back pain. Magnetic resonance imaging scan with contrast reveals a lesion in the cauda equina inseparable from conus medullaris with fat droplets within the central spinal canal extending up to the medulla. Patient was operated with laminectomy and near complete excision of the lesion was done. Patient's low back pain was relieved following surgery. However patient had persistent urinary incontinence and on clean intermittent self-catheterization. Histopathology was suggestive of dermoid cyst.

Erratum: Correction of Title. Ruptured Conus Medullaris Dermoid Cyst with Fat Droplets in the Central Canal

This article on Asian Spine Journal was initially published without the word 'Canal' in the title.

Functional Paraganglioma: A Rare Conus-cauda Lesion.

Conus-cauda syndrome is caused due to involvement of the lower end of the spinal cord and arising bunch of nerve roots. It is caused commonly due to traumatic injury, spinal stenosis, spinal tumors, inflammatory, and infectious conditions, but paraganglioma is a rare cause. These tumors are rarely functional and secrete catecholamine. Till now only five case reports of functional spinal paragangliomas are available to the best of our knowledge. We report a 50-year-old hypertensive male patient with a lobulated lesion extending from lower border of D12 to L2, which was reported as ependymoma on imaging studies done preoperatively. This lesion was confirmed to be a functional paraganglioma postoperatively after the patient died because of its furious complication, thus highlighting the importance of its preoperative diagnosis and management. In conclusion conus-cauda functional paragangliomas are very rare entity. Diagnosing them in preoperative condition is critical from the therapeutic point of view, both medical and surgical. During surgery these tumors should be handled very gently to avoid spillage of catecholamines into blood. These tumors require assistance of expert anesthetist and endocrinologist in the perioperative period.

Primary Lumbo-sacral Spinal Epidural Non-Hodgkin's Lymphoma: A Case Report and Review of Literature

We present a case of 24-year-old male presented with low back pain radiating to the left lower limb, tingling numbness and weakness of 6 months duration. Magnetic resonance imaging scan with contrast reveals an extradural mass at lumbosacral region. Patient was operated with laminectomy and complete excision of the lesion was done. Patient's radicular pain relieved following the surgery and weakness also improved. Histopathology was suggestive of non-Hodgkin's lymphoma. Patient received chemotherapy which was followed by radiotherapy. Primary Non-Hodgkin's lymphoma of the lumbosacral spinal epidural tissue is an uncommon lesion. Lymphoma involves the central nervous system in 5-11% of cases either at presentation of the disease or during its course. The spinal epidural tissue is involved primarily in 0.1-3.3% of cases with spinal cord compression being the commonest presentation. Excision of the lesion followed by chemotherapy and radiotherapy is required to achieve cure.