Bilateral epidural D-wave monitoring during resection of an eccentric cervical astrocytoma with evidence of asymmetrical corticospinal desynchronization.

BACKGROUND AND IMPORTANCE: The surgical management of intramedullary spinal cord tumours (IMSCT) poses inherent risk to neurologic function. Direct-wave (D-wave) monitoring is routinely reported to be a robust prognostic measure of spinal cord function via midline recording within the epidural or intradural space in a cranial-caudal montage. We explored the feasibility of bilateral epidural D-wave monitoring with routine evoked potentials in promoting safe and maximal resection in a patient with diminished midline D-wave baselines associated with an eccentric intramedullary cervical astrocytoma. CLINICAL PRESENTATION: We describe the presentation, surgical management, electrophysiological findings and post-operative outcome of a 46 year-old female patient who underwent two resections for an eccentric intramedullary cervical astrocytoma. During the first procedure we encountered clinically significant motor evoked potential signal change and discontinuation of resection pending further review. Midline D-wave signals showed no change, however peak amplitude was diminutive (7 uV) and overall morphology was characteristic of corticospinal desynchronization. Post-operatively the patient experienced significant but transient left sided weakness. A subsequent revision procedure incorporating ipsilesional and contralesional D-wave monitoring in addition to routinely incorporated evoked potentials was proposed in order to facilitate a safer resection. The ipsilesional D-wave response was considerably lower in amplitude (2.5 uV) in contrast to the contralesional D-wave (20 uV). CONCLUSION: To the authors' knowledge this is the first description of bilateral D-wave monitoring as an adjunct to cranial-caudal D-wave montages during IMSCT surgery. In patients with corticospinal desynchronization evidenced by abnormal midline D-wave morphology, bilateral D-wave monitoring in conjunction with routine evoked potentials may be clinically indicated for preservation of motor function and promotion of safe and maximal resection.

Cord Herniation through the Site of Undiagnosed Thoracic Dermoid Tumour during Spinal Anaesthesia; Report of a Case and Describing Ways to Avoid.

Spinal anaesthesia (SA) is one of the most prevalent types of anaesthetic procedures. There are very few reports of cord herniation through the site of spinal canal stenosis due to tumour. A 33-year-old female presented with acute paraparesis after spinal anaesthesia for caesarean section. Magnetic resonance imaging (MRI) revealed an intradural mass from posterior of T6 to T8-T9 interface. We operated the patient and after laminectomy of T6 to T9, dermoid tumour containing hairs was totally resected and cord was completely decompressed. After 6 months, the patient is without any neurological deficit. Puncturing the dura with cerebrospinal fluid (CSF) in the presence of an extramedullary mass could cause cord herniation through the blockade. In these cases, awareness about related signs even in absence of symptoms or complaints could help us to prevent post-SA neurological deficit.

Intramedullary spinal cord and filum tumours-long-term outcome: single institution case series.

BACKGROUND: Intramedullary spinal cord tumours are rare and account for about 2-4% of primary CNS tumours. Ependymomas and astrocytomas are most frequent. The aim of this study was to evaluate the long-term neurological outcome, quality of life (QoL), survival, need for additional treatment and frequency of neuropathic pain in a patient group treated at a tertiary university hospital. METHOD: Retrospective descriptive study of 52 long-term survivors with intramedullary or filum tumours consenting to participate in this study. Fifty-six operations were performed in 48 patients. Clinical and radiological follow-up period was 113 and 117 months, respectively. RESULTS: Good neurological outcome (ASIA score D or E, modified McCormick grade 1 or 2) was achieved in 88%. We found two negative prognostic factors in regards of severe disability which were large craniocaudal tumour size (p = 0.004) and histologic verified astrocytomas (p = 0.002). SF-36 results showed significantly lower results on all five subdomains concerning physical function, whereas scores for mental health and role emotional showed no significant differences compared to Norwegian norms. Ten patients including all astrocytoma patients, one primitive neuroectodermal tumour and three recurrent tumours of filum terminale had adjuvant therapy. None of the patients with intramedullary ependymoma had adjuvant therapy. Neuropathic pain was present in 54% of patients at the last follow-up. CONCLUSION: This series shows that good results can be obtained with surgery for intramedullary tumours, even without perioperative neurophysiological monitoring. Multicentre studies are needed for further evaluation of negative and positive prognostic factors to further improve outcome.

Iatrogenic post-surgical tension pneumosyrinx-a first reported case.

We describe the first ever-reported occurrence of a post-operative tension pneumosyrinx occurring after a resection of an intradural intramedullary spinal tumour in a 40-year-old patient. Post-operatively, he developed sudden onset paraplegia and imaging revealed a tension pneumosyrinx which was subsequently surgically decompressed. He made a gradual neurological recovery. This is an extremely rare complication with potentially long-lasting deleterious effects on patients' neurological status if not recognized. We aim to bring this pathology to the attention of our neurosurgical colleagues and share our surgical approach and management to assist those who may encounter this pathology in the future.

Thoracic Extraosseous Epidural Venous Haemangioma Arising From Nerve Root in a Nasopharyngeal Carcinoma Survivor: A Case Report.

A 66-year-old man presented to the outpatient clinic with back pain and progressive bilateral lower limb weakness over a period of 6 months. Magnetic resonance imaging showed a large extraosseous epidural lesion at T6-T7 arising from the left T6 spinal nerve root complicated with cord compression leading to cord oedema. The lesion was excised en bloc and histopathological examination revealed benign venous haemangioma. We report this rare case of venous epidural haemangioma to be considered as a differential diagnosis in a patient with a background of previous lumbar discectomy surgery and who was a nasopharyngeal carcinoma survivor.

Use of ultrasonic aspirator for CNS tumour resection.

Ultrasonic aspirator (UA), or the Cavitron Ultrasonic Aspirator (CUSA) as it is commonly referred to, utilizes ultrasonic waves of variable range of frequencies to disintegrate and excise tumours. It is developed as a substitute of bipolar diathermy; a tool commonly employed for coagulation that uses focussed electric current and may damage tissues by virtue of contact, or by the heat that it produces. Over the last 30 years, CUSA has become increasingly popular in several soft tissue surgeries, especially brain and spine tumour resection, as it allows reduction in the use of bipolar diathermy. It is assumed that CUSA improves both surgical safety and clinical outcomes, and also reduces surgical time. Herein the authors have reviewed the available literature on the advantages of CUSA.

Surgical outcomes of intramedullary spinal cord ependymomas.

Intramedullary Spinal Cord Ependymomas (ISCE) are uncommon pathologies that need to be aggressively managed before clinical deterioration sets in. Novel application of different therapeutic strategies is being assessed for improving long-term outcomes in patients presenting with these rare neoplasms. In this review, we have discussed the existing literature on ISCEs, and the role of surgery in determining outcomes in terms of neurological status, progression-free survival (PFS) and overall survival (OS).

Tuberculoma of spine mimicking intramedullary tumour: A case report.

INTRODUCTION: Spinal intramedullary tuberculoma (IMTB) is a rare disease that accounts for 1 to 2/100,000 patients with tuberculosis [1]. This case demonstrated that this patient had atypical presentations compared to common tuberculosis considering that IMTB cases are really rare. CASE PRESENTATION: A 19-year-old male presenting with back pain and weakness of both lower limbs, which started in the left lower limb and subsequently involved the right lower limb for three months. He had sensory impairment below T6 and hypoesthesia. He complained of urine hesitancy and a feeling of incomplete voiding of urine. He was on anti-tubercular treatment (ATT) for last two months. MRI exhibited hypointense portion on T1-weighted images. T2-weighted image also showed hypointensity at T6, which suggested for intramedullary mass. Excisional biopsy was suggestive for tuberculoma. DISCUSSION: In TB-endemic country like in Indonesia, tuberculoma should be considered as a differential diagnosis for intramedullary SOL irrespective of age or presence of extra-cranial focus of TB. MRI is the optimal tool for evaluating and diagnosing IMTB at an early stage and useful in follow-up. However, IMTB imaging characteristics may vary with immune response of individual or the stage of the tuberculoma formation [3]. The aim of early surgery is to decompress the spinal cord and achieve improvement in neurological function. CONCLUSION: This case was reported to emphasize that early surgical decompression is required as a delay might cause damage to the spinal cord. This case also provides some evidences based data, thus contributing to the future research studies and clinical practice.

A rare case of thoracic spinal intradural extramedullary enterogenous cyst with acute onset: case report and literature review.

The intraspinal enterogenous cyst, also called an neurenteric cyst, is a rare congenital disease. It was reported to be local to the C1 to L2 spinal segments, with the majority located in the cervicothoracic region. Most patients present with symptoms of progressive focal pain, myelopathic signs or radicular symptoms. We report a rare case of thoracic spinal intradural extramedullary enterogenous cyst with rapidly progressive weakness of both lower extremities. Additionally, we analysed the literature concerning the clinical features, diagnosis and prognosis of this disease.

Intramedullary spinal cord metastasis from thyroid carcinoma: Case report and a systematic pooled analysis of the literature.

Intramedullary spinal cord metastasis (ISCM) is rare and occurs most commonly in the setting of advanced malignancy. The optimal management pathways are not well defined and treatment outcomes from contemporary therapies remain variable. We report a case of a 49-year-old woman with known primary papillary thyroid carcinoma, who presented with rapidly progressive clinical features of Brown-Sequard syndrome. A detailed pooled analysis of the literature was conducted to characterise the clinical and demographic features, management options, and expected survival outcomes for cases of ISCM. We secondarily performed a subgroup analysis on the incidence, clinical and management characteristics of thyroid carcinoma ISCM.

[Primary intramedullary melanoma: Case report and literature review]. / Melanoma primario intramedular: reporte de caso y revisión de la literatura.

A dark pigmented intramedullary mass is very rarely encountered in daily practice, and poses a diagnostic challenge. Several entities have to be considered, including melanin-containing tumours (melanotic ependymoma and melanotic schwannoma) and melanocyte-containing tumours (melanocytoma, primary melanoma and melanoma metastases). The case is presented of a 47 year-old male with a pigmented intramedullary tumour located at T7-T8 level. Magnetic resonance images (MRI) revealed a tumour with hyperintensity on T1 and hypointensity on T2. The tumour was resected partially and treated with adjuvant radiotherapy. The diagnosis of primary intramedullary melanoma (PIM) was established based on histology and the absence of other lesions outside of the CNS. A literature review is presented on the other 26 PIM cases reported. PIM are extremely rare tumours, but are the most frequent cause of pigmented intramedullary tumour. Complete surgical resection is the treatment of choice whenever possible, followed by radiotherapy.

Clinical presentation and surgical outcomes of an intramedullary C2 spinal cord cavernoma: a case report and review of the relevant literature.

BACKGROUND: The spinal cord intramedullary cavernoma (SCIC) is a rare form of hemangioma that typically behaves as a space-occupying lesion resulting in neurological symptoms, including bladder and bowel dysfunction. To date, there have been few reports characterizing the clinical presentations and surgical outcomes of cavernomas at the C2 spinal level or the potential for resolution of bladder and bowel symptoms postoperatively. This case details the clinical course of a patient with a C2 cavernoma with an atypical neurological presentation and rapid improvement in both bladder and bowel function postoperatively. This case reviews the relevant literature and describes the patient's clinical presentation, radiological and pathological findings and post-surgical progress. METHODS: A 56-year-old male presented with sensory changes in his right hand, which rapidly progressed over ensuing weeks to bilateral sensory changes in the upper and lower limbs, gait imbalance, urinary and faecal incontinence and loss of temperature perception. He subsequently developed significant weakness in the upper limbs. A MRI identified a hematoma in the cervical cord at the C2 level. Given his rapid neurological decline and the social and clinical implications of his bladder and bowel instability, a surgical approach to therapy was adopted. RESULTS: Postoperatively, there was steady improvement in motor and sensory function and a complete return of bladder and bowel function. CONCLUSIONS: Intramedullary spinal cord cavernomas, although rare, can cause significant neurological deficits and morbidity. Surgical excision can provide significant benefits, including restoration of bladder and bowel function.

Solitary sclerosis: Progressive neurological deficit from a spatially isolated demyelinating lesion: A further report.

CONTEXT: Progressive myelopathy can be a manifestation of a variety of disorders including progressive multiple sclerosis. However it is extremely uncommon for a single lesion to cause a progressive myelopathy in MS. Such a myelopathy, i.e. a progressive neurological deficit from a solitary demyelinating lesion, not fulfilling the International diagnostic criteria for MS or Neuromyelitis Optica was first reported in 2012 and termed 'solitary sclerosis'. METHOD: We report 3 further cases of progressive myelopathy fulfilling the diagnostic criteria for solitary sclerosis. FINDINGS: Two patients had a single demyelinating lesion in the cervical cord and the third patient had it in the brain stem. All patients had serial MRI scans showing no dissemination or progression of lesions. Extensive diagnostic tests including aquaporin 4 antibodies were negative in all. At last follow-up at a median of 3.8 years, all patients continued to clinically progress despite immunosuppressive treatment. CONCLUSION/CLINICAL RELEVANCE: Solitary demyelinating lesions can cause a progressive myelopathy without clinical or radiological evidence of dissemination. Importantly, clinicians, both surgical and medical should be aware of such a diagnosis, to avoid invasive and often harmful tests particularly biopsies.

Solitary fibrous tumour with intramedullary component: case report and review of the literature.

Solitary fibrous tumours (SFTs) are rare WHO grade I mesenchymal neoplasms that were first described in the visceral pleura. A wide variety of locations of SFT have been reported but only twelve cases of intramedullary solitary fibrous tumour. We report a case of thoracic spinal cord SFT. A 49-year-old woman presented with clinical signs of dorsal myelopathy. Magnetic resonance imaging revealed an intradural mass at level T9-T10 which showed imaging features consistent both for an intra- and an extramedullary location of a solid tumour. Imaging findings were confirmed during surgery which was successful in resecting the extramedullary component. The intramedullary component could only be partially resected. Solitary fibrous tumour is a rare pathological entity in the central nervous system. The course of intramedullary SFT is unknown and careful long-term follow-up is recommended.

Myxopapillary ependymoma as a cause of back pain in a young male - A case report.

OBJECTIVE: Primary spinal cord tumours are rare causes of low back pain but can be a significant cause of morbidity if undiagnosed and untreated. The following is a case of a young male patient presenting with low back pain and radicular symptoms caused by myxopapillary ependymoma. CLINICAL FEATURES: A nineteen year old male presented to an orthopaedic surgeon with a long history of back pain. He was initially diagnosed with soft tissue injuries and discharged. He began to experience erectile and bowel dysfunction two years later and was re-referred to the orthopaedic surgeon by his family physician but was lost to follow-up. The patient did not present to the surgeon until two years after his symptom profile changed. At that point, MRI examinations revealed a large myxopapillary ependymoma extending from T12 to L4 that was confirmed by a pathologist. INTERVENTION AND OUTCOME: The tumour was surgically resected with subsequent adjuvant radiotherapy. After one year, the patient required continued catheterization and had poor anal tone. His back and leg complaints were almost normal. Follow-up MRI examinations revealed no disease progression or new spinal lesions at 4 years after the initial diagnosis. CONCLUSION: The clinical presentation of primary spinal cord tumours is non-specific and can easily be missed. In cases of chronic back pain, signs and symptoms should be regularly monitored for changes indicative of progressive neurological compromise such as sensory, motor and bowel/bladder dysfunction. If there is deterioration of clinical signs and symptoms, a spinal tumour should be considered in the list of differential diagnoses. Delayed diagnosis and treatment of these rare causes of back pain could lead to poor outcomes; therefore, a referral to a surgeon should be done immediately with proper follow up to ensure continuity of care.

OBJECTIF: Les tumeurs primaires de la moelle épinière sont des causes rares de lombalgies, mais peuvent être une importante cause de morbidité si elles sont pas diagnostiquées ni traitées. Le cas suivant concerne un jeune homme qui présente une lombalgie et des symptômes radiculaires causés par un épendymome myxopapillaire. CARACTÉRISTIQUES CLINIQUES: Un homme de dix-neuf ans s'est présenté chez un chirurgien orthopédique avec de longs antécédents de douleur dorsale. Il lui a d'abord diagnostiqué des blessures des tissus mous et il a été libéré par la suite. Deux ans après, il a commencé à souffrir de dysfonctionnement érectile et intestinal et a été renvoyé vers le chirurgien orthopédique par le médecin de famille mais a été perdu au suivi. Le patient s'est présenté au chirurgien deux ans après que son profil de symptôme a changé. À ce moment-là, les examens par IRM ont révélés un épendymome myxopapillaire se prolongeant de T12 à L4, confirmé par un pathologiste. INTERVENTION ET RÉSULTAT: La tumeur a été prélevée chirurgicalement à l'aide d'une radiothérapie adjuvante subséquente. Après un an, le patient avait besoin d'un cathétérisme continu et présentait un tonus anal faible Il ne se plaignait presque plus de douleurs au dos et aux jambes. Les examens de suivi par IRM n'ont pas révélé de progression de la maladie ou de nouvelles lésions de la moelle épinière, quatre ans après le diagnostic initial. CONCLUSION: La présentation clinique de tumeurs primaires de la moelle épinière n'est pas spécifique et peut facilement ne pas être repérée. Dans les cas de douleurs dorsales chroniques, les signes et symptômes devraient être contrôlés régulièrement dans le cas de changements indiquant des troubles neurologiques progressifs tels que les dysfonctionnements sensoriels, moteurs, intestinaux et érectiles. Dans le cas de dégradation des signes et symptômes cliniques, une tumeur de la moelle épinière devrait être considérée parmi les diagnostics différentiels. Un diagnostic tardif et un traitement de ces causes rares de douleur dorsale peut mener à de pauvres résultats; et un renvoi chez un chirurgien devrait par conséquent être effectué dans les plus brefs délais avec un suivi approprié pour assurer la continuité des soins.