Primary intramedullary melanocytoma in the thoracic cord: a case report and literature review.

Background: Primary intramedullary melanocytoma (PIM) is extremely rare, only 25 cases of PIM have been reported previously. Herein we report a case of PIM in the thoracic cord and reviewed its clinicopathological features, imaging features, therapeutic strategies and prognosis to provide helpful information in the diagnosis and treatment of PIM. Case Description: A 56-year-old man presented with weakness and numbness in both legs for several years. Contrast-enhanced magnetic resonance imaging (MRI) of the spinal cord was performed. Based on the imaging examination, cavernous malformation with subacute hematoma was considered as the initial diagnosis. However, histopathological and immunohistochemical analyses confirmed the final diagnosis of PIM in the thoracic cord after surgical resection. The patient had no signs of recurrence or metastasis during a 17-month follow-up. Conclusions: MRI is the preferred method for the evaluation of PIM. PIM is characterized by a high signal on T1WI and a low signal on T2WI. It is difficult to make the differential diagnosis from cavernous malformation with hematoma before surgery due to its rarity. However, the symptom is not sudden but gradually worsened over a relatively long period in the PIM patients, which is an important difference from the cavernous malformation with hematoma. Therefore, PIM should receive diagnostic con¬sideration for an intramedullary lesion that is high signal on T1WI and low signal on T2WI in a patient with gradually worsened symptoms rather than sudden onset. It is of great importance for neurosurgeons and radiologists to recognize the characteristics of this disease, make the correct diagnosis in time and avoid delayed treatment.

An aneurysmal bone cyst ruptured and compressed the spinal cord: a case report.

Spinal aneurysmal bone cyst (ABC) is a rare benign bone lesion with various prognosis. Common clinical symptoms of spinal ABCs include local pain, swelling. But we presented a case of a teenager girl who exhibited symptoms of acute thoracic cord compression after a slight trauma and was then diagnosed with ABC in her thoracic spine. A unique aspect is that this patient did not have symptoms before she fell down on her hip, and had an acute worsening of her neurological deficits. In the vast majority of cases, for a teenager, the trauma on the spine is tiny after falling down on the hips. That is the reason we initially felt confused before she had an urgent CT scan. In order to achieve early decompression of the thoracic cord and stabilization of the local spine around T4, we proceeded with urgent lesion resection and pedicle screws fixation from T2 to T5 to remove the liquid containing cyst and achieve spinal stability. Postoperative pathology indicated the lesion was an ABC. The patient gained good neurological recovery without any adverse effect in the final follow-up. We believe spinal ABC of teenagers can have no symptoms until a slight trauma leading to acute neurological deficits. Careful preparing for emergency surgery, prompt resection of the lesion as well as spinal stability reconstruction can promote good recovery and minimal adverse effect.

A Randomized Controlled Trial of Early versus Late Surgical Decompression for Thoracic and Thoracolumbar Spinal Cord Injury in 73 Patients.

Convincing clinical evidence exists to support early surgical decompression in the setting of cervical spinal cord injury (SCI). However, clinical evidence on the effect of early surgery in patients with thoracic and thoracolumbar (from T1 to L1 [T1-L1]) SCI is lacking and a critical knowledge gap remains. This randomized controlled trial (RCT) sought to evaluate the safety and efficacy of early (<24 h) compared with late (24-72 h) decompressive surgery after T1-L1 SCI. From 2010 to 2018, patients (≥16 years of age) with acute T1-L1 SCI presenting to a single trauma center were randomized to receive either early (<24 h) or late (24-72 h) surgical decompression. The primary outcome was an ordinal change in American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade at 12-month follow-up. Secondary outcomes included complications and change in ASIA motor score (AMS) at 12 months. Outcome assessors were blinded to treatment assignment. Of 73 individuals whose treatment followed the study protocol, 37 received early surgery and 36 underwent late surgery. The mean age was 29.74 ± 11.4 years. In the early group 45.9% of patients and in the late group 33.3% of patients had a ≥1-grade improvement in AIS (odds ratio [OR] 1.70, 95% confidence interval [CI]: 0.66-4.39, p = 0.271); significantly more patients in the early (24.3%) than late (5.6%) surgery group had a ≥2-grade improvement in AIS (OR 5.46, 95% CI: 1.09-27.38, p = 0.025). There was no statistically significant difference in the secondary outcome measures. Surgical decompression within 24 h of acute traumatic T1-L1 SCI is safe and is associated with improved neurological outcome, defined as at least a 2-grade improvement in AIS at 12 months.

A Consecutive 25-Week Program of Gait Training, Using the Alternating Hybrid Assistive Limb (HAL®) Robot and Conventional Training, and Its Effects on the Walking Ability of a Patient with Chronic Thoracic Spinal Cord Injury: A Single Case Reversal Design.

Background and Objectives: In this study, we examined the effect of a consecutive 25-week gait training program, consisting of 5-week alternating phases of Hybrid Assistive Limb (HAL)-assisted robot gait training and conventional gait training, on the walking ability of a 50-year-old man with a chronic thoracic spinal cord injury (SCI). Materials and Methods: Clinical features of this patient's paraplegia were as follows: neurological level, T7; American Spinal Cord Injury Association Impairment Scale Score, C; Lower Extremity Motor Score, 20 points; Berg Balance Scale score, 15 points; and Walking Index for Spinal Cord Injury, 6 points. The patient completed a 100 m walk, under close supervision, using a walker and bilateral ankle-foot orthoses. The intervention included two phases: phase A, conventional walking practice and physical therapy for 5 weeks, and phase B, walking using the HAL robot (3 d/week, 30 min/session), combined with conventional physical therapy, for 5 weeks. A consecutive A-B-A-B-A sequence was used, with a 5-week duration for each phase. Results: The gait training intervention increased the maximum walking speed, cadence, and 2-min walking distance, as well as the Berg Balance and Walking Index for Spinal Cord Injury from 15 to 17 and 6 to 7, respectively. Walking speed, stride length, and cadence improved after phase A (but not B). Improved standing balance was associated with measured improvements in measured gait parameters. Conclusion: The walking ability of patients with a chronic SCI may be improved, over a short period by combining gait training, using HAL-assisted and conventional gait training and physical therapy.

Novel Strategy of Ventral Dural Repair for Idiopathic Thoracic Spinal Cord Herniation: Report of Outcomes and Review of Techniques.

BACKGROUND: Idiopathic ventral thoracic spinal cord herniation is a rare condition that usually presents with progressive myelopathy or Brown-Séquard syndrome. More than 100 cases have been reported with significant variance in surgical treatment strategies and likewise, significant variance in patient outcomes. Although laminectomy has often been used, to date, there is no consensus regarding the optimal surgical approach or strategy for ventral dural repair. OBJECTIVE: To report and illustrate a novel approach to repair the ventral dural defect with more than 2 yr of clinical follow-up. The specific approach and graft used are both detailed. METHODS: A retrospective chart review of all known cases of idiopathic spinal cord herniation at the Cleveland Clinic over the last 15 yr was performed. Postoperative outcome scores (including the Japanese Orthopedic Association score, European Myelopathy score, and Nurick) were calculated preoperatively and postoperatively. RESULTS: A total of 5 patients were identified. Four of five patients improved clinically after surgery and 1 patient remained unchanged at last follow-up (average 23.2 mo, range 12-60 mo). There were no complications. All patients had postoperative magnetic resonance imaging demonstrating realignment of the spinal cord and no recurrence of tethering. CONCLUSION: A unilateral dorsolateral, transpedicular approach combined with laminectomy provides excellent exposure for ventral or ventrolateral dural defects associated with idiopathic spinal cord herniation and minimizes spinal cord manipulation. A collagen matrix graft used as an onlay between the spinal cord and ventral dural defect is a safe and effective option for ventral dural repair.

Aggressive Vertebral Hemangioma Causing Spinal Cord Compression: Presenting a Study of Two Cases and Review of Literature.

INTRODUCTION: Asymptomatic vertebral hemangiomas are common, but extension into the spinal canal causing cord compression with neurologic symptoms is rare. CASE REPORTS: Case 1:A 20-year-old male patient presented with difficulty in walking for 6 months with gradually progressive weakness of both the lower limbs. On examination, upper motor neuron signs were present in both the lower limbs with a sensory level below T8 and no bladder involvement. Magnetic resonance imaging (MRI) showed a vascular tumor arising from T6 lamina and pedicle and compressing the cord. Pre-operative computerized tomogram angiography and embolization of the tumor was done, followed by decompression, stabilization of the spine, and vertebroplasty. Postoperatively, the patient received radiotherapy. Case 2: A 71-year-old male patient presented with the recurrence of vertebral hemangioma and cord compression. He had a history of hemangioma with cord compression 13 years back, which was treated by embolization, followed by decompression and fixation. The patient had gradually improved neurologically to normal activities. He was asymptomatic till 7 months back when he noticed difficulty in walking. On examination, pyramidal signs were found to be positive. MRI revealed an expansile lesion at T7 vertebra which was causing compression of the spinal cord. Pre-operative embolization, followed by decompression, stabilization, and vertebroplasty was performed. He also received radiotherapy postoperatively. The diagnosis of benign capillary hemangioma was made after histopathological examination. Neurological recovery was almost complete in both the cases. At6-month follow-up after surgery, both the patients were able to perform all the activities of daily living. CONCLUSION: Aggressive vertebral hemangiomas causing progressive neurological deficit should be treated with surgical decompression, stabilization, and vertebroplasty. Pre-operative angiography, embolization, and post-operative low-dose radiation therapy are recommended.

Posterior surgery versus combined laminectomy and thoracoscopic surgery for treatment of dumbbell-type thoracic cord tumor: A long-term follow-up.

OBJECTIVE: The goal of this study was to compare the clinical outcomes of posterior surgery with combined laminectomy and thoracoscopic surgery for treating dumbbell-type thoracic cord tumors. PATIENTS AND METHODS: We retrospectively analyzed 32 cases of dumbbell-type thoracic cord tumors treated by two surgical procedures in our center from February 2003 to July 2013. CASES WERE DIVIDED INTO TWO GROUPS DEPENDING ON THE TYPE OF SURGERY: Group A cases (n = 12) underwent posterior surgery followed by laminectomy, costotransversectomy and instrumentation; Group B cases (n = 20) underwent posterior laminectomy and anterior video-assisted thoracoscopic surgery in a single-stage procedure. Operation time, blood loss, hospitalization, recovery of neurological function, and complications were compared between the two groups. RESULTS: Complete surgical excision was achieved in both groups. All patients were followed up for an average of 7.4 ±â€¯2.8 years (range, 3-13). At the final follow-up visit, there was no tumor recurrence and no differences in neurological results between the two groups (P > 0.05). However, the average operative duration, blood loss, hospitalization, and rate of complications were significantly lower in Group A compared to Group B (P < 0.05). CONCLUSION: Both posterior surgery and the posterior surgery combined with anterior thoracoscopic surgery were effective for removing dumbbell-type thoracic cord tumors. However, posterior surgery alone was associated with reduced operative duration and rate of complications compared to the combined surgical approach.

Surgical Exercise Intramedullary Cysticercosis in Thoracic Cord

Cysticercosis of the central nerve system seldom involves spinal structures. When it does, the parasites grow much more often in the subarachnoid space than within the cord or epidural space. Recently we have experienced a cases of intramedullary cysticercosis in thoracic cord, which was characterized by paraparesis and voiding difficulty of 1 1/2 years duration in 34-year old man, and the patient's symptoms were improved after operation. We discuss this rare condition with brief review of the literature relevant to spinal cysticercosis.

THE EFFERENT PROJECTIONS OF THE ROSTRAL VENTROLATERAL MEDULLA TO THE HYPOTHALAMIC PARAVENTRICULAR NUCLEUS AND THE THORACIC CORD IN THE CAT / 解剖学报

The efferent projections of the rostral ventrolateral medulla(RVL) to the hypothalamic paraventricular nucleus(Pa) and the thoracic cord were studied in the adult cat by using WGA-HRP or fluorescent retrograde tract-tracing method. After injection of WGA-HRP or fluorescent tracer Fast blue(FB) into one side of the Pa, retrogradely labelled cells were found in bilateral RVL, with an ipsilateral predominance. The labelled cells decreased in number from the caudal to the rostral level. After injection of FB into one side of the thoracic cord at T_2-T_3 segments, retrogradely labelled cells in the RVL were observed which increased in number from the caudal to the rostral level and reached the peak at 1.0-1.5mm caudal to the trapezoid body. Most of these cells were distributed in the ipsilateral RVL, and clustered in the region 0.0-1.0mm from the ventral surface of the medulla. After Diamino yellow 2HC1 and FB were injected into the Pa and the thoracic cord respectively, only single labelled cells were detected in the RVL, no double labelled cells were found. The above results suggest that the Pa and the thoracic cord receive separate fiber projections from different cells of the RVL.