From Diagnosis to Resolution: A Case Study of Myxopapillary Ependymoma Survival.

Myxopapillary ependymoma (MPE) is a rare, slow-growing tumor that commonly arises in the lumbosacral region of the spinal cord, within the filum terminale and cauda equina. The frequent presentation of MPE is back, sacral, or leg pain. The tumor's size, site, and extension usually influence these symptoms. MPE is usually evaluated using magnetic resonance imaging (MRI) because of its superior soft tissue contrast. The best treatment modality is total surgical resection, which improves the long-term survival rate, with follow-up imaging recommended to ensure total resolution. Here, we present the case of a 29-year-old male who presented with symptoms suggestive of severe neurological impairment. An MRI scan revealed an intradural lesion arising from the cauda equina with peripheral and intrathecal haemorrhage, consistent with MPE. He was managed with laminectomy and microsurgical resection of the tumor, which achieved total resection. Postoperative follow-up found gradual improvement in his symptoms, and routine surveillance imaging confirmed the complete resolution of the tumor.

Mexican Multicenter Experience of Metastatic Spinal Disease.

Background Spinal metastatic disease is a silent progressive cancer complication with an increasing prevalence worldwide. The spine is the third most common site where solid tumors metastasize. Complications involved in spinal metastasis include root or spinal cord compression, progressing to a declining quality of life as patient autonomy reduces and pain increases. The main objective of this study is to report the incidence of patients and typology of spinal metastases in three reference centers in Mexico. Methodology Retrospective cohorts of patients diagnosed with spinal metastases from January 2010 to February 2017 at the National Cancer Institute, National Rehabilitation Institute, and the Traumatology and Orthopedics Hospital "Lomas Verdes" in Mexico City were analyzed. Results A total of 326 patients (56% males) with spinal metastases were reported. The mean age was 58.06 ± 14.05 years. The main sources of spinal metastases were tumors of unknown origin in 53 (16.25%) cases, breast cancer in 67 (20.5%) cases, prostate cancer in 59 (18%) cases, myeloma in 24 (7.4%) cases, and lung cancer in 23 (7.1%) cases. Conclusions The data obtained in this analysis delivers an updated standpoint on Mexico, providing the opportunity to distinguish the current data from global references. Collecting more epidemiological information for better recording of cancer and its associated complications, as well as further studies on them, is necessary.

Mature Teratoma at the Lumbar Spinal Cord: A Case Report and Literature Review.

Mature spinal teratoma is a rare type of germ cell tumor that arises from any of the three germ cell layers (ectoderm, mesoderm, and endoderm) and consists of differentiated tissues and structures that reflect the cellular organization and morphology of normal adult tissues. It has the ability to grow independently and cause compressive symptoms when found in this rare location. In this article, we present the case of a 29-year-old male patient with the onset of neurological symptoms beginning with pelvic limb paresthesias and progressing to back pain. Magnetic resonance imaging (MRI) revealed a tumor at L1-L4, which was resected by laminotomy, and histopathology revealed a mature intradural teratoma. Fortunately, this histologic type had a good prognosis for our patient, who had a significant clinical improvement. A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology with PubMed and Google Scholar to find similar case reports and to summarize the main features of this disease, which contributes to the understanding of its diagnostic presentation, treatment, and prognosis, improving clinical practice in the management of similar cases. The rarity of this condition, together with its wide clinical heterogeneity and prognosis, underscores the importance of a thorough evaluation of cases of intramedullary lesions, where the consideration of uncommon diseases in the differential diagnosis should be highlighted.

Accessible Spinal Surgery: Transformation Through the Implementation of Exoscopes As Substitutes for Conventional Microsurgery in Low- and Middle-Income Settings.

Advancements in neurosurgical visualization have been made possible by the introduction of the operating microscope (OM) and the emergence of exoscopic technology (EX). Both OMs and EXs provide enhanced magnification and illumination, but they come with their own set of advantages and disadvantages. OMs provide high-quality magnification and illumination and have been used successfully in a variety of surgical procedures. They can be customized to fit the specific needs of the surgeon and are a well-established technology. However, they can be bulky, expensive, and cause discomfort during extended procedures. EXs provide high-definition magnification and illumination, improved depth perception and ergonomics, and can be cost-effective. They can be customized to fit the specific needs of the surgeon and can be made using locally available materials, reducing the need for expensive imports. However, they may require adjustment and have a learning curve for surgeons who are used to operating with OMs. Additionally, they may have limited availability in some healthcare settings. The choice between OMs and EXs will depend on the specific needs of the surgeon and the healthcare setting. The integration of 3D EX systems has revolutionized neurosurgery, offering improved depth perception and ergonomics. EX's cost-effectiveness addresses accessibility concerns, making it an attractive alternative, particularly for low and middle-income healthcare settings. The exoscope seems to be a safe alternative compared to an operative microscope for the most common brain and spinal procedures. The exoscope may help expand access to neurosurgical care and training worldwide. In conclusion, both technologies have their own set of advantages and disadvantages, and the choice between them will depend on the specific needs of the surgeon and the healthcare setting.

Feasibility of multimodal intraoperative neurophysiological monitoring for extramedullary spinal cord tumor surgery in elderly patients.

BACKGROUND/PURPOSE: Extramedullary spinal cord tumors (EMSCTs) are mostly benign tumors which are increasingly diagnosed and operatively treated in the elderly. While there are hints that multimodal intraoperative neurophysiological monitoring (IONM) could be influenced by age and age-related comorbidities, no study has ever systematically evaluated its feasibility and value for EMSCT surgery in elderly patients. METHODS: We retrospectively evaluated all patients with microsurgical EMSCT resection under continuous multimodal IONM with SSEPs, MEPs and electromyography between 2016 and 2020. Epidemiological, clinical, imaging and operative/IONM records as well as detailed individual outcomes were analyzed and compared for the cohort < / ≥ 65 years. RESULTS: Mean age was 45 years in cohort < 65 years (n = 109) and 76 years in cohort ≥ 65 years (n = 64), while baseline/operative characteristics did not significantly differ. Mean baseline SSEPs' latencies (left-right average) were significantly higher in the cohort ≥ 65 years for both median (20.9 ms vs. 22.1 ms; p < 0.01) and tibial nerve (42.9 ms vs. 46.1 ms; p < 0.01) without significant differences for SSEPs' amplitudes. Stimulation intensity to elicit intraoperative MEPs was significantly higher in the cohort ≥ 65 years (surrogate-marker: left-right-averaged quotient ID1-muscle/abductor-hallucis-muscle; 1.6 vs. 2.1; p < 0.001). Intraoperatively, SSEP and MEP monitoring were feasible in 99%/100% and 99%/98% for the cohort < / ≥ 65 years without significant differences in rates for significant IONM changes during surgery or postoperatively new sensorimotor deficits. Sensitivity of IONM was 29%/43%, specificity 99%/98%, positive and negative predictive values 67%/75% and 95%/93% for the cohort < / ≥ 65 years. Overall, age was no risk factor for IONM feasibility or rate of significant IONM changes. DISCUSSION: Multimodal IONM is feasible/reliable for EMSCT surgery in elderly patients. An age-related prolongation of SSEPs' latencies and demand for higher stimulation intensities for MEPs' elicitation has to be considered.

Rare Radiographic Changes in a Cervicomedullary Spinal Ependymoma After Biopsy and Drainage of an Intratumoral Cyst: A Staged Approach.

Spinal ependymomas are the most common intramedullary spinal tumor, with a large proportion containing a small intratumoral cyst. Although the signal intensity varies, spinal ependymomas are generally well-demarcated, are not associated with a pre-syrinx, and do not extend above the foramen magnum. Our case demonstrates unique radiographic findings of a cervical ependymoma with a staged approach to diagnosis and resection. The patient is a 19-year-old female who presented with a three-year history of neck pain, progressive arm and leg weakness, falls, and functional decline. MRI revealed an expansile dorsal and centrally located T2 hypointense cervical lesion with a large intratumoral cyst extending from the foramen magnum to the C7 pedicle. Contrasted T1 scans showed an irregular enhancement pattern along the superior tumoral border down to the C3 pedicle. She underwent a C1 laminectomy for open biopsy and cysto-subarachnoid shunt. Postoperative MRI revealed a well-demarcated enhancing mass extending from the foramen magnum to C2. Pathology revealed Grade II ependymoma. She underwent an occipital to C3 laminectomy with gross total resection. Postoperatively she experienced weakness and orthostatic hypotension that improved remarkably upon discharge. Initial imaging was concerning for a higher-grade tumor, with holocervical cord involvement and cervical kyphosis. Given concern for grade and possible extensive C1-7 laminectomy and fusion for resection, a smaller surgery involving drainage of the cyst and biopsy was performed. Postoperative MRI revealed regression of the pre-syrinx, improved tumoral definition, and improvement of cervical kyphosis. This staged approach spared the patient unnecessary surgical intervention such as extensive laminectomy and fusion. We conclude that in cases of a large intratumoral cyst in an extensive intramedullary spinal cord lesion, open biopsy and drainage followed by resection in a staged fashion should be considered. Radiographic changes from the first procedure may affect the surgical approach for ultimate resection.

Efficacy of Transcranial Motor Evoked Potential Monitoring During Intra- and Extramedullary Spinal Cord Tumor Surgery: A Prospective Multicenter Study of the Monitoring Committee of the Japanese Society for Spine Surgery and Related Research.

STUDY DESIGN: Multicenter prospective study. OBJECTIVES: Although intramedullary spinal cord tumor (IMSCT) and extramedullary SCT (EMSCT) surgeries carry high risk of intraoperative motor deficits (MDs), the benefits of transcranial motor evoked potential (TcMEP) monitoring are well-accepted; however, comparisons have not yet been conducted. This study aimed to clarify the efficacy of TcMEP monitoring during IMSCT and EMSCT resection surgeries. METHODS: We prospectively reviewed TcMEP monitoring data of 81 consecutive IMSCT and 347 EMSCT patients. We compared the efficacy of interventions based on TcMEP alerts in the IMSCT and EMSCT groups. We defined our alert point as a TcMEP amplitude reduction of ≥70% from baseline. RESULTS: In the IMSCT group, TcMEP monitoring revealed 20 true-positive (25%), 8 rescue (10%; rescue rate 29%), 10 false-positive, a false-negative, and 41 true-negative patients, resulting in a sensitivity of 95% and a specificity of 80%. In the EMSCT group, TcMEP monitoring revealed 20 true-positive (6%), 24 rescue (7%; rescue rate 55%), 29 false-positive, 2 false-negative, and 263 true-negative patients, resulting in a sensitivity of 91% and specificity of 90%. The most common TcMEP alert timing was during tumor resection (96% vs. 91%), and suspension surgeries with or without intravenous steroid administration were performed as intervention techniques. CONCLUSIONS: Postoperative MD rates in IMSCT and EMSCT surgeries using TcMEP monitoring were 25% and 6%, and rescue rates were 29% and 55%. We believe that the usage of TcMEP monitoring and appropriate intervention techniques during SCT surgeries might have predicted and prevented the occurrence of intraoperative MDs.

Minimally Invasive Approach for Complete Resection of a Cervical Intramedullary Tumor via a Dorsal Root Entry Zone Using Fixed Tubular Retractor.

We describe the surgical aspects of the resection of a large 2cm intramedullary ependymoma at the C6-7 level associated with an extensive syrinx using a unilateral minimally invasive approach through a fixed tubular retractor. A gross total resection was achieved. Total operative time was 5 hours. Estimated blood loss was less than 100 cc. Postoperative evolution was favorable, with the improvement of the patient's neurological status. There was no cerebrospinal fluid (CSF) fistula. Hospital stay was four days. All narcotics were stopped on day 1 after surgery. Post-operative MRI showed no residual tumor. At the six-month follow-up, there was continued improvement in his neurological status. Scoliosis films did not reveal any cervicothoracic kyphosis.

"Unsteady Gait": An Unusual Presentation of Extrapulmonary Tuberculosis.

Intramedullary tuberculoma (IMT) is a rare form of spinal cord tuberculosis (TB). Unlike Pott's spine, IMT is without osseous involvement and is indolent. These features may account for why the diagnosis is often overlooked as a cause of compressive myelopathy. Our case is unique in that we discuss an unusual presentation of a patient who presented with gait disturbance as the first symptom of spinal cord TB without foci of TB infection elsewhere. The patient's neurological symptoms improved with surgery and multidrug-resistant antituberculosis treatment. Although MRI is the preferred modality to characterize IMT, findings may be nonspecific, ultimately requiring biopsy. When IMT is diagnosed and managed appropriately, it carries a good prognosis. An interdisciplinary approach would provide the best outcomes.