Retro-odontoid pseudotumor concomitant with proximal adjacent cervical spondylotic myelopathy after multilevel anterior cervical discectomy and fusion

Introduction and importanceAdjacent cervical spondylotic myelopathy (CSM) following anterior cervical discectomy and fusion (ACDF) presenting as a retro-odontoid pseudotumor (ROP) is uncommon. This consequence adversely affects hand function, causes gait imbalance and results in other disabilities for the patient. This report describes the successful surgical treatment of a patient with ROP associated with adjacent CSM following multilevel ACDF of the subaxial cervical vertebrae by performing posterior cervical decompression and fusion.Case presentationA 60-year-old-male presented with progressive, disabling cervical myelopathy. He had undergone ACDF C3-C7 for treatment of CSM 16 years ago and his symptoms had fully resolved. Magnetic resonance imaging (MRI) revealed severe cervical spinal cord compression caused by a retro-odontoid mass at the C1-C2 level with upper adjacent segment disease (ASD) of C1-C3. The patient received C1-C3 posterior cervical spinal fusion by C1 lateral mass C2 and C3 pedicle screw fixation and C1-C3 laminectomy. After the surgery, he was able to ambulate independently and the myelopathic symptoms were significantly improved at the 6 months follow-up.Clinical discussionRetro-odontoid pseudotumor concomitant with proximal ASD following ACDF is a rare occurrence. Both diagnosis and surgical management are challenging.ConclusionsPosterior cervical decompression and fusion of C1-C3 is an effective option for treatment of severe cervical spinal cord compression by a retro-odontoid mass at the C1-C2 level combined with ASD after ACDF.     

Subependymoma of the cervical spinal cord

A case of subependymoma of the spinal cord in the cervical region is presented. Our experience with this patient and the seven cases of spinal cord subependymoma previously reported show that this tumor predominates in the cervical region and in males (3:1). Although radical removal is considered the rational goal of treatment, larger experience is necessary to know both the rate of growth and prognosis of subependymomas when these tumors arise within the spinal cord.     

Histoire naturelle des cavernomes intramédullaires et traitement chirurgical. Résultats de l'étude française multicentrique

IntroductionThe prevalence of cerebral cavernomas is about 0.5% in the general population. In contrast, spinal cord cavernomas are considered as rare. The objective of this study was to determine the natural history of spinal cord cavernomas in a multicentric study.MethodsClinical and neuroradiological findings were retrospectively collected. Diagnosis was based on pathological criteria or magnetic resonance (MR) findings.ResultsFifty-three patients were included (26 males, 27 females). Mean age at onset of symptoms was 40.2 years (range: 11-80). Initial symptoms were progressive (32) and acute myelopathy (20). One patient was asymptomatic. Clinical symptoms were related to spinal cord compression (24) and hematomyelia (19). Cavernoma location was dorsal (41) and cervical (12.). MR findings consisted of hyperintense signal on T1 and T2 sequences (19 cases), mixed hyperintense and hypointense signal (33 cases), and hypointense signal on T1 and T2 sequences in 1 case. Mean size was 16.3 mm (range: 3-54). Forty patients underwent surgical resection. Improvement was observed in 20 patients and worsening of neurological symptoms in 11. Length of follow up was 7.1 years. At the end of the study, 26 patients were autonomous, 18 handicapped and 1 beddriden.ConclusionThis study provided precise data on the clinical and MR patterns of these lesions. The natural history is associated with a higher risk of hemorrhage recurrence, but is favorable in many operated patients. Microsurgery is the treatment of choice for most of these lesions.     

Abstracts from the 43rd Annual Scientific Conference of the American Paraplegia Society—September 2-4, 1997, Las Vegas,Nevada

Abstract

Background: Diagnosing patients with cervical cord compressive myelopathy in a timely manner can be challenging due to varying clinical presentations, the absence of pathognomonic findings, and symptoms that are usually insidious in nature.

Objective: To describe the clinical course of a patient with primary complaint of left medial knee pain that was nonresponsive to surgical and conservative measures; the patient was subsequently diagnosed with cervical cord compressive myelopathy.

Design: Case report.

Subject: A 63-year-old man with a primary complaint of left medial knee pain.

Findings: Physical examination of the left knee was normal except for slight palpable tenderness over the medial joint line. During treatment, he noted loss of balance during activities of daily living. Reassessment revealed bilateral upper extremity hyperreflexia, bilateral Babinski reflex, and positive bilateral Hoffman reflex. Magnetic resonance imaging of the cervical spine demonstrated moderately severe spinal stenosis at the C3-C4, C5-C6, and C6-C7 levels. After C3-C7 laminoplasty for cervical cord compressive myelopathy, he reported substantial improvement of his left medial knee. Three years later, he had no complaint of knee pain.

Conclusion: Appropriate diagnosis and treatment of cervical cord compressive myelopathy may avoid unnecessary diagnostic imaging, medical evaluations, invasive procedures, and potential neurologic complications.     

Cervical myelopathy resulting from combined ossification of the ligamentum flavum and posterior longitudinal ligament: report of two cases and literature review

Background contextIn the cervical spine, the combination of ossification of the ligamentum flavum (OLF) and ossification of the posterior longitudinal ligament (OPLL) is rarely seen. There have been only four cases reported in the English literature.PurposeWe describe two more cases that exhibited cervical myelopathy resulting from the combination of cervical OLF and OPLL and required surgery. A literature review with a comparative analysis between previous reports and present cases was also performed.Study designCase report and literature review.Patient sampleTwo patients with combined OLF and OPLL.Outcome measuresPreoperative computed tomography, magnetic resonance imaging, and pathological findings from operative specimens were used to confirm the diagnoses.MethodsA 76-year-old man (Case 1) presented with disturbance of gait and fine finger movement. Magnetic resonance imaging showed severe spinal canal stenosis and cord compression at the C3–C4 level. Computed tomography showed OPLL at the C2–C6 levels (segmental type) and OLF at the left C3–C4 level. The patient underwent posterior decompression and OLF resection. A 75-year-old man (Case 2) presented with sensory disturbance and muscle weakness in his bilateral upper extremities and disturbance in fine finger movements. Magnetic resonance imaging showed severe spinal canal stenosis and cord compression at the C2–C3 and C3 levels. Computed tomography showed OPLL at the C3–C7 levels (mixed type) and OLF at the left C2–C3 and C3 levels. The patient also underwent posterior decompression and OLF resection.ResultsIn both cases, histological examination of the surgical specimens showed osseous tissue and enchondral ossification within the ligamentum flavum, and the diagnosis in each case was OLF. After surgery, both patients' symptoms immediately improved, and no recurrence was observed at 2 years after surgery.ConclusionsWe experienced two cases of cervical myelopathy resulting from the combination of OLF and OPLL in the cervical spine. The symptoms of myelopathy were treated successfully by laminectomy and laminoplasty with OLF resection in both cases. The literature review including the present two cases revealed that cervical OLF tended to occur adjacent or close to the margin of cervical OPLL, suggesting that the increased mechanical stress at the junction of OPLL may be a causative factor.     

Spinal intramedullary subependymomas: case report and review of the literature.

A cervical spinal intramedullary subependymoma in a 53-year-old man is reported, and the relevant literature is reviewed. Spinal cord subependymomas seem to follow a benign course. Radiotherapy should not be administered to these patients. Magnetic resonance imaging, even with enhancement, is not able to distinguish between a subependymoma and the more common ependymoma.     

Neurofibromatosis: An Unusual Cause of Cervical Myopathy

Abstract

Generalized neurofibromatosis (NF) is characterized by café au lait spots, deformity of the skeleton and tumors involving the skin as well as spinal, peripheral and cranial nerves. The spine is that part of the skeleton most commonly affected in NF, although involvement of the cervical spine in NF has only rarely been reported. The majority of neurofibromas involving spinal nerves are asymptomatic or present with symptoms consistent with nerve root involvement. Classic symptoms of myelopathy secondary to spinal cord compression in NF are rare. We describe a 35-year-old male with generalized NF who presented with worsening gait instability. Magnetic resonance imaging (MRI) revealed enhancing masses producing spinal cord compression at the C1-C2 and C4 levels. The patient underwent decompressive laminectomy and, at eight weeks after surgery, was once again ambulatory. The literature discussing the sequelae and treatment of NF when it produces myelopathy is reviewed.     

Symptomatic retro-odontoid pseudotumor causing calcium pyrophosphate dihydrate deposition combined with multilevel cervical spondylotic myelopathy

IntroductionSymptomatic retro-odontoid pseudotumor (ROP) caused by cervical compression and myelopathy is rare. Pathological diagnosis is recommended for differential diagnosis including the following: inflammatory disease, primary bone tumor, metastatic disease and calcium pyrophosphate dihydrate deposition (CPPD) also known as “crowned dens syndrome”. The authors report a rare case of ROP caused by CPPD deposition combined with multilevel cervical spondylotic myelopathy (MCSM) which was treated by tumor resectioning using a transoral approach combined with posterior decompression and fusion.Case presentationA 66-year-old male presented with progressive neck pain and spastic gait with no history of trauma. Radiographic imaging revealed degenerative change involving the atlanto-axial and atlanto-occipital joints with calcified enhancing soft tissue around the odontoid process causing cord compression and cervical instability at the C1-C2 level combined with MCSM and spinal cord compression at C3 to C7. Microscopic assisted transoral tumor resection combined with posterior decompression and fusion was performed at the occiput to T2. The pathology report describes a rhomboid-shaped crystal caused by calcium pyrophosphate dihydrate deposition (CPPD) disease. At the 6-month follow-up following the operation, the patient's neck pain and spastic gait were improved compared to the preoperative examination.DiscussionCervical compression and myelopathy from ROP causing CPPD combined with MCSM is rare. Pathology diagnosis and surgical management are highly recommended.ConclusionIn this case, a combined surgical approach: tumor resection using a transoral approach and a posterior approach for decompression and fusion at occiput to T2 was an effective option for this condition.     

Intradural extramedullary cavernoma of a lumbar nerve root mimicking neurofibroma. A report of a rare case and the differential diagnosis

Background contextIntradural extramedullary (IDEM) cavernomas are rare vascular malformations. They are well-circumscribed dark berry-like lesions with a histologic appearance of sinusoidal vascular channels. Neurofibromas are the most common IDEM tumors, originating from all nerve elements and leading to firm enlargement of the affected nerve root. These lesions are completely different; however, they may involve the spinal nerve roots or the major nerve trunks. Any similarities in clinical findings are based on different pathophysiology.PurposeTo present a rare resemblance of an IDEM cavernoma to a neurofibroma.Study designThis is a case report with review of the literature focused on the differential diagnosis.MethodsA 79-year-old patient presented with acute sensorimotor disturbance from L2–S1 levels. The investigations showed an L2–L3 lesion occupying the canal. Findings resembled a neurofibroma and a surgical resection was decided.ResultsThe complete surgical resection revealed a vascular lesion originating from a nerve root. The histology confirmed an IDEM cavernoma. This is a unique case as such a clinical resemblance and a macroscopical appearance has not been reported for an IDEM cavernoma as yet. The patient showed full postoperative recovery from his initial symptoms.ConclusionsIntradural extramedullary cavernoma is a rare cause of compression to spinal cord or nerve roots. Its manifestation characteristics are well defined and should always be part of the differential diagnosis. Intraoperative findings aid the diagnosis in nontypical cases before the final histology. The nontraumatic and nerve tissue sparing surgical resection warrants optimal postoperative results and excellent prognosis.     

Intramedullary subependymoma occupying the right half of the thoracic spinal cord--case report

A 37-year-old female presented with a rare spinal subependymoma manifesting as progressive weakness of her right lower extremity over an 8-month period. She had a 10-year history of back pain and urinary disturbance. Magnetic resonance imaging showed diffuse enlargement of the spinal cord from T-2 to T-7 on the T1-weighted images. The enlarged spinal cord was divided into two compartments by a vertical septum-like structure on the T2-weighted images. The tumor occupied the right half of the thoracic spinal cord, and was totally removed through a laminectomy from T-2 to T-7. The histological diagnosis of the resected specimen was subependymoma. Subependymomas are slow-growing tumors usually found in the ventricular system. Spinal subependymomas are difficult to distinguish from other intramedullary spinal tumors based on neuroradiological findings. Subependymomas are surgically curable tumors, so if the tumor is well demarcated and a subependymoma is indicated, an attempt should be made to totally remove the tumor.     

The relationship between preoperative cervical alignment and postoperative spinal cord drift after decompressive laminectomy and arthrodesis for cervical spondylotic myelopathy

BackgroundCervical spondylotic myelopathy represents a debilitating disorder, often resulting in significant neurological impairment over time. Cervical laminectomy has enjoyed a successful track record in the surgical management of these patients. Little is understood regarding the significance of postdecompressive migration of the spinal cord in relation to patient outcome.MethodsPreoperative and postoperative cervical spine MRIs of 28 patients who underwent cervical laminectomy and fusion for the treatment of CSM were reviewed. Radiographic parameters including preoperative cervical alignment, LDI, space available at the level cepahlad/caudad to the decompression, percent spinal cord expansion at the radiographically most compressed level, and spinal cord drift to the midpoint of the spinal cord were measured and subsequently analyzed for statistical correlation. The recovery rate based on the mJOA score was calculated for each patient and analyzed for correlation with spinal cord drift.ResultsThe Cobb angle C2-7, cervical spinal angle, and CCI represented tightly correlated measures of cervical alignment. The preoperative cervical alignment did not statistically correlate with postoperative spinal cord drift. No statistical correlation was revealed between postdecompressive spinal cord drift and recovery rate.ConclusionsPreoperative cervical alignment does not statistically correlate with postoperative spinal cord drift in patients undergoing multisegmental decompressive laminectomy and fusion for CSM. The observation of significant posterior shifting of the spinal cord in the context of straight or kyphotic preoperative alignment suggests that posterior decompression and arthrodesis represent a viable option in the surgical management of patients with CSM with nonlordotic preoperative alignment.     

Intramedullary subependymoma of the cervical spinal cord: case report

The third case of intramedullary subependymoma of the cervical spinal cord is reported. This is the first such case for which intraoperative views are available. It was possible to remove most of this lesion with the aid of the operating microscope, the carbon dioxide laser, and the use of somatosensory evoked potentials. The diagnosis was clouded by the coexistence of Holmes-Adie pupils and absent reflexes in the lower extremities. All three reported intramedullary subependymomas have been found in the cervical spinal cord of middle-aged patients. Tumors in this clinical setting should not be assumed to be unresectable astrocytomas without careful histopathological and intraoperative evaluation.     

Hemorrhagic intramedullary hemangioblastoma of the cervical spinal cord presenting with acute-onset quadriparesis: Case report and review of the literature

Context

Hemangioblastomas of the spinal cord are uncommon vascular tumors. Patients commonly present with subtle neurologic findings that are thought to represent growth of the lesion over time. Hemorrhage of an intramedullary hemangioblastoma presenting as acute neurologic deficit is an extremely rare occurrence. Although the cervical spine is the most common location for hemangioblastoma of the spinal cord, there have been no previously published cases in the literature of intramedullary hemorrhage from such a lesion.

Findings

A 22-year-old woman with a previously undiagnosed spinal cord hemangioblastoma presented with sudden-onset dense quadriparesis due to intramedullary hemorrhage in the cervical spinal cord. The patient did not have any clinical findings of von-Hippel Lindau disease. Laminoplasty from C5 to T2 and posterior midline myelotomy for resection of the intramedullary tumor with hematoma evacuation were completed without complication.

Conclusion

Intramedullary hemangioblastoma of the spinal cord is uncommon, and hemorrhage from a cervical spinal cord lesion has not previously been reported. Symptoms from these usually indolent lesions are commonly associated with tumor growth, edema, or associated syrinx, whereas devastating acute neurologic deficit from hemorrhage is exceedingly rare. Microsurgical resection should be done in cases of symptomatic lesions and considered in isolated symptomatic lesions without the known diagnosis of von Hippel-Lindau disease.     

Bilateral and symmetric C1–C2 dumbbell ganglioneuromas associated with neurofibromatosis type 1 causing severe spinal cord compression

Background ContextGanglioneuromas are rarely located in the cervical region compressing the spinal cord. Only two cases of bilateral and symmetric dumbbell tumor have been reported previously.PurposeThe purpose of the study was to present an additional case with bilateral and symmetric dumbbell ganglioneuromas of the cervical spine as part of multiple ganglioneuromas of the spine in a patient with neurofibromatosis type 1 (NF-1).Study DesignThe study design was a case report.MethodsA 15-year-old boy with NF-1 presented with a 6-month history of progressive tetraparesis. Magnetic resonance imaging showed voluminous bilateral and symmetric dumbbell masses at the C1–C2 level severely compressing the spinal cord. The spinal cord was also indented by a dumbbell mass at the left C3–C4 level. A systemic imaging survey of the patient showed numerous asymptomatic foraminal and extraforaminal tumors at all neuroforamina of the spine.ResultsThe result was found to be surgical decompression of the spinal cord by subtotal resections of bilateral tumors at the C1–C2 level and unilateral tumor at the left C3–C4 level alleviated patient symptoms. Histopathological diagnosis was ganglioneuroma for all resected tumors.ConclusionMultiple ganglioneuromas, particularly bilateral and symmetric dumbbell tumors, are extremely rare but could be associated with NF-1.     

Isolated spinal cord sarcoidosis mimicking an intramedullary tumor

A case of cervical intramedullary sarcoidosis and its uncommon magnetic resonance imaging with contrast medium are reported. Spinal cord sarcoidosis is very rare. It is difficult to diagnose intramedullary sarcoidosis without a previous diagnosis of systemic sarcoidosis or other apparent symptom. The patient had subacute myelopathy. Contrast-enhanced images revealed intense focal enhancement of the C6-7 cervical cord. The preoperative diagnosis was an intramedullary tumor. Subtotal resection was performed after intraoperative frozen section study was interpreted as malignant lymphoma. Subsequent pathologic examination of the biopsied specimens revealed spinal cord sarcoidosis. After surgery, steroid therapy was performed, but the patient's symptoms hardly improved. Even if imaging study and intraoperative frozen section show neoplasm, the first surgery should be limited to decompressing the cord and biopsy in cases of suspected sarcoidosis.     

Cervical pyogenic spondylodiscitis: 4 cases report and a review of the literature

We report 4 cases of cervical spondylodiscitis presenting neurological and/or neuroradiological abnormalities. Such a lesion is rare in the cervical spine of adults, but should be suspected when the patient has radiculopathy and/or myelopathy associated with inflammatory signs. We discussed the clinical characteristics and the procedures of the diagnosis and treatment of cervical spondylodiscitis. Early and definitive diagnosis can be achieved by cervical X-ray, MR imaging and biopsy. It is very important to evaluate the pyogen for the lesion by needle biopsy. When the patient has the compression of the spinal cord and/or nerve roots and the neurological findings of radiculopathy and/or myelopathy, surgical exploration and decompression of the spinal cord and/or nerve roots should be carried out as soon as possible. Anterior debridement and fusion should be performed using the effective antibiotics. We were able to achieve good prognosis by treatment following this procedure of diagnosis in the four cases of cervical spondylodiscitis mentioned.     

Spinal cord injury following operative shoulder intervention: A case report

Abstract

Context

Cervical myelopathy is a spinal cord dysfunction that results from extrinsic compression of the spinal cord, its blood supply, or both. It is the most common cause of spinal cord dysfunction in patients greater than 55 years of age.

Findings: A

57-year-old male with right shoulder septic arthritis underwent surgical debridement of his right shoulder and sustained a spinal cord injury intraoperatively. The most likely etiology is damage to the cervical spinal cord during difficult intubation requiring multiple attempts in this patient with underlying asymptomatic severe cervical stenosis.

Conclusion

Although it is not feasible to perform imaging studies on all patients undergoing intubation for surgery, this patient's outcome would suggest consideration of inclusion of additional pre-surgical screening examination techniques, such as testing for a positive Hoffman's reflex, is appropriate to detect asymptomatic patients who may have underlying cervical stenosis.     

Acute spontaneous cervical epidural hematoma with neurological deficit after low-molecular-weight heparin therapy: role of conservative management

Background ContextSpontaneous spinal hematoma (SSH) after low-molecular-weight heparin (LMWH) therapy is a rare cause of compressive myelopathy with neurological deficit. Emergent surgical decompression is commonly advocated for optimal neurological recovery. Only three cases of spontaneous spinal subdural hematomas after LMWH therapy have been reported in the literature, and this is the first report of a spontaneous cervical epidural hematoma (EDH).PurposeTo highlight the importance of conservative management in an unusual case of cervical EDH with neurological deficit after LMWH therapy.Study DesignClinical case report.MethodsA 65-year-old man presented with weakness of upper and lower limbs with bowel and bladder dysfunction after LMWH therapy for an acute coronary syndrome. Magnetic resonance imaging (MRI) revealed an anterior cervical EDH extending from C4 to T1 with significant cord compression. Associated comorbidities precluded emergent surgical intervention, and the patient was managed conservatively with cessation of LMWH therapy.ResultsThe patient showed signs of early neurological recovery within 24 hours (ASIA C [American Spinal Injury Association] to ASIA D) of cessation of LMWH, and hence surgery was deferred. Complete motor and sensory recovery was observed at 1-month follow up with resolution of the cervical EDH without any cord compression evident on the MRI.ConclusionsLMWH therapy is an important cause of SSH leading to significant neurological deficits. Conservative management is a viable treatment option in patients who demonstrate early and sustained neurological recovery with the cessation of LMWH therapy.     

Surgical outcome of thoracic myelopathy secondary to ossification of ligamentum flavum

ObjectivesThoracic myelopathy secondary to OLF is a rare disease described almost exclusively in Japanese patients. Few series of OLF in South Korean subjects has previously been published. This study is to describe the clinical and radiologic aspects, as well as surgical outcomes in a group of South Korean patients.MethodsA retrospective study of 8 consecutive patients, including 4 men and 4 women (mean age, 55.6 years), was conducted from 2002 to 2005. Diagnosis in each case was established using CT. Magnetic resonance imaging was also performed in every case. All patients treated surgically and pathologic studies were performed. A comparison between the preoperative neurological status and the status at follow-up was done using Japanese Orthopaedic Association (JOA) scoring system.ResultsWalking difficulties were the most common presenting complaint. A picture of spastic paraparesis associated with sphincter dysfunction was the most common finding on initial examination. In each case, CT provided sufficient information to establish a diagnosis of OLF, while magnetic resonance imaging was helpful for showing spinal cord involvement. In most of the patients, OLF was located in the lower thoracic spine (T10–T11). Decompressive laminectomy with excision of the OLF resulted in significant improvement in motor weakness and gait in 5 (2 excellent, 3 good) patients who had short duration and no hyperintense intramedullary lesion of spinal cord on MRI. All patients improved in their gait and spasticity, but 2 patients had persistent sensory deficit.ConclusionOLF is a rare cause of thoracic myelopathy. The frequency appears to have been rarely reported in South Korean subjects. CT with sagittal reconstructions and MRI are helpful for diagnosis and spinal cord involvement. When neurologic symptoms develop, decompressive laminectomy should be done immediately and the surgical outcome is generally good if hyperintense intramedullary signal changes of spinal cord have not yet developed.