Giant Ventral Midline Schwannoma of Cervical Spine : Agonies and Nuances

Pure ventral midline giant schwannoma is an extremely rare entity. Spinal intradural extramedullary schwannomas commonly occur posterolateral or anterolateral to the spinal cord. A case of a pure midline ventrally situated giant pan cervical extramedullary schwannoma in an 18-year-old male patient with compressive myelopathy and sphincter involvement is presented. Spinal MR imaging showed a midline ventrally situated extramedullary tumor with severe spinal cord compression extending from clivus to C7 vertebra. It was resected through a posterolateral approach. Histology was consistent with a schwannoma. Post operative MR imaging showed no evidence of the tumor. The radiological features, pathogenesis and surgical strategies in management of these difficult tumors are discussed and the relevant literature is briefly reviewed.     

Extended spontaneous spinal epidural anterior hematoma over multiple spinal segments. A case report]

We reported a case of extended spontaneous spinal epidural hematoma over multiple spinal segment. A 68-year-old man presented with sudden onset of back pain. He rapidly developed tetraplegia within 15 minutes. On admission, he showed tetraplegia, sensory loss below C4 dermatome, right Horner's sign and bilateral Babinski's signs. These neurological signs gradually improved and disappeared completely within 5 hours. MR imaging showed extended hematoma in the anterior part of spinal epidural space. Spinal angiogram showed no vascular anomaly. The patient had nine years history of antiplatelet therapy, which would produce this episode of the spinal epidural hematoma. The hematoma located in the anterior part of the epidural space and extended over multiple spinal segments was characteristic features in this case. In the case which could have early neurological recovery, conservative therapy might be indicated.     

Cervical disc prolapse in childhood associated with Klippel-Feil syndrome

Klippel-Feil syndrome is characterized by a variable degree of congenital fusion of the cervical spine. It can exist in association with other mesodermal deformities affecting several systems. Symptomatic cervical disc prolapse in the context of the syndrome is well documented in young adults. We present a case of a 5-year-old girl with the syndrome, who presented with mild motor developmental delay and cervical cord compression from a prolapsed C3/4 intervertebral disc, seen on MR scan. She also had posterior elements fused from C-2 to C-4. She improved after cervical discectomy. The presence of degenerative disc disease at such a young age and at a level mechanically protected by posterior element fusion indicates a congenital primary defect, rather than mechanical stress fatigue. Received: 3 February 2000 Revised: 21 July 2000     

Intradural herniation of intervertebral disc at the level of Lumbar 1-Lumbar 2

Intradural disc herniation is a serious and rare complication of intervertebral disc rupture. The preoperative diagnosis of intradural disc herniation is still difficult despite new neuroradiologic investigation possibilities including computerized tomography and magnetic resonance imaging and it is usually diagnosed by during surgery. Here we present an intradural disc herniation case at the level of L1-L2 with accompanying significant myelopathic neurologic deficits. A 50-year-old female patient was admitted to the hospital with pain and weakness in both legs. Her neurological examination revealed paraparesis. Magnetic resonance imaging showed an extruded disc hernia of central localization at the L1-L2 level. She underwent total laminectomy at the level of L1-L2 and her intradural disc fragment was extirpated by microsurgical methods.     

MR imaging of peripheral nervous system involvement: Parsonage-Turner Syndrome

A 55-year-old woman complained of right scapular pain, like burning, radiating down his right arm and numbness in the first three fingers of the hand. Neurologic examination showed a slight deficit of the right brachial triceps muscle. Neurophysiological assessment showed a mild involvement of the seventh right spinal root (C7). Conventional MR imaging of the cervical spine showed mild disc protrusion at level C5-C6 without spinal root compression. High resolution MR neurography with multiplanar reconstruction along the course of the right brachial plexus showed a mild increase in signal intensity and thickening of the C7 root, middle trunk and posterior cord, consistent with Parsonage-Turner Syndrome. STIR images showed increased signal intensity in the right infraspinatus muscle innervated by the suprascapular nerve. In our case, sensitivity and specificity of the new MR sequences are higher than the clinical and neurophysiological evaluations.     

A gas filled intradural cyst with intradural disc herniation: a case report

Intradural disc herniation is rare. In a colon cancer patient who suffered from low back pain for several years, MRI examination showed evidence of vacuum phenomenon and ring enhancement at the level of L3-4. Intradural herniation of an intervertebral disc was confirmed surgically. Pathological evidence of intradiscal gas is rarely reported in the literature, however, an association between intradural disc herniation and pneumocysts was demonstrated in this case. The implications of our sequential radiological and pathological findings for the pathogenesis of intradural pneumocysts are discussed.     

Transient long segment spinal cord hyperintensity after anterior cervical discectomy

A 69-year-old man was admitted to our hospital with progressive numbness in both feet and gait disturbance. MR imaging revealed a large cervical disc herniation resulting in significant spinal cord compression with hyperintensity of the spinal cord on T2-weighted images at C-5/6. Immediately after undergoing anterior cervical discectomy, the patient developed severe weakness of his left hand and lower extremities. MR imaging obtained 5 days after surgery revealed a long segment hyperintensity between C-3 and T-2 on T2-weighted images. This long segment hyperintensity disappeared after 2 weeks of steroid administration. We suspect that the persistent, localised, patchy C-5/6 cord hyperintensity represents spinal cord degeneration due to ischaemia and trauma resulting from the disc herniation. However, the transient long segment hyperintensity may represent oedema, probably due to minor trauma of an already compromised cord, during the decompression surgery. Clinicians should be aware that even careful surgery can result in a significant change in radiological studies and neurological condition.     

Spontaneous cervical intradural disc herniation

Cervical intradural disc herniation (IDH) is a rare condition with very few case reports in the literature. We report a 64-year-old man who presented with sudden onset neck pain and rapidly progressing weakness in the left upper and lower limb. There was no history of trauma. MRI of the cervical spine showed a C6–C7 disc prolapse, for which he underwent a C6–C7 discectomy and fusion with bone graft through an anterior cervical approach. To our knowledge, all patients with a cervical IDH reported in the literature have a traumatic etiology. To the best of our knowledge, we report the first patient with a spontaneous cervical IDH.     

Acute reversible paraparesis secondary to probable fibrocartilaginous embolism

Fibrocartilagenous embolism (FCE) of the intervertebral disc represents a very rare cause of spinal infarct. Up to now only 33 others cases in human beings have been reported in the literature, most of them diagnosed post mortem. We present a 14-year-old boy who developed acute dorsal back pain after lifting a heavy gate, followed by progressive paraparesis. An MRI of the spine showed a degenerative disc at D10-D11 without compromise of the spinal canal lumen associated with an acute Schmorl's nodule situated in the superior endplate of D11. A week later, a second MRI disclosed an intraxial spinal cord lesion at D7-D8 vertebral level involving the vascular territory of the anterior spinal artery. It also showed an abnormal signal located in the posterior third of the D8 vertebral body. These clinical and neuro-radiological findings are similar to those mentioned in the literature and support the diagnosis of an anterior spinal infarct secondary to a probable fibrocartilaginous embolism. This case highlights the importance of considering this etiology among the causes of spinal cord infarct, especially in young people, and underlines the utility of MRI in its diagnosis in vivo.     

Effect of a compression load on intradiscal pressure of the cervical spine: in vitro investigation

BACKGROUND AND PURPOSE: The aim of this paper was to investigate the effects of intervertebral fusion (Cloward and Robinson-Smith techniques) on the intradiscal pressure at the adjacent levels exposed to compression loads. MATERIAL AND METHODS: A biomechanical study was performed using cadaveric cervical spine. 12 cervical spines exposed to a compression load were analyzed. Intact spines and spines after internal stabilisation using bone grafts and metal plates were already studied. All biomechanical testing was performed on the material testing machine (MTS 858 MiniBionix Test System). RESULTS: The results of investigation confirmed a linear distribution of pressure related to the applied compression loads. This study showed that intradiscal pressure was always inferior in the disc above the stabilisation segment as compared to the disc underneath (even by 49%), regardless of the investigated system (intact spine or spine with a fixator). Intradiscal pressure in the spine with a bone graft, using Cloward technique or Robinson-Smith techniques, did not show significant differences between the two methods of stabilisation. Additionally, stabilisation (in the form of a fixator plate) did not show an essential influence of the fixator on changes of the intradiscal pressure. CONCLUSION: Clinical studies have reported increased rates of disc degeneration at levels adjacent to fusion. The results presented in this paper have not shown a significant increase of the intradiscal pressure at the adjacent levels after stabilisation.     

A case report of an intramedullary cervical teratoma in an adult patient with cervical spondylotic radiculopathy

Spinal cord teratomas are rare. There are few reports of teratomas affecting the cervical spine and their association with spondylotic radiculopathy has not been described. A 59-year-old woman with history of fecal incontinence attended with cervical radicular pain radiating to upper limbs. Physical examination showed distal muscle hypotrophy and abolishment of bicipital, tricipital, and brachioradialis reflexes of the right arm, preserving proximal strength. Also, hiporreflexia and loss of proprioception in the right lower limb was observed. Magnetic resonance imaging showed an intramedullary mass at C7-T1, accompanied by intervertebral disk protrusions and dural sac compressions at the same level. One-stage posterior–anterior operative approach for tumor resection, decompression of the radiculopathy and replacement of intervertebral discs was performed. The histopathological diagnosis was for a mature teratoma. We described the first case of an intramedullary cervical teratoma associated with radiculopathy in an adult, providing evidence of rare long-lasting teratomas affecting the cervical spine.     

Extradural meningioma en-plaque of the cervical cord

A rare case of cervical extradural en-plaque meningothelial meningioma is reported. The magnetic resonance imaging revealed an extradural sheet of tumor encasing the cervical cord from anterior, posterior and right lateral aspects and emerging from the right C3-4 intervertebral foramina. Though a differential diagnosis of lymphoma and tubercular granulation tissue were considered, its isointense intensity patterns on T1 and T2 weighted images and the intratumoral calcification on intrathecal contrast computed tomographic scan suggested a meningioma. At surgery, the lesion was fibrous, avascular and densely adherent to the dura. The radiological features and management options of the lesion are discussed.     

Cervical Disc Herniation Producing Acute Brown-Sequard Syndrome

Brown-Sequard syndrome may be the result of penetrating injury to the spine, but many other etiologies have been described. This syndrome is most commonly seen with spinal trauma and extramedullary spinal neoplasm. A herniated cervical disc has been rarely reported as a cause of this syndrome. We present a case of a 28-year-old male patient diagnosed as large C3-C4 disc herniation with spinal cord compression. He presented with left hemiparesis and diminished sensation to pain and temperature in the right side below the C4 dermatome. Microdiscectomy and anterior cervical fusion with carbon fiber cage containing a core of granulated coralline hydroxyapatite was performed. After the surgery, rapid improvement of the neurologic deficits was noticed. We present a case of cervical disc herniation producing acute Brown-Sequard syndrome with review of pertinent literature.     

Cervicothoracic Spinal Epidural Hematoma after Anterior Cervical Spinal Surgery

The purpose of this case report is to describe a rare case of a cervicothoracic spinal epidural hematoma (SEH) after anterior cervical spine surgery. A 60-year-old man complained of severe neck and arm pain 4 hours after anterior cervical discectomy and fusion at the C5-6 level. Magnetic resonance imaging revealed a postoperative SEH extending from C1 to T4. Direct hemostasis and drainage of loculated hematoma at the C5-6 level completely improved the patient''s condition. When a patient complains of severe neck and/or arm pain after anterior cervical spinal surgery, though rare, the possibility of a postoperative SEH extending to non-decompressed, adjacent levels should be considered as with our case.     

Two-level artificial disc placement for spondylotic cervical myelopathy.

This report describes a 49-year-old woman who presented with a myeloradiculopathy with two-level spinal cord compression. She underwent C5-6 and C6-7 anterior cervical decompressions and placement of two Bryan disc (Medtronic Sofamor-Danek. Memphis, TN) prostheses. Whilst single-level cervical arthroplasty using the Bryan disc prosthesis has been described before, this is the first two-level case reported in the literature and opens the way for the possible future management of multilevel cervical cord compression in a way that maintains cervical motion, avoids donor site bone graft problems, and may reduce the incidence of adjacent segment disease.     

Intervertebral disc calcification in children

Calcification of cervical intervertebral discs in children is due to an uncommon, but distinct, disease of unknown etiology. Signs and symptoms of nerve root or spinal cord compression are unusual and acute symptoms are followed by a benign course and spontaneous recovery. We describe a 5-year-old patient with symptomatic cervical disc calcification and discuss the relevant clinical and radiographic features.     

Guillain-Barr�� Syndrome Combined with Acute Cervical Myelopathy

Authors describe a patient who developed a myelopathy associated with Guillain-Barré syndrome and cervical myelopathy. We provide radiological evidence of non-compressive herniated cervical intervertebral disc with cord signal changes and show the clinical and electrophysiological result of coexisting Guillain-Barré syndrome and cervical myelopathy. We tried to introduce and review the case of Guillain-Barré syndrome which was combined with cervical myelopathy to let us recollect the presumptive cause.     

Cervical intradural disc herniation and cerebrospinal fluid leak

Cervical intradural disc herniation (IDH) is a rare condition and only 25 cases of cervical have been reported. We report a 45-year-old male who presented with sudden onset right lower limb weakness after lifting heavy weight. Magnetic resonance imaging of the cervical spine showed C5/6 disc prolapse with intradural extension. The patient underwent C5/6 discectomy through anterior cervical approach. Postoperatively, the patient improved in stiffness but developed cerebrospinal fluid leak and the leak resolved with multiple lumbar punctures.     

A case of juvenile-type distal and segmental muscular atrophy of upper extremities (Hirayama disease) with the isolated cervical fusion at the C3-C4 levels

The case, 29-year-old male, had suffered from muscular weakness and atrophy of the bilateral forearms and hands with tremor of the bilateral fingers for about 13 years. A neurological examination showed normal muscle-stretch reflexes and no sensory disturbances. A cervical spinogram revealed a fusion at the C3-C4 levels and mild spondylotic changes. We clinically diagnosed him as juvenile-type distal and segmental muscular atrophy of upper extremities (Hirayama disease) with the isolated congenital cervical fusion. Magnetic resonance imaging demonstrated an enlargement of the anterior epidural space from the C4-C5 levels to the Th 1-Th 2 levels. This abnormal epidural space showed relatively high signal intensity partially with low signal intensity on the T2 weighted spin-echo image and decreased in signal on the T1 weighted spin-echo image. And the dural sac was shifted backward and narrowed. And the soft discs was slightly protruded at the level of C4-5, C5-6 and C6-7. These findings suggest the over swelling and the delayed blood flow of the internal vertebral venous plexus. In this case, the degeneration of the cervical spine and soft disc derived from the congenital cervical fusion seems to have caused the internal vertebral venous plexus congestion and then have damaged the anterior horn cells.     

Cervical Spinal Epidural Hematoma Following Cervical Posterior Laminoforaminotomy

A 65-year-old man who had lateral cervical disc herniation underwent cervical posterior laminoforaminotomy at C5-6 and C6-7 level right side. During the operation, there was no serious surgical bleeding event. After operation, he complained persistent right shoulder pain and neck pain. Repeated magnetic resonance image (MRI) showed diffuse cervical epidural hematoma (EDH) extending from C5 to T1 level right side and spinal cord compression at C5-6-7 level. He underwent exploration. There was active bleeding at muscular layer. Muscular active bleeding was controlled and intramuscular hematoma was removed. The patient''s symptom was reduced after second operation. Symptomatic postoperative spinal EDH requiring reoperation is rare. Meticulous bleeding control is important before wound closure. In addition, if patient presents persistent or aggravated pain after operation, rapid evaluation using MRI and second look operation is needed as soon as possible.