Ossification in an extra-intradural spinal meningioma—pathologic and surgical vistas

Background contextIntradural and intratumorous ossification in spinal meningiomas are rare compared to their cranial counterparts. Extradural extension of the spinal meningioma is not uncommon. To the best of our knowledge, the ossification in an extra-intradural spinal meningioma is not yet reported in the literature.PurposeThe authors report a rare case of an extra-intradural spinal meningioma with ossification and calcification. The review of literature including the surgical challenges and the histologic variations as well as histogenesis of the ossified spinal meningioma is discussed.Study designCase report and review of the literature.MethodsA 61-year-old woman presented with complaints of numbness and weakness for 3 years, and gait disturbances for 6 months. Magnetic resonance imaging revealed a mass compressing the spinal cord at the T4 level.ResultsComplete resection of the tumor was achieved with coagulation and partial resection of the dura. Histopathological examination demonstrated a psammomatous spinal meningioma with intratumorous and intradural mature lamellar bone formation, complete with marrow and hematopoietic cells. The patient is asymptomatic at 3-year postoperative follow-up.ConclusionsDespite adherence of the ossified mass to the dura, arachnoid, and spinal cord, complete atraumatic resection of the mass was possible with favorable surgical outcome. In addition to calcification as a likely forerunner of ossification in the psammomatous subtype of meningioma, metaplastic differentiation of neoplastic cells to osseous and hematopoietic component might play a crucial role.     

Long segment spinal intramedullary dermoid cyst: A case report

IntroductionSpinal intramedullary dermoid is very rare, accounting for <1% of intraspinal tumors. It can be congenital or acquired. They usually present in 2nd or 3rd decade of life in adults. It may or may not associated with spinal dysraphism. It is asymptomatic in most cases, manifest acutely if it ruptures.Long segment involvement of spinal intramedullary tumor in adult without the history of trauma makes this case unique. Fat suppression imaging helps to distinguish adipose tissue from lesions causing hematomyelia in patients presented with intramedullary hyperintensity in both T1 & T2 sequences of MRI spine.Case presentationWe report here a rare case of 30 years old male who presented to us with sudden urinary retention followed by rapidly progressive quadriparesis and paresthesia in his right arm. In MRI, spinal intramedullary tumor was noted from medulla till D5 vertebra. We performed subtotal excision of tumor and sample sent for histopathology which proved it to be intramedullary spinal dermoid cyst.ConclusionLong segment involvement of spinal intramedullary dermoid cyst in adult without history of trauma makes this case different. Fat suppression imaging must be done in patients with intramedullary hyperintensity in both T1 and T2 sequences of MRI spine. Early diagnosis and appropriate management will be helpful in reducing morbidity.     

对比分析间变型脑膜瘤与非典型脑膜瘤的MRI特征

目的比较间变型脑膜瘤与非典型脑膜瘤MRI征象。方法回顾性分析经手术病理证实的20例间变型脑膜瘤与30例非典型脑膜瘤的MRI资料,比较两种脑膜瘤的MRI征象。结果间变型脑膜瘤与非典型脑膜瘤相比,肿瘤分叶征、坏死囊变、瘤周水肿及瘤脑界面模糊4项差异均有统计学意义(P均0.05);肿瘤出血、强化均匀性、脑膜尾征及邻近骨质改变4项差异无统计学意义(P均0.05)。结论间变型脑膜瘤与非典型脑膜瘤MRI征象存在差异,有助于鉴别诊断。     

Long-level intramedullary spinal cord astrocytoma complicated with spine scoliosis: Report of two cases

Introduction and importanceLong-level intramedullary astrocytomas complicated with spine scoliosis are rare. Surgical treatment of such tumors becomes more complicated and challenging when spinal scoliosis is present. However, studies describing the treatment of long segmental intramedullary spinal cord astrocytomas complicated with severe spine scoliosis have been rarely reported.Case presentationTwo cases of long-level intramedullary astrocytomas complicated with severe spine scoliosis were surgically treated with one-stage operation of tumor resection and scoliosis correction in this report. Case 1: A 16-year-old boy presented to our hospital with a five-month progressive paresthesia, weakness of the left lower limb, and a long-time abnormal body appearance. MRI showed a T4-T12 intramedullary tumor combined with spinal scoliosis. Case 2: A 14-year-old boy presented at our service with a 6-year history of visible spine scoliosis and a 1-year progressive motor disability of bilateral lower limbs. Spine MRI indicated a long-level abnormal syringomyelia signal from C4 to L1 and there was irregular enhancement after intravenous contrast medium administration at C7-T2 and T9-T12 level.DiscussionWe performed a laminectomy over the whole length of the tumor and corrected the scoliosis with trans-pedicle screws. The patients exhibited a long-time tumor free with largely neurological function preservation. One-stage operation did not generate severe short- or long-term complications. The correction of the scoliosis prevented the progression of the spinal deformity and facilitated the recovery of normal life.ConclusionThis case report demonstrates that the one-stage resection of long-level intramedullary astrocytoma and correction of the complicated scoliosis might be a feasible option.     

Intractable hiccups caused by syringobulbia and syringomyelia associated with intramedullary spinal hemangioblastoma

Introduction

Hiccups caused by a neoplasm in the spinal cord are rare.

Materials and methods

We report a case of intractable hiccups caused by syringobulbia and syringomyelia associated with cervical intramedullary spinal hemangioblastoma, which was successfully treated by surgical excision. A 60-year-old man was referred from the neurology department after presenting with hiccups for 1 year. The hiccups were aggravated 3 months ago and were sustained during eating or sleeping. Several doctors administered a muscle relaxant and an anticonvulsant, but they were ineffective. Spinal MRI revealed a huge syringomyelia from C2 to T2, associated with a highly enhancing intramedullary mass lesion at the C5 level. The hiccups were ceased after removal of the tumor through a right hemilaminectomy. The pathology of the specimen was hemangioblastoma. The size of the syringobulbia and syringomyelia decreased markedly on MRI checked 5 months after surgery.

Conclusions

Intractable hiccups can be caused by syringobulbia associated with an intramedullary cord tumor in the cervical area and possible mechanisms of hiccups were reviewed.

     

A Large Intramedullary Neurofibroma in the Thoracic Spinal Cord: Case Report

Neurofibromas are occasionally present in spinal roots; however, an intramedullary neurofibroma is especially rare. Although a few cases of intramedullary neurofibromas in cervical spinal cord have been reported, to the best of our knowledge, there are no reports of intramedullary neurofibromas in thoracic spinal cord, and moreover, no reports have clearly reported immunohistochemical findings. We report a rare case of a large intramedullary neurofibroma in the thoracic spinal cord and show immunohistochemical examination of the tumor. A 52-year-old man presented with a 2-year history of progressive gait disturbance. Neurological examinations demonstrated complete motor and sensory deficit of his legs. Magnetic resonance imaging of the thoracic spine demonstrated an intramedullary enhancing mass within the spinal cord between T4 and T5 levels. The patient underwent T3–T6 laminectomy surgery. The dura mater was opened to reveal fusiform dilatation of the spinal cord and a midline myelotomy was performed. An intramedullary mass was revealed and could be resected totally. Histopathological examination revealed that the tumor cells exhibited spindle-shaped and wavy nuclei with abundant collagen, which resembled schwannoma or fibrous meningioma. By immunohistochemical examination, some tumor cells were positive for S-100 proteins; however, most tumor cells were strongly positive for CD34. From these pathological findings and immunohistochemical reactions, we diagnosed the intramedullary tumor as a neurofibroma.     

3D MRI在脊柱侧弯畸形矫形术前的临床应用价值

目的探讨3D MRI在脊柱侧弯患者矫形术前的临床应用价值。方法对100例脊柱侧弯患者行术前3DMR检查,采用3D-SPACE T2W序列,多平面重组图像,测量T4、顶椎、L1水平脊髓和椎体的轴位旋转角,观察测量所得顶椎脊髓旋转角与Cobb角的相关性,并进行统计学分析,对顶椎水平脊髓旋转与椎体旋转进行对比。结果顶椎水平脊髓旋转角与Cobb角存在相关性。顶椎水平脊髓旋转可分为3种类型,过度旋转型80例,旋转不足型13例,相反旋转型7例。35例患者最大脊髓旋转角不在顶椎水平。脊髓旋转与椎体旋转不同,在Cobb角大者,大部分脊髓旋转角度大于椎体旋转。MR检查发现2例合并多发神经纤维瘤,1例脊髓空洞,1例蝴蝶椎畸形,5例半椎体并蝴蝶椎畸形,1例合并腹股沟斜疝。结论脊髓、椎体旋转的大小及类型存在差异。脊柱侧弯患者常合并脊髓及椎体多发畸形,3DMR检查在脊柱侧弯畸形矫形术前评估中起着重要作用。     

Metachronous mediastinal lymph node metastasis from ascending colon cancer: A case report and literature review

IntroductionMetachronous mediastinal lymph node metastasis without pulmonary metastasis is extremely rare in colorectal cancer, which makes the clinical diagnosis difficult and treatment strategy unclear.Prsentation of caseA case was a 59-year-old man, who had undergone right hemicolectomy for ascending colon cancer 2 years and 8 months previously, presented with enlarged mediastinal lymph nodes. ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography revealed FDG was accumulated only into the mediastinal lymph nodes. Serum carcinoembryonic antigen (CEA) level was within the normal range. Six months later, the size and FDG uptake of the mediastinal lymph nodes had increased. We assumed a possibility that the mediastinal lymph nodes were metastasized from ascending colon cancer and so performed thoracoscopic-assisted resection of the mediastinal lymph nodes. Histopathological analysis revealed the resected lymph nodes were filled with moderately differentiated adenocarcinoma and a diagnosis of mediastinal lymph nodes metastasis from previously-resected ascending colon cancer was made. The patient was postoperatively followed for more than 1 year and 8 months without any sign of recurrence.DiscussionOnly 7 cases of metachronous mediastinal lymph node metastasis from colorectal cancer, including our case, have been reported in the English literature. It is difficult to clinically diagnose mediastinal lymph node metastasis.ConclusionWe report a rare case of metachronous mediastinal lymph node metastasis from ascending colon cancer with literature review. If the mediastinal lymph nodes are enlarged after colorectal cancer resection, we need to make a treatment strategy as well as a diagnostic approach considering the possibility of mediastinal lymph node metastasis.     

Stereotactic radiosurgery results in three cases of intramedullary spinal cord arteriovenous malformations

Background contextIntramedullary spinal cord arteriovenous malformations (AVMs) are rare and have an unfavorable prognosis. We report our experience of treating three symptomatic patients with stereotactic radiosurgery (SRS). The standard treatment for these lesions are embolization or microsurgical resection. There are only a few reports of efficacy of radiosurgery in these cases.PurposeTo study the efficacy of radiosurgery in intramedullary spinal cord AVM patients, who failed or refused conventional treatment.Study settingThis study reports the results of SRS in 3 cases of intramedullary spinal cord AVMs.Patient sampleThree symptomatic patients diagnosed with intramedullary spinal cord AVMs. Two patients underwent embolization previously and one was newly diagnosed.Outcome measuresThe AVM obliteration was assessed by yearly high-resolution magnetic resonance imaging (MRI). Clinical examination was carried out every 6 months.MethodsThree symptomatic patients with intramedullary spinal cord AVMs were treated with SRS using the cyberknife system from January 2010 to May 2011. All the three patients presented with acute neurologic symptoms. Two patients were treated previously with embolization. As per protocol, patients underwent a plain computed tomography (CT), CT angiography, high-resolution MRI, and conventional spinal angiography for radiotherapy planning. The mean target volume was 4.05 cc. The prescribed dose was 21 Gy in three fractions on consecutive days. No special immobilization was done during treatment. Continuous image guidance of the treated area was done using the specialized spine tracking software. Follow-up was done by yearly clinical examination and high-resolution spine MRI after SRS.ResultsMean follow-up was 36 months. Follow-up MRI revealed absence of flow voids, suggesting complete obliteration of the AVM in two patients, with significant improvement in neurologic and functional symptoms. The third patient did not show any clinical improvement or deterioration. There was no incidence of hemorrhage after SRS in any patient and the treatment was well tolerated without any significant complications.ConclusionsStereotactic radiosurgery for intramedullary spinal AVMs appears to be well tolerated and effective in selected cases.     

Sequential changes of ascending myelopathy after spinal cord injury on magnetic resonance imaging: a case report of neurologic deterioration from paraplegia to tetraplegia

Background contextMarked neurologic deterioration within a few days of traumatic spinal cord injury, known as subacute posttraumatic ascending myelopathy, is rare. Although several hypotheses regarding the pathogenesis of this condition have been proposed, the details remain elusive.PurposeTo report a case of ascending myelopathy in which a series of magnetic resonance images (MRIs) taken through the course of the illness helped follow the course of the disease and discuss possible pathogenesis.Study designCase report and review of the literature.Patient sampleA 75-year-old woman involved in a motor vehicle collision sustained a fracture dislocation of T7–T8 with complete paraplegia below T8.MethodsNeurologic examination and radiologic imaging taken by various means.ResultsPosterior surgical stabilization was performed 18 hours after the injury. Both the surgical and postsurgical courses were uneventful. Four days after the injury, however, the patient reported feeling a tingling sensation in the right-hand fingers and gradually suffered from motor weakness of the upper extremities, deteriorating within a few hours to complete tetraplegia and ventilator dependence. Subsequent cervicothoracic MRI showed abrupt cord swelling with abnormal areas of signal intensity in the cervical and upper thoracic spinal cord during the interval between the onset of tingling and the development of motor paralysis in the arms. On the 20th postsurgical day, an area of hypointensity within the region of high intensity was observed on T2-weighted MRIs, indicating intramedullary spinal cord hemorrhage.ConclusionsOur MRI findings suggest that systemically increased intraspinal pressure resulting from the impairment of spinal venous drainage is involved in the pathogenesis of ascending myelopathy. Although ascending myelopathy is often thought to be partly reversible, persisting increase of the intraspinal pressure may result in intramedullary hemorrhage and irreversible neurologic deficit.     

Treatment outcomes of 17 patients with atypical spinal meningioma,including 4 with metastases: a retrospective observational study

BACKGROUND CONTEXT

Because of the scarcity of atypical spinal meningioma, there is a lack of research on this type of tumor or its associated metastases.

Intramedullary spinal cord metastasis associated with hemorrhage: a case report

A rare case of intramedullary spinal cord metastasis associated with hemorrhage was reported. A 74-year-old man had a subacute onset of paraparesis. He became almost paraplegic within a few days. MRI revealed an intramedullary spinal lesion in the epiconus at the Th 11 and Th 12 level, but spinal angiography did not show any abnormality. Since repeated MRI showed enlargement of the lesion, surgery was performed under the diagnosis of an intramedullary spinal cord tumor. Under general anesthesia, a midline myelotomy of about 3 cm was performed and a grayish, elastic and circumscribed tumor as well as a liquefied hematoma in the caudal part was observed. Both the tumor and the hematoma were removed almost totally. The patient's paraparesis improved slightly after surgery. The histological diagnosis was adenocarcinoma. The primary source was unknown, but multiple small metastatic tumors were found in the lung, liver and brain, etc. Hemorrhage from intramedullary spinal cord metastasis is extremely rare with only 6 reported cases in the recent literature. Rapid deterioration of symptoms caused by the hematoma may make the diagnosis more difficult. Indication of surgical treatment should be carefully determined because prognosis of intramedullary spinal cord metastasis is generally very poor.     

Primary spinal oligoastrocytoma: a case report

BACKGROUND: Primary oligoastrocytomas of the spinal cord are rare, and the treatment options for low-grade intramedullary tumors are controversial. DESCRIPTION: A 10-year-old girl presented with thoracic scoliosis. Magnetic resonance imaging (MRI) revealed an enhancing intramedullary mass lesion extending from C-5 to T-5, associated with whole spine syringomyelia and syringobulbia. (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) showed high uptake in the lesion. The patient underwent C-5 to T-5 laminoplastic laminotomy and subtotal removal of the tumor. Histologic examination revealed that the tumor was an oligoastrocytoma without anaplastic findings. Genetic analysis revealed loss of heterozygosity of 1p and 19q but not 10q, which is characteristic of oligodendroglial tumors. CONCLUSIONS:To our knowledge, this is only the second report describing primary oligoastrocytoma of the spinal cord. Genetic analysis may provide a clue in selecting optimal adjuvant therapies.     

Intramedullary clear cell meningioma

Summary Intramedullary clear cell meningioma (CCM), which is more aggressive than other meningioma variants, is extremely rare. To date, only one case of such a spinal tumour has been documented. We report the first case of an intramedullary CCM originating in the thoracic region of the spinal cord.     

胸腰椎管内神经鞘膜瘤影像学表现和手术治疗的临床观察

目的:探讨胸腰段神经鞘膜瘤的影像学特点和手术治疗效果。方法:自2005年6月至2012年12月,手术治疗胸腰椎管内神经鞘膜瘤17例,其中男11 例,女6 例;年龄46～67 岁,平均53 岁;病程3～5 年,平均3.3 年。胸段患者表现为胸背痛,逐渐出现下肢麻木无力或行走不稳;腰段表现为腰背痛,下肢放射痛或感觉麻木,以及间歇性跛行。术前VAS评分 (疼痛视觉模拟标尺法) 5～8分,平均6.12分。11例患者神经功能受损,Frankel C级4例,D级5例,E级2例。CT和MRI检查提示病变部位:胸段3例,胸腰段5例,腰段3例,腰骶段6例;硬膜外5例,髓外硬膜下12例。6例单纯行椎管减压、肿瘤切除术,11例行椎管减压、肿瘤切除及后路内固定植骨融合术。结果:术中未发生大血管或脊髓损伤,术后伤口均正常愈合。17例患者术后均获随访,时间12～60 个月,平均32个月。胸背痛、腰背疼痛和下肢放射痛等显着改善,下肢麻木感明显缓解。末次随访VAS评分 0～3分,平均1.5分。神经功能受损患者末次随访Frankel分级:D级5例,E级6例。结论:MRI 是胸腰段神经鞘膜瘤有效的辅助诊断方法,影像学表现决定具体手术方法,手术目的是椎管有效减压、肿瘤彻底切除和脊柱稳定性的重建。     

Central neuropathic pain after surgical resection in patients with spinal intramedullary tumor

Study designRetrospective case series.ObjectiveTo examine central neuropathic pain after surgical resection of intramedullary spinal cord tumor (IMSCT).Summary of background dataBecause of the rarity of IMSCT, there is little information about postoperative neuropathic pain after surgical resection.MethodsEighty-five of 105 patients treated surgically for IMSCT at our hospital between 2000 and 2008 completed the Neuropathic Pain Symptom Inventory (NPSI) and the short form (SF)-36 health inventory. The NPSI score was analyzed against the tumor type and the postoperative Japanese Orthopaedic Association (JOA) score for neurological symptoms.ResultsThe mean NPSI score of the patients was 13.5. The subscore for paresthesia/dysesthesia was significantly higher than the other subscores. Analysis of the NPSI scores by tumor type revealed no significant differences among patients with ependymoma, astrocytoma, and vascular tumors. The postoperative JOA score showed a weak negative correlation with the NPSI score in patients with thoracic spinal cord tumor, and no correlation in those with cervical tumor. In the 11 patients with hemangioblastoma, intense pain was reported at the level of the tumor, although postoperative paralysis was mild. All the postoperative SF-36 subscores of our study patients were significantly lower than the national average, and a significant negative correlation was observed between the SF-36 and the NPSI subscores.ConclusionNeuropathic pain after surgical resection reduces the QOL of patients with IMSCTs, and pain severity varies with the tumor's location and histological features, the severity of paralysis, and the location of pain relative to the tumor.     

Idiopathic Spinal Cord Herniation: Case Report and Review of the Literature

Background: Idiopathic spinal cord herniation (ISCH) is a rare cause of progressive myelopathy frequently present in Brown-Séquard syndrome. Preoperative diagnosis can be made with magnetic resonance imaging (MRI). Many surgical techniques have been applied by various authors and are usually reversible by surgical treatment.

Methods: Case report and review of the literature.

Findings: A 45-year-old woman with Brown-Sequard syndrome underwent thoracic MRI, which revealed transdural spinal cord herniation at T8 vertebral body level. During surgery the spinal cord was reduced and the ventral dural defect was restorated primarily and reinforced with a thin layer of subdermal fat. The dural defect was then closed with interrupted stitches.

Results: Although neurologic status improved postoperatively, postsurgical MRI demonstrated swelling and abnormal T2-signal intensity in the reduced spinal cord. Review of the English language literature revealed 100 ISCH cases.

Conclusions: ISCH is a rare clinical entity that should be considered in differential diagnosis of Brown-Séquard syndrome, especially among women in their fifth decade of life. Outcome for patients who initially had Brown-Séquard syndrome was significantly better than for patients who presented with spastic paralysis. Although progression of neurologic deficits can be very slow, reduction of the spinal cord and repair of the defect are crucial in stopping or reversing the deterioration.     

Sarcoidosis of the spinal cord. Case report.

A case of intramedullary sarcoidosis simulating a tumor of the cervical spinal cord is presented. Autopsy showed that the disease was limited to the cervical cord and hilar lymph nodes. The literature is reviewed and six cases of histologically documented spinal cord sarcoidosis are discussed.     

Surgical management of a huge intramedullary ependymoma from oblongata to T4: A case report

Introduction and importanceHuge intramedullary tumor is a rare condition. Surgical management of such huge ependymoma is technically challenging. We reported one case of 300 mm long intramedullary spinal cord ependymoma from oblongata to T4, which was satisfactorily en bloc gross total resected and the cervical spine alignment was successfully maintained by laminoplasty.Case presentationA 30-year-old man presented to our service with two-year progressive neck pain combined with bilateral sense disorders of both the upper and lower extremities. The neurological grade was ASIA D. Repeat MRI imaging demonstrated a “medulla oblongata to T4” intramedullary spinal cord tumor complicated with cervical physiological curvature loss.Clinical discussionLaminectomies were made at the C1-T4 level by a milling cutter. The tumor was gently separated bilaterally. The ventral part of the tumor was separated from the cranial and the caudal ends until reaching the middle site of the tumor. The whole tumor was isolated en bloc. Titanium miniplates were used bilaterally to fix both sides of the laminoplasty section on each level. At the 2-year postoperative follow-up, the muscle strength of both the upper and lower limbs were grade Ⅳ. No tumor recurrence was detected.ConclusionThe total removal of an intramedullary ependymoma should be recommended as soon as the diagnosis is made, regardless of its extension. Long-level laminoplasty could be an effective alternative option to maintain the proper spine alignment.     

Cervical Extradural Meningioma: Case Report and Literature Review

Abstract

Background: Extradural lesions are most commonly metastatic neoplasms. Extradural meningioma accounts for 2.7 to 10% of spinal neoplasms and most commonly is found in the thoracic spine.

Design: Case report.

Findings: A 45-year-old woman presented with posterior cervicothoracic pain for 8 months following a motor vehicle crash. Magnetic resonance imaging of the cervical spine revealed an enhancing epidural mass. Computerized tomography of the chest, abdomen, and pelvis revealed no systemic disease. Due to the lesion’s unusual signal characteristics and location, an open surgical biopsy was completed, which revealed a psammomatous meningioma. Surgical decompression of the spinal cord and nerve roots was then performed. The resection was subtotal due to the extension of the tumor around the vertebral artery. Conclusion: Meningiomas should be considered in the differential diagnosis of contrast-enhancing lesions in the cervical spine.