Microsurgery for intradural epidermoid cyst at cauda equina level in a 9-year-old child: A case report

Introduction and importanceEpidermoid cysts are rare benign tumors. Here, we present a case of spontaneous intradural epidermoid cyst at cauda equina level in a 9-year-old patient, which we believed the first case to be reported in Vietnam.Case presentationA 9-year-old boy presented with 4 months of spontaneous left lower extremity muscle weakness and paresthesia. The MRI images suggested the diagnosis of intradural epidermoid cyst at cauda equina level. The patient underwent L5–S1 laminectomy and durotomy for tumor resection. The histology confirmed the diagnosis of epidermoid cyst. Post-operative images demonstrated total cyst removal.Clinical discussionThe epidermiology, presentation and diagnosis and strategy of treatments as well as their outcomes were discussed.ConclusionDiagnosis of spinal epidermoid cyst is often delayed for its obscure presentation. Microsurgical dissection along with intra-operative mobile C-Arms enable total tumor resection while preserving spinal stability and neurological function. Follow-up with post-operative magnetic resonance imaging and tumor marker are helpful.     

Tarlov cyst: Case report and review of literature

We describe a case of sacral perineural cyst presenting with complaints of low back pain with neurological claudication. The patient was treated by laminectomy and excision of the cyst. Tarlov cysts (sacral perineural cysts) are nerve root cysts found most commonly in the sacral roots, arising between the covering layer of the perineurium and the endoneurium near the dorsal root ganglion. The incidence of Tarlov cysts is 5% and most of them are asymptomatic, usually detected as incidental findings on MRI. Symptomatic Tarlov cysts are extremely rare, commonly presenting as sacral or lumbar pain syndromes, sciatica or rarely as cauda equina syndrome. Tarlov cysts should be considered in the differential diagnosis of patients presenting with these complaints.     

Hemorrhagic synovial lumbar cyst: a case report and review of the literature

The authors report a case of an 81-year-old woman affected by a synovial cyst arising from the left facet joint of L3. The patient presented with severe pain and claudicatio spinalis. Diagnosis was based upon standard x-rays and MRI; the patient was operated on and the histology of the lesion confirmed the pre-operative diagnosis. On MRI images the lesion appeared as a roundish extradural mass arising from the left facet joint of L3, compressing the cauda equina posteriorly, and it appeared with an increased heterogeneous signal, consistent with a high quantity of fluid and hemosiderin within the cyst. A communication between the lesion and the joint space was evident on the MRI sagittal reconstruction. Grossly the cut surface of the mass had a cystic aspect, with some hemorrhagic areas between whitish myxoid tissue. Histologically the lesion was formed by fibrous connective tissue covered by synovium; focal inflammation and hemosiderin-laden macrophages were also present in some areas. At one year follow-up the patient is symptom-free.     

马尾神经功能障碍型腰椎间盘突出症的诊断与治疗

目的：介绍合并有马尾神经功能障碍的腰椎间盘突出症的诊断与治疗方法。方法：发生马尾神经功能障碍型腰椎间盘突出症的病人，大多为青壮年，强体力劳动者或体育运动员，因急性腰扭伤而发病。受伤后出现瘫痪症状和马鞍区麻痹、大小便失禁等现象，经X线拍片、CT和MRI检查，明确诊断后，应立即进行手术治疗。结果：作者报告10例，均经关节突间或半椎板切除入路，切除巨块型椎间盘，彻底减压马尾神经，术后均能得到良好的功能恢复，疼痛消失，唯大小便的功能恢复较迟，约在术后1～3周后尚能恢复。结论：马尾神经功能障碍型腰椎间盘突出症，应与马尾肿瘤相鉴别，一旦被确诊为巨块型腰椎间盘突出症，就应立即进行手术治疗，越早手术效果越好。     

Acute onset of paraganglioma of filum terminale: A case report and surgical treatment

IntroductionParagangliomas of filum terminale are rare benign tumors, arising from the adrenal medulla or extra-adrenal paraganglia. These lesions usually present with chronic back pain and radiculopathy and only two cases of acute neurological deficit have been reported in literature.Presentation of caseA case with an acute paraplegia and cauda equina syndrome due to an hemorrhagic paraganglioma of the filum terminale is described. Magnetic resonance imaging showed an intradural tumor extending from L1 to L2 compressing the cauda equina, with an intralesional and intradural bleed. An emergent laminectomy with total removal of the tumor was performed allowing a post-operative partial sensory recovery. Histopathological examination diagnosed paraganglioma.DiscussionParagangliomas are solid, slow growing tumors arising from specialized neural crest cells, mostly occurring in the head and neck and rarely in cauda equina or filum terminale. MRI is gold standard radiological for diagnosis and follow-up of these lesions. They have no pathognomonic radiological and clinical features and are frequently misdiagnosed as other spinal lesions. No significant correlation was observed between the duration of symptoms and tumor dimension. Acute presentation is unusual and emergent surgical treatment is fondamental. The outcome is very good after complete excision and radiotherapical treatment is recommended after an incomplete resection. Conclusion: Early radiological assessment and timely surgery are mandatory to avoid progressive neurological deficits in case of acute clinical manifestation of paraganglioma of filum terminale.     

Cauda Equina Intradural Extramedullary Cavernous Haemangioma: Case Report and Review of the Literature

Cavernous haemangioma (cavernoma) is a benign vascular lesion, exceptionally located in cauda equina. We report a case, diagnosed and operated in the Department of Neurosurgery from Pitesti County Emergency Hospital, of a 60-year-old woman with history of lumbar region distress, who presented with low back pain, paravertebral muscle contracture, and bilateral lumbar radiculopathy, with sudden onset after lifting effort. The preoperative diagnosis was done using computed tomography (CT) and magnetic resonance imaging (MRI), and the patient underwent surgery—two level laminectomy, dural incision, and tumor dissection from the cauda equina nerve roots under operatory microscope. Histopathological examination confirmed the positive diagnosis of cavernoma of cauda equina. The patient''s outcome was favorable, without postoperative neurological deficits.     

Magnetic resonance image findings of primary intradural Ewing sarcoma of the cauda equina: case report and review of the literature

Background contextInvolvement of the cauda equina in Ewing sarcoma (ES) is extremely rare, and only few cases are reported in literature. However, ES of cauda equina shares some neuroradiological features with other neoplasms that can involve the intradural space. Therefore, differential diagnosis with other tumors of cauda equina should be considered by neuroradiologists and neurosurgeons to provide appropriate treatment.PurposeTo present a rare case of intradural extramedullary primary ES.Study designCase report.MethodsWe report a case of a 44-year-old woman presenting with the rapid onset of cauda equina syndrome. Radiological analysis showed multiple intradural masses, extending from L1 to S3 level. After radical surgery, lesions were histologically defined as ES. We present a literature review, analyzing magnetic resonance image (MRI) features of primary intradural ES of the cauda equina.ResultsFour cases of primitive ES arising from the cauda equina have been reported in the literature.ConclusionsBecause of the low number of reported cases, it is not possible to describe pathognomonic MRI findings for intradural ES of the cauda equina. However, few tumors show similar MRI features. Therefore, despite its rarity, intradural ES should be taken into account in the differential diagnosis of spinal tumors involving cauda equina.     

MRI of epidermoid cyst of the conus medullaris

STUDY DESIGN: A case report of an epidermoid cyst in the conus medullaris with characteristic magnetic resonance imaging (MRI) findings. OBJECTIVE: To describe an epidermoid cyst in the conus medullaris with characteristic MRI findings and point out these findings that correlated well with histologic findings. SETTING: Taiwan. CASE REPORT: A 49-year-old man who suffered from pain and weakness in his right leg for 16 years. MRI showed a heterogeneous signal mass in the conus medullaris. The hyperintense signal area within the lesion may be attributed to the keratin content, whereas the hypointense signal area was related to calcification and soft-tissue component. The histologic findings were compatible with an epidermoid cyst. CONCLUSION: Epidermoid cysts in the conus medullaris must be considered in the differential diagnosis of mass lesions with long duration of related symptoms. The characteristic MRI findings are useful to differentiate epidermoid cysts from other tumors.     

Epidermoid tumor of the cauda equina presenting with urinary stress incontinence

Spinal cord tumors are a rare cause of urinary incontinence. Tumors of the spinal cord usually present with pain, not with isolated urinary complaints. We report a case in which a patient with an epidermoid tumor of the cauda equina presented initially to a gynecologist complaining of urinary incontinence and pelvic relaxation symptoms. Failure to appreciate the neurologic signs on physical examination may have led to a delay in diagnosis and inappropriate management of the patient.     

Paraganglioma of the filum terminal: Case report and review of the literature

Paraganglioma of the filum terminal/cauda equina is a rare slow growing tumor which originates from the ectopic sympathetic neurons. Surgically, total excision may be difficult for this well demarcated tumor surrounded by couple of rootlets but is usually possible in nearly all cases. Actually, final diagnosis cannot be determined intraoperatively, but is possible only after an immunohistochemical staining. Herein, the authors present a middle age woman whose initial symptoms were lower back pain and radiculopathy. Her MRI was found to be compatible with a cauda equina tumor. During her excisional surgery a hard and relatively vascular tumor was fully removed. The Immunohistochemical results were compatible with paraganglioma of the filum terminale. In addition to case presentation, thorough review of the literature is also done.     

Paraganglioma of the cauda equina. Case report with 33-month recurrence free follow-up and review of the literature

Paraganglioma of the cauda equina is an unusual tumor and do not have the secretory properties of the same tumors arising outside the nervous system. In none of the few cases reported in literature a preoperative diagnosis was possible, and the surgical findings raised questions in the differential diagnosis with ependymomas. A rare case of paraganglioma of the cauda equina studied both pre- and postoperatively by MRI, and treated with subtotal excision combined with radiotherapy is described. Results and recurrence rates of the cases reported in literature are reviewed. Though MRI imaging has proven to be more sensitive than other radiological procedures, we stress the difficulties of preoperative diagnosis of paragangliomas in this site. The correct diagnosis of the paraganglioma of the cauda equina still relies on immunochemistry and electron microscopy. Total excision is often very difficult owing the tendency of these neoplasms to infiltrate cauda's roots. A 33-month recurrence free follow-up of our patient confirms that successful treatment is achieved by subtotal resection combined with radiotherapy.     

Cauda equina syndrome: false-positive diagnosis of neurogenic bladder can be reduced by multichannel urodynamic study

The present consensus suggests urgent surgical decompression if clinical features of cauda equina syndrome (CES) are supported by MRI evidence of pressure on cauda equina. However, clinical diagnosis has a high false-positive rate and MRI is a poor indicator. Though urodynamic studies (UDS) provide objective information about the lower urinary tract symptoms experienced by patients including neurogenic bladder, its role in the diagnosis of CES is not established. To evaluate the ability of an objective urological assessment protocol using uroflowmetry + USG-PVR as screening test and invasive UDS as confirmatory test in patients with suspected CES to rule out neurological impairment of the bladder function. A retrospective study was conducted on all patients who were referred to our institution with equivocal findings of cauda equina syndrome from January 2014 to December 2018 with positive MRI findings. An algorithm using multichannel UDS was followed in all the included patients. Out of 249 patients who fulfilled the inclusion criteria, 34 patients (13.65%) had normal uroflowmetry and USG-PVR findings; 211 patients underwent the invasive UDS. Only 141(57.6%) patients out of 245 patients had neurovesical involvement due to compression of cauda equina; 67 patients were treated conservatively using the objective protocol. Only one patient treated conservatively had to undergo emergency decompression for deterioration in symptoms. Multichannel UDS provides an objective diagnostic tool to definitively establish the neurovesical involvement in CES. Utilising multichannel UDS as an adjunct to clinical findings avoids the probability of false-positive diagnosis of CES. These slides can be retrieved under Electronic Supplementary Material.     

Giant epidermoid cyst of the scrotum: a case report]

A 74-year-old male with the chief complaint of painless enlargement of a mass in the scrotum was diagnosed as having a giant epidermoid cyst on July 8, 1991. He had no past history of injury or pain of the scrotum. Magnetic resonance imaging (MRI) of the scrotum demonstrated a well-circumscribed homogeneous mass, and was distinguished from both normal testes. Under the diagnosis of intrascrotal epidermoid cyst, the mass was resected surgically. The mass measured 23 x 15 x 15 cm, and it contained liquids. The pathological diagnosis was epidermoid cyst of the scrotum.     

The value of interhospital transfer and emergency MRI for suspected cauda equina syndrome: a 2-year retrospective study

INTRODUCTION

The timing of surgery in cauda equina syndrome due to prolapsed intervertebral disc remains controversial. Assessment of these patients requires magnetic resonance imaging (MRI), which is of limited availability outside normal working hours in the UK.

PATIENTS AND METHODS

We reviewed radiological results in all patients undergoing emergency MRI within our unit for suspected cauda equina syndrome over a 2-year period, and all subjects undergoing emergency lumbar discectomy for cauda equina syndrome within the same period. Outcome measures were: proportion of positive findings in symptomatic patients and proportion of patients referred with diagnostic MRI scans undergoing emergency surgery. We also assessed outcomes of patients having surgery for cauda equina syndrome in terms of improvement of pain, sensory and sphincter disturbance.

RESULTS

A total of 76 patients were transferred for assessment and ‘on-call’ MRI; 27 were subsequently operated upon. Only 5 proceeded to emergency discectomy that night (prior to next scheduled list). This may be due to delays in timing – from referral to acceptance, to arrival in the department, to diagnostic scan and to theatre. With the second group of patients, 43 had emergency discectomy for cauda equina syndrome during the study period. Of these, 6 patients had an out-of-hours MRI at our hospital for assessment (one patient living locally). Most surgically treated patients experienced improvement in their pain syndrome, with approximately two-thirds experiencing improvement in sensory and sphincter disturbance.

CONCLUSIONS

These data support a policy of advising MRI scan for cauda equina syndrome at the earliest opportunity within the next 24 h in the referring hospital, rather than emergency transfer for diagnostic imaging which has a relatively low yield in terms of patients operated on as an emergency.     

Cauda equina syndrome caused by primary lumbosacral and pelvic hydatid cyst: a case report.

INTRODUCTION: Hydatid disease occurs in humans as a result of faeco-oral contamination and spinal echinococcosis is rare even in areas where echinococcosis is endemic. Hydatid cyst primarily occurs in the liver and lungs. Bone involvement constitutes only 0.5-2% of all hydatidoses. About half of the bone involvement occurs in vertebrae. The thoracic spine is the most common site of the spinal hydatidosis. Primary hydatid cysts of the lumbar and sacral spinal canal are very rare. CASE REPORT: We present a 31-year-old man with cauda equina syndrome caused by a primary hydatid cyst of the lumbosacral and pelvic areas. He had been admitted to hospital with left foot and low back pain three years ago. Magnetic resonance imaging revealed an intraspinal hydatid cyst extending from L2 to S2. The cyst had been totally removed. He was symptom-free for three years. After three years, he presented with acute cauda equina syndrome. His neurological examination revealed total plegia of dorsal flexion of the left foot and perianal hypoaesthesia. MRI showed lumbosacral and pelvic hydatidosis again. After total removal of the cyst, his neurological status revealed immediately relief. DISCUSSION: Hydatid cyst is an important health problem in some countries including Turkey. Bone involvement is seen in only 0.5-2% of cases. Furthermore sacral and lumber vertebral involvement is extremely rare. We presented a case with a spinal hydatid cyst which classified as a combination of intraspinal extradural, vertebral and paravertebral forms according to the Braitwate and Lees classification. Surgical excision and additional medical treatment is still the most effective treatment. Cysts located intraspinally have a tendency to rupture spontaneously. For this reason the high recurrence rate (30- 40%) is still a major problem in management.     

Cauda equina syndrome following combined spinal and epidural anesthesia: a case report

Purpose

To describe a case of complete neurological recovery from cauda equina syndrome lasting ten months following spinal anesthesia with 0.5% hyperbaric bupivacaine and epidural anesthesia with ropivacaine, and to discuss the possible mechanisms involved.

Clinical findings

A 79-yr-old man with Paget’s disease was scheduled for surgery to remove a skin tumour below his scrotum. He had no history of radicular pain or back pain and no pre-existing neurologic disorder. Surgery was performed with the patient in the supine position. He received 0.5% hyperbaric bupivacaine intrathecally for the procedure and ropivacaine through an epidural catheter for postoperative pain management. After catheter removal, the patient developed urinary retention, fecal incontinence, and perianal hypoesthesia. A lumbosacral magnetic resonance imaging (MRI) revealed no tumour, infarction, degeneration, spinal stenosis, or compression on the cauda equina nerve roots. A diagnosis of cauda equina syndrome was made, and the etiology was thought to be toxicity of bupivacaine either alone or in combination with ropivacaine. After three months, the patient reported some return of sensation at the perianal area, with complete resolution at four months. At the ten-month follow-up visit, the patient had recovered from his urinary retention and fecal incontinence.

Conclusion

This case suggests that spinal anesthesia, even with an ordinary dose of hyperbaric 0.5% bupivacaine, might induce cauda equina syndrome in older patients.     

Metastatic Grawitz's tumor to the cauda equina: case report

A case of Grawitz's tumor metastasizing to the cauda equina is presented. A 51-year-old male was hospitalized due to severe low back pain radiating to the left lower extremity. Neurological examination showed only hyporeflexia of the left patella reflex and positive Lasegue's sign. MRI showed intradural mass at the L4 level. Preoperatively, we diagnosed a cauda equina tumor. A laminectomy of both L3 and L4 was performed, and total removal of the cauda equina tumor was performed. Microscopically, the tumor cells were large, the appearance of the cytoplasm ranging from optically clear with sharply outlined boundaries, to deeply granular, with many transitional forms. These histological findings were typical findings of Grawitz's tumor, and were the same as those of this patient's renal tumor. Finally, we diagnosed Grawitz's tumor metastasizing to the cauda equina. Metastatic cauda equina tumor from outside the central nervous system is very rare and only 7 cases have been reported. This case is the first one of Grawitz's tumor spreading to the cauda equina.     

Cauda equina syndrome after intradural anesthesia with bupivacaine

A 70-year-old man developed pain and functional weakness in the lower limbs with dysesthesia and urinary retention after subarachnoid anesthesia with 0.5% hyperbaric bupivacaine. Neurological and electrophysiological tests and follow-up, as well as diagnostic images (CAT and MR), ruled out spinal cord lesions. The diagnosis was cauda equina syndrome. Cauda equina syndrome is a neurological complication of subarachnoid anesthesia. Associated with use of microcatheters for continuous subarachnoid anesthesia and 5% hyperbaric lidocaine, cauda equina syndrome is rare after a single injection of bupivacaine. Although the pathogenesis of cauda equina syndrome is poorly understood, there is agreement on the neurotoxicity of local anesthetics, particularly of 5% hyperbaric lidocaine.     

伴有马尾神经松弛影像学改变的腰椎椎管狭窄症患者手术疗效

目的探讨伴马尾神经松弛影像学改变的腰椎椎管狭窄症患者的临床特征及手术效果。方法收集2016年9月—2017年9月接受手术治疗的16例影像学上存在马尾神经松弛改变的腰椎椎管狭窄症患者的临床及影像学资料。16例患者腰椎MRI均可见狭窄节段上方马尾神经迂曲成团,均行常规腰椎后路椎板减压椎间植骨融合内固定术治疗,其中3例患者因术中硬膜撕裂行硬膜内探查。记录所有患者术前与术后3个月的日本骨科学会(JOA)评分评估手术疗效。结果所有患者术后腰痛及下肢放射痛等症状均缓解,无并发症发生。3例患者硬膜内探查可见马尾神经迂曲成团,无粘连及占位。16例患者术后3个月JOA评分为9～14(12.56±0.75)分,较术前4～9(7.44±0.73)分明显改善,差异有统计学意义(P 0.05)。其中6例患者术后3个月复查腰椎MRI,显示马尾神经迂曲成团现象消失。结论马尾神经松弛是腰椎椎管狭窄症发展进程的一部分,椎管内马尾神经迂曲成团是导致其影像学改变的原因。治疗腰椎原发病可以获得较好的治疗效果,不需要松解马尾神经,也不必担心马尾神经松弛现象。     

腰骶神经损害致马尾神经综合征的临床分期及早期诊断

目的: 探讨马尾神经综合征临床发病特点, 分析其分期。方法: 分析马尾神经综合征患者的临床表现、实验室检查和影像学检查的变化规律。结果: 马尾神经综合征的临床主要表现为鞍区感觉、大小便、性功能障碍,首发症状为感觉功能的障碍, 继而出现括约肌功能及性功能的障碍。临床表现出现前BCR (bulbo cavernosus reflex)、ICR (ischio cavernosus reflex) 等已有明显异常。影像学研究认为, 大部分表现为多节段椎管狭窄。结论: 马尾神经综合征分前期、早期、中期、晚期。电生理改变和鞍区感觉的功能改变是早期诊断的指标。在前期、早期诊断马尾神经综合征称为早期诊断。