Multilevel costovertebral echinococcosis: effectiveness of a combined approach

Hydatid disease generally involves the liver and the lung, but rarely can be encountered in bones. The disease predominantly occurs in vascularized areas, involving in descending order: vertebrae, long bones, ilium, skull, and ribs. Vertebral and rib hydatidosis may result from vascular or lymphatic migration of a fertile cell from a hepatic focus. In humans, the two main forms are due to Echinococcus granulosis and less frequently, E. multilocularis (alveolaris). The hydatid cysts usually grow slowly asymptomatically and compression of the involved or the neighboring organ causes clinical manifestations. In this patient, hydatid disease occurred in the chest wall with secondary spinal canal involvement successfully treated by removal of cysts via T7, T8, T9, T10, and T11 laminectomies via a posterior approach, followed by resection of the involved ribs. Total removal of cysts without rupture appears to provide effective protection against late recurrences.     

椎管内蛛网膜囊肿临床表现及其手术方式

目的:分析椎管内蛛网膜囊肿的临床表现、手术方式及其治疗效果,为椎管内蛛网膜囊肿诊断和手术治疗方案的合理选择提供依据.方法:回顾分析21例椎管内蛛网膜囊肿临床表现、手术方式及术后效果,男9例,女12例;年龄21～55岁,平均36.15岁;病程2个月～3年,平均6.2个月.21例椎管内蛛网膜囊肿中1例发生于颈段、1例发生于胸段、19例发生于骶部,表现为受累神经支配区的放射性疼痛、感觉异常、功能障碍.16例经CT结合椎管造影明确诊断,其余通过MRI明确诊断.8例采用囊肿切除、囊颈部结扎、硬膜重叠紧缩缝合手术;11例囊肿壁与神经难以分离,采用囊肿壁部分切除、交通口肌肉堵塞、硬膜紧缩缝合手术;2例串珠状囊肿,其交通口未能找到,采用囊肿开窗引流、囊壁部分切除、硬膜重叠紧缩缝合、游离肌肉压迫固定.结果:19例患者获得随访,随访时间2个月～5年3个月,平均21.2个月.囊肿切除、囊颈部结扎手术组的优良为6例,囊肿壁部分切除、交通口肌肉堵塞组的优良为8例.结论:椎管内蛛网膜囊肿是蛛网膜的先天性畸形,以骶部椎管好发,大多数临床表现为受累神经的功能异常;具有手术指征的病例,术中应根据囊肿开口、囊肿壁是否能与神经分离等情况选择不同的囊肿处理方法.     

Computed tomography and magnetic resonance imaging in spinal hydatidosis

Computed tomography and magnetic resonance imaging in patients with spinal hydatidosis provide comprehensive evaluation of the actual extent of the disease. Paravertebral uncalcified cysts, hardly recognizable by conventional radiologic examinations, are clearly shown by both methods. Initial involvement of the spongy bone is evident in computed tomography scans, in contrast to what usually appears to be normal in plain films or tomograms. Occurrence of cysts within the spinal canal is revealed by both types of computed scans, with magnetic resonance imaging being able to provide further information on the involvement of the spinal cord.     

Management of a ruptured hydatid cyst involving the ribs: Dealing with a challenging case and review of the literature

IntroductionHydatid liver cysts can rupture into neighboring structures in 15–60% of patients, and most often involves the bile duct, the bronchi, and the peritoneal/pleural cavities. Rarely, chest or abdominal wall involvement occurs that are challenging to manage. This case report and literature review describes the management of patients with chest wall and rib invasion.Presentation of caseA 74-year-old woman, of Spanish origin, presented with right upper quadrant abdominal pain and tender localized swelling. On computer tomography (CT) assessment, the rupture of a hydatid cyst into the right anterior chest wall was identified. Partial involvement of the 10th and 11th rib were noted. The diagnosis was confirmed by a serological test. Surgical treatment involved a radical en bloc right hepatic resection together with resection of the involved ribs, diaphragm and subcutaneous tissue. Primary diaphragm and wall closures were performed. The postoperative course was uneventful with three weeks of albendazole treatment. CT follow-up at six months demonstrated the absence of recurrence.DiscussionComplete resection is the gold standard treatment of patients with hydatid cysts with the aim to remove all parasitic and pericystic tissues.ConclusionThe present report illustrates that an aggressive surgical en bloc resection is feasible and should be preferred for the treatment of hydatid cysts with rupture into the chest wall, even when the ribs are involved.     

Unusual Location of Hydatid Cysts: A Case Report and Literature Review

Hydatid cysts develop most frequently in the liver and lungs, but they are occasionally found in other organs. Hydatid cysts in the axillary space are an extremely rare event in areas where the disease is endemic, and are still common in many countries, including Turkey. A 73-year-old man presented to our clinic with a painful axillary mass. Thoracoabdominal computed tomography revealed multilocular cystic masses localized in the left axillary space, with minimal invasion of the peripheral soft tissue and no pulmonary or hepatic involvement. An echinococcal indirect hemagglutination test was negative. The masses were dissected through their stalks and removed completely. Macroscopic and microscopic examination of the specimens confirmed hydatid cysts. This case report demonstrates that hydatid cysts should be considered as a possible cause for palpable lesions in the axillary region or chest wall, especially in endemic locations.     

Giant cell tumor expanded into the thoracic cavity with spinal involvement

This article describes a case of a giant cell tumor that expanded into the thoracic cavity and through the spinal canal into the vertebrae. A 36-year-old man presented with a 6-month history of back pain and dyspnea. Plain chest radiographs showed a huge mass accompanied by right pleural effusion. The mass involved the 12th thoracic spine, and the spinal cord was severely compressed. The tumor was resected with a 2-stage procedure. As a first stage to separate the tumor from the anterior vital structures under direct vision, thoracic surgeons performed a right thoracotomy with chest wall reconstruction from the 8th to 11th ribs. The right lung and inferior vena cava were gently retracted, and the tumor was carefully detached from these structures. We were not able to separate the tumor from the right diaphragm due to severe invasion; therefore, we performed partial resection of the right diaphragm with the tumor. After excision of the anterior part of the tumor, the thoracic wall was reconstructed with the right eighth rib and Marlex mesh. When the patient's general condition improved 2 weeks later, spondylectomy by posterior approach was performed. We achieved excision of a giant cell tumor that had expanded into the thoracic cavity and through the spinal canal into the vertebrae. The patient had achieved full rehabilitation with no neurological or respiratory abnormalities at 7 years postoperatively.     

A spinal thecal sac constriction model supports the theory that induced pressure gradients in the cord cause edema and cyst formation

OBJECTIVE: Spinal cord cysts are a devastating condition that occur secondary to obstructions of the spinal canal, which may be caused by congenital malformations, trauma, spinal canal stenosis, tumors, meningitis, or arachnoiditis. A hypothesis that could explain how spinal cord cysts form in these situations has been presented recently. Therefore, a novel spinal thecal sac constriction model was implemented to test various aspects of this hypothesis. METHODS: Thecal sac constriction was achieved by subjecting rats to an extradural silk ligature at the T8 spinal cord level. Rats with complete spinal cord transection served as a second model for comparison. The animals underwent high-resolution magnetic resonance imaging and histological analysis. RESULTS: Thecal sac constriction caused edema cranial and caudal to the ligation within 3 weeks, and cysts developed after 8 to 13 weeks. In contrast, cysts in rats with spinal cord transection were located predominantly in the cranial spinal cord. Histological sections of spinal cords confirmed the magnetic resonance imaging results. CONCLUSION: Magnetic resonance imaging provided the specific advantage of enabling characterization of events as they occurred repeatedly over time in the spinal cords of individual living animals. The spinal thecal sac constriction model proved useful for investigation of features of the cerebrospinal fluid pulse pressure theory. Edema and cyst distributions were in accordance with this theory. We conclude that induced intramedullary pressure gradients originating from the cerebrospinal fluid pulse pressure may underlie cyst formation in the vicinity of spinal canal obstructions and that cysts are preceded by edema.     

A case of cervical endodermal cyst

A very rare case involving an endodermal cyst of the cervical spinal canal was documented. In 1999, a 28-year-old male presented with mild tetraplegia due to a traffic accident and consequently, he was admitted to another hospital. Magnetic resonance imaging (MRI) performed at that time demonstrated a cervical cord cyst. He was treated conservatively and as a result, complete resolution of symptoms was achieved. Five years later, he presented with progressive right hemiparesis and was referred to our institute. MRI at the time of admission exhibited an intradural extramedullary cystic lesion on the ventral side of the spinal cord at the C5-6 levels, which was characterized by low intensity on T1-weighted, and by high intensity on T2-weighted images. The cyst, which had increased in size, compressed the spinal cord remarkably backward. The anterior central vertebrectomy approach was performed. Subtotal resection of the cyst wall was conducted due to its tight partical adhesion to the spinal cord. The vertebral defect was reconstructed with an autogenous iliac graft. According to histological findings the cyst wall consisted of a single layer of columnar epithelial cells with secretory granules and immunohistochemical examination revealed that the cyst wall was positive for cytokeratin 7. Symptoms improved immediately. Subsequently, the patient was discharged with good performance status. Endodermal cysts are very rare developmental cysts derived from the embryonic endodermal layer. Moreover, these lesions are usually located intradurally in the cervical and upper dorsal spine ventral to the spinal cord. Total removal of the cyst is recommended if it is possible. However, total resection is often difficult due to adhesion of the cyst wall to the neural tissue so invasive resection should be avoided. In such cases, follow-up MRI is necessary in order to exclude recurrence of the remnant lesion.     

A case of paraffinoma after plombage with spinal paralysis

A 55-year-old woman was presented with large left-sided chest wall mass and spinal paralysis. She had undergone pleural plombage using paraffin for pulmonary tuberculosis at age 40 years. Thoracotomy was performed and all paraffin was removed. Paraffin provoked granulomatous change (paraffinoma) and invaded to vertebral canal. She remains well at 16 months postoperatively without spinal paralysis.     

Cystic acoustic neurinomas: Studies of 14 cases

Summary Cystic acoustic neurinomas (ANs) are less frequent and are different from solid ANs in clinical and radiological features. We had 14 cystic ANs (13.5% of 104 cases) in the last 17 years. Computerized tomographic or magnetic resonance images allowed for the classification of these cystic ANs into three types: Type A being large single cysts with a thin tumourous wall (7 cases); type B single cysts with a thick tumourous wall (3 cases); type C multicystic (4 cases). Half of the cystic ANs were not accompanied by enlargement of the internal auditory canal, despite the largeness of the cysts. The mean size of the tumours was 29 mm in diameter. Type A cysts had a shorter clinical history than types B and C. One patient had intact hearing. In five cases, an atypical initial symptom such as facial pain, dysgeusia, facial palsy, unsteadiness or vertigo presented. The trigeminal nerve was involved in 12 cases, the facial nerve in nine. The characteristic features of cystic ANs are largeness of the tumour, a short clinical history, an atypical initial symptom, facial nerve involvement, and/or no enlargement of the internal auditory canal. In addition, the histological features are a lobular growth pattern, high nuclear atypia, and numerous macro phages.     

Posterior midline approach for single-stage en bloc resection and circumferential spinal stabilization for locally advanced Pancoast tumors. Technical note

The treatment of Pancoast (superior sulcus) tumors that extensively invade the vertebral column remains controversial. Different surgical approaches involving multistage resection techniques have been previously described for superior sulcus tumors that invade the chest wall and spinal column. Typically a posterior approach to stabilize the spine is followed by a second-stage thoracotomy (posterolateral or trap door) for definitive en bloc resection of stage T4 Pancoast tumors. The authors report and elaborate on a surgical technique successfully used for an en bloc resection as well as spinal stabilization through a single-stage posterior approach without any added morbidity. Two patients with histologically proven Pancoast tumors were treated by single-stage resection and stabilization through a posterior approach at the H. Lee Moffitt Cancer Center. A wedge lung resection or lobectomy was performed by the chest surgeon utilizing the chest wall defect. Placement of an anterior cage (in one case) and posterior cervicothoracic spinal instrumentation (in both cases) was performed during the same operation. Average blood loss was 675 ml and surgical time was 7 hours. The median hospital stay was 9 days (range 7-11 days). Both patients did well postoperatively and were free of recurrence at the 2-year follow-up. Radical resection of Pancoast tumors including lobectomy, chest wall resection, costotransversectomy, and partial or complete vertebrectomy with simultaneous instrumentation for spinal stabilization can be performed through a posterior single-stage approach.     

Synovial cysts and the lithotomy position causing cauda equina syndrome

We describe a case of cauda equina syndrome caused by synovial cysts and the lithotomy position. A transurethral resection of the prostate was performed under spinal anesthesia in the lithotomy position. We believe that this is the first case report of facet joint synovial cysts and the lithotomy position causing ischemic neurologic injury to the cauda equina. Other etiologies such as needle trauma, neurotoxicity, hematoma, and abscess were not evident. We believe that positioning the patient in the lithotomy position narrowed the cross-sectional area of the spinal canal in a patient with a coexisting critically stenosed lumbar spinal canal. The resultant mechanical pressure caused an ischemic compression injury to the cauda equina.     

Ventral intradural endodermal cyst in the cervical spine treated with anterior corpectomy--case report

A 14-year-old girl who presented with an endodermal cyst manifesting as severe neck and shoulder pain along with vesicorectal disturbances. Cervical magnetic resonance imaging showed a slightly enhanced intradural cyst at the C6-7 level in the ventral side of the spinal canal, with significant dorsal shortening and thinning of the spinal cord. Anterior corpectomy was chosen because of the dorsal effacement of the spinal cord. The cyst wall was subtotally removed to avoid damage to the normal spinal cord. After cyst removal, the iliac bone and an anterior cervical plate were used for anterior fusion. Postoperatively, her pain subsided without neurological deficits. The histological diagnosis was endodermal cyst. The cyst did not recur during a follow-up period of 18 months. Endodermal cysts are rare congenital lesions of the spine lined by endodermal epithelium. The natural history of this lesion is unclear, and the surgical strategy for the approach route and the extent of removal of the cyst wall remain controversial. We suggest that the anterior approach may allow a safer and more effective surgical route for the treatment of ventrally located endodermal cyst compared to the posterior approach.     

Multiple neurenteric cysts in the posterior fossa and cervical spinal canal--case report

A 46-year-old woman presented with multiple neurenteric cysts in the posterior fossa and spinal canal. Neuroimaging demonstrated neurenteric cysts in the interspace between the left cerebellar hemisphere and vermis, the lateral side of the right cerebellar hemisphere, and the ventral side of the spinal cord at the C-2 and C-4 levels. Total resection of the paravermian cyst and partial removal of the spinal cyst at the C-4 level were performed. Histological examination showed the cyst wall consisted of single or multiple layers of columnar epithelial cells with secretory granules, with mucin secretion verified by periodic acid-Schiff staining. Immunohistochemical staining showed the walls were positive for the cytokeratin, epithelial membrane antigen, and carcinoembryonic antigen, and negative for glial fibrillary acidic protein and S-100 protein. These findings confirmed the endodermal origin. The diagnosis was neurenteric cyst. The paravermian cyst disappeared, but the spinal cyst at the C-4 level recurred 8 months later. Reoperation became necessary 16 months later. The other two cysts also showed enlargement at 6 or 15 months. Total removal of neurenteric cyst is recommended if possible.     

Lumbar intradural extramedullary bronchiogenic cyst

The pathological findings of an intradural and extramedullary cyst at the L1 level of the spinal canal are described in a 28-year-old male who presented with chronic lumbago and progressive weakness and numbness in both lower limbs. Histopathological examination revealed the diagnosis of bronchiogenic cyst. Bronchiogenic cysts in the spinal canal are uncommon, and cysts at the L1 level are extremely rare. Their pathogenesis is still poorly understood. They are thought to be a malformation arising from a split notochordal syndrome. We conclude that intradural extramedullary bronchiogenic cysts may appear also at lumbar levels. Surgical resection can be achieved with good outcome.     

Polyvisceral echinococcosis with involvement of the heart and chest wall: follow-up and review of literature.

Echinococcosis remains an endemic surgical problem in countries where sheep and cattle raising is carried out, particularly in many Mediterranean countries. The life cycle of echinococcosis is usually marked by the filtration of larvae through the liver and lungs which are the organs most commonly affected by a hydatid cyst. Hydatid cysts in other sites are not common. Cardiac echinococcosis has been reported infrequently even in countries in which hydatid disease is endemic, only isolated sporadic cases have been reported in the literature. Here we report a case of polyvisceral hydatid cyst with involvement of heart and chest wall and reviewed the literature and discussed clinical procedures and management.     

Ganglion cyst of a lumbar facet joint in an adolescent—a case report

‘Lumbar facet joint synovial cyst’ is the recent terminology used to describe cysts within and outside the lumbar spinal canal. These include ganglion cysts, synovial cysts and cysts arising from the ligamentum flavum. Ganglion or synovial cysts typically arise from the joints and tendon sheaths of the appendicular skeleton but are uncommon in the spinal facet joints and rare in an adolescent. This case report illustrates a 14-year-old female patient of the senior author (JHP) with lumbar facet joint cyst who presented with lower back pain. Excisional biopsy was performed and the histology confirmed the diagnosis of a ganglion cyst.     

胸腰椎爆裂骨折损伤部位和椎管内占位程度与神经损伤的关系

目的探讨胸腰椎爆裂骨折骨折部位及椎管内骨块占位程度与神经损伤的关系。方法对213例胸腰椎爆裂骨折根据骨折部位及CT测出的椎管内骨折骨块占位程度与神经损伤进行分析评定。结果神经损伤组椎管骨折骨块占位程度明显高于无神经损伤组;在有神经损伤情况下,骨折部位椎管内骨块占位程度腰段大于胸腰段;神经损伤程度与椎管内骨块占位程度无显著相关。结论胸腰椎爆裂骨折椎管内骨块占位压迫是神经损伤的重要因素;神经损伤与骨折部位和椎管内骨块占位程度联合相关。     

Racemous cysticercosis of the cauda equina and cystic arachnoiditis. Apropos of 2 cases

Central nervous system infection by the larval form of the pork tapeworm, taenia solium is a major public health problem in view of its prevalence. The high incidence of neurocysticercosis in Reunion Island has been precised by computerized tomography and Elisa test. Spinal involvement is an uncommon form of cysticercosis, occurring with a frequency of less than 1% in large series. The types of involvement that are most common are subarachnoid cysts which appear as intradural extramedullary masses and meningeal reaction with appearance of arachnoiditis at myelography. Intramedullary involvement is less frequent. Epidural and subpial masses have been reported very rarely. The authors report the two first cases of spinal cysticercosis in Reunion Island which are both extramedullary leptomeningeal forms. A radicular syndrome was present in both cases; incontinence and sacral hemihypoesthesia in one case. Myelography showed lumbosacral arachnoid cysts. Immunodiagnostic tests were positive in blood and C.S.F. in the two cases. Laminectomy was performed and the arachnoid membrane appeared opaque and thickened; the cysts were removed. Microscopically the cystic wall had a thin and curved cuticle, no scolex was found. Treatment was completed with the anti-helminthic agent Praziquantel. Full recovery was observed in one case. In the other case low back pain spread out to the lower extremities with a non radicular distribution and was associated with lumbosacral spinal fibrosis.     

Primary hydatid disease of the chest wall.

The chest wall is an unusual location for primary echinococcus disease. We report on case of a primary chest wall hydatid cysts, resembling a mass lesion, in a 50-year-old woman who had no prior surgery for hydatid disease before. Chest wall hydatid disease should be considered in the atypical location and differential diagnosis of chest wall masses.