Correlation analysis of demographic and anthropometric factors,hip flexion angle and conus medullaris displacement with unilateral and bilateral straight leg raise

Purpose

It has been shown that the conus medullaris displaces significantly and consistently in response to both unilateral and bilateral SLRs. Point of interest is represented by whether the magnitude of this displacement can be predicted in asymptomatic subjects. The purpose was to investigate whether any correlations existed between demographic and anthropometric factors and hip flexion angle with magnitude of conus medullaris displacement with the unilateral and bilateral SLR. This was done following the notion that there is the possibility that cord movement may contain aspects of predictability in asymptomatic subjects.

Methods

Using the same methods as in our previous MRI studies, we further investigated whether any correlations existed between age, height, weight, BMI or hip flexion angle and magnitude of conus medullaris displacement with the unilateral and bilateral SLR.

Results

Moderate to strong positive correlation was found between degree of hip flexion and magnitude of conus medullaris caudal displacement with unilateral and bilateral SLRs and CuMeD. A negligible inverse correlation between subjects’ height and magnitude of conus medullaris displacement in response to unilateral SLR was found, while no correlation (r < 0.1) emerged with bilateral SLR and CuMeD. No correlation was found for other values such as age, weight or BMI.

Conclusions

The data show that in in vivo and structurally intact asymptomatic volunteers, the degree of hip flexion may have strong predictive values for magnitude of neural displacement in response to unilateral and bilateral SLRs. This provides further justification to its quantification in clinical settings. Magnitude of conus medullaris displacement in response to unilateral and bilateral SLRs is not likely to be predicted from easily clinically collectable measures such as age, height, weight and BMI. This study offers information relevant to investigation of prediction of neuromechanical responses in neurodynamic tests.

     

Co-existence of L5-S1 disc herniation and conus medullaris ependymoma

INTRODUCTION

The lumbar disc herniations are seen very common than spinal ependymomas in the neurosurgery polyclinic routine.

PRESENTATION OF CASE

In our case, both pathologies were seen at the most frequently located levels compatible with the literature.Aim of this case report is, to remind once more that, different pathologies can be found at the same time in a single patient; differential diagnosis must be done very carefully.

DISCUSSION

The routine Computed Tomography (CT) imaging for low back pain can not show the conus medullaris pathology. Spinal tumors or other similar pathologies should be kept in mind for differential diagnosis. A good medical history and a good physical examination must be completed before the final diagnosis.

CONCLUSION

Viewing of spinal canal with Magnetic Resonance Imaging (MRI) will be useful for the patients who we intend to do disc surgery.     

Metachronous benign ovarian tumors are not uncommon in children

Purpose

To evaluate the risk for metachronous ovarian tumor in pediatric patients with mature ovarian teratoma.

Methods

During 1981–2011, 22 children underwent oophorectomy for mature teratoma at the median age of 11.4 (range 1.5–15.3) years. The patients were followed-up in median 4.4 (range 0.5–25.5) years.

Results

None of the patients had synchronous bilateral tumor at the time of primary operation, but during follow-up five patients (23%) got metachronous contralateral ovarian tumor. The contralateral tumor was observed in median 3.6 (range 1–8.8) years after the primary operation. According to Kaplan–Meier analysis the risk for contralateral tumor was 14% ± 8% (SE) within five years and 66% ± 26% (SE) within 10 years. In this series, the contralateral tumor was operated by ovary preserving surgery. Three of the metachronous tumors were mature teratomas and two were seromucinous infantile cystadenomas. One patient had a second teratoma recurrence 14 years after the first recurrence.

Conclusions

More than one fifth of the children with ovarian mature teratoma get metachronous benign tumor to the contralateral ovary. Therefore a yearly ultrasound follow-up is needed for these patients up to potential pregnancy to enable early diagnosis, ovary preserving surgery and maintenance of fertility in the case of metachronous tumor.     

Adult-onset intradural spinal teratoma: report of 18 consecutive cases and outcomes in a single center

Study design

Eighteen consecutive patients with adult-onset intradural spinal teratoma underwent surgical treatment in our center from 1998 to 2013.

Background and purpose

Teratoma is defined as a neoplasm composed of elements derived from three germ cell layers (ectoderm, endoderm and mesoderm). Intraspinal teratoma is extremely rare and accounts for 0.2–0.5% of all spinal cord tumors. Moreover, teratoma occurs primarily in neonates and young children. Adult-onset intradural spinal teratoma is even rare. The aim of this study was to discuss the clinical characteristics, diagnosis and therapeutic strategies of adult-onset intradural spinal teratoma.

Methods

This retrospective study included 18 consecutive adult patients with intradural teratoma who were surgically treated in our center between 1998 and 2013. The clinical features, pathogenesis, diagnostic strategies and surgical outcomes were discussed. Neurological function outcomes were evaluated by the JOA scoring system.

Results

Of the 18 included patients, 4 patients received subtotal resection and the other 14 patients received total resection. All the 18 cases were diagnosed with mature teratoma. The mean follow-up period was 79.7 (median 60.5; range 27–208) months. Local recurrence occurred in two of the four patients who underwent subtotal resection and in no patient who underwent total resection. The neurologic status improved in 16 cases and remained unchanged in the other two patients.

Conclusions

Adult-onset intradural spinal teratoma is extremely rare. To the best of our knowledge, this is the largest series of patients with this disease. Despite the slow-growth and indolent nature, radical resection remains the recommended treatment to reduce tumor recurrence.

     

Differentiation of spinal myxopapillary ependymomas from schwannomas by contrast-enhanced MRI

Background

Spinal myxopapillary ependymomas (MPEs) and schwannomas (SCHs) are both frequently located at the conus and caudal regions. The differentiation between MPEs and SCHs before surgery is crucial. Signal patterns of MPEs and SCHs on T2-weighted (T2W) magnetic resonance imaging (MRI) are diverse. Gadolinium (Gd+)-enhanced areas in MRI scans areas are areas where tumor cells are abundant. Therefore, investigating these enhanced areas should facilitate the differentiation. This study aimed to evaluate Gd+ areas in MRI scans in spinal MPEs and SCHs. Furthermore, the relation between MRI pattern and pathological features was investigated.

Huge thoracolumbar extradural arachnoid cyst excised by recapping T-saw laminoplasty

Background context

Spinal extradural arachnoid cysts are rare expanding lesions in the spinal canal. Total removal of the cyst and repair of the dural defect is the primary treatment for symptomatic spinal extradural arachnoid cysts.

Purpose

To report the usefulness of recapping T-saw laminoplasty in treating huge extradural arachnoid cyst.

Study design

Case report.

Methods

We report the case of a 43-year-old man who presented with a 2-year history of progressive muscle weakness and numbness of the lower extremities. Magnetic resonance imaging (MRI) showed a huge extradural arachnoid cyst at the T12–L3 level extending into bilateral neural foramina and severe posterior compression of the spinal cord and cauda equina.

Results

The patient underwent total resection of the cyst and closure of the communication. En bloc recapping T-saw laminoplasty of T12–L2 including the T12–L1 and L1–L2 facet joints was performed to obtain extensive exposure and preserve posterior stability. Postoperatively, the patient achieved complete recovery of neurologic functions. Follow-up MRI demonstrated no recurrence of the cyst. Bone union after laminoplasty was obtained within 6 months.

Conclusion

Total resection of the cyst and closure of the communication is curative for this rare lesion. Recapping T-saw laminoplasty provides extensive exposure for removal of a large cyst while allowing complete preservation of the posterior spinal elements.     

Diagnosis and management of the growing teratoma syndrome: A single-center experience and review of the literature

Objectives

To evaluate the diagnostic, surgical as well as oncological outcome of patients with a growing teratoma syndrome.

Spontaneous conus medullaris infarction in a 79 year-old female with cardiovascular risk factors: a case report

Objective:

To detail the case of a 79 year-old female who presented with sudden bilateral neurological deficits of the lower extremities and was later diagnosed with non-traumatic conus medullaris infarction. The purpose of this case report is to inform primary contact practitioners of the presentation, diagnosis and the associated risk factors of this condition in order to facilitate prompt management.

Clinical Features:

Spinal cord infarction presenting as low back pain with a high degree of bilateral loss of motor strength, sensation and reflexes in the lower extremities and bowel/bladder dysfunction, in a patient with previous coronary artery bypass graft surgery and renal insufficiency.

Intervention and Outcome:

Referral to emergency within hours of symptom onset allowed for immediate assessment, management and relatively favourable partial recovery.

Summary:

Although rare, conus medullaris infarction is potentially devastating and requires an appropriate clinical index of suspicion for timely diagnosis, treatment and optimal neurological recovery.     

Chronic expanding hematoma after spinal surgery

Background context

Chronic expanding hematoma after spinal surgery is extremely rare, with no case previously reported in the literature.

Purpose

To report a rare case of a chronic expanding hematoma of the spine that occurred 24 years after thoracic laminectomy and spinal cord tumor resection.

Study design

Case report.

Methods

A 71-year-old man presented with a spinal mass located approximately at the level of the sixth thoracic vertebral body. The patient had undergone thoracic laminectomy with tumor resection 24 years previously. The mass had appeared 5 years after this and had gradually enlarged over 19 years.

Results

The tumor was resected en bloc. The lamina and spinous processes had been partially eroded by the tumor at the fifth and sixth thoracic vertebrae, but the dura was intact. Histopathologic examination confirmed the diagnosis of chronic expanding hematoma. The hematoma had not recurred at the 1-year follow-up.

Conclusion

We report herein an extremely rare case of chronic expanding hematoma after spinal surgery. This entity may be considered a late complication after surgery regardless of the number of years that have passed since the index surgery.     

Changes in Level of the Conus after Corrective Surgery for Scoliosis: MRI-Based Preliminary Study in 31 Patients

Background

Detection of postoperative spinal cord level change can provide basic information about the spinal cord status, and electrophysiological studies regarding this point should be conducted in the future.

Methods

To determine the changes in the spinal cord level postoperatively and the possible associated factors, we prospectively studied 31 patients with scoliosis. All the patients underwent correction and posterior fusion using pedicle screws and rods between January 2008 and March 2009. The pre- and postoperative conus medullaris levels were determined by matching the axial magnetic resonance image to the sagittal scout image. The patients were divided according to the change in the postoperative conus medullaris level. The change group was defined as the patients who showed a change of more than one divided section in the vertebral column postoperatively, and the parameters of the change and non-change groups were compared.

Results

The mean pre- and postoperative Cobb''s angle of the coronal curve was 76.80° ± 17.19° and 33.23° ± 14.39°, respectively. Eleven of 31 patients showed a lower conus medullaris level postoperatively. There were no differences in the pre- and postoperative magnitude of the coronal curve, lordosis and kyphosis between the groups. However, the postoperative degrees of correction of the coronal curve and lumbar lordosis were higher in the change group. There were also differences in the disease entities between the groups. A higher percentage of patients with Duchene muscular dystrophy had a change in level compared to that of the patients with cerebral palsy (83.3% vs. 45.5%, respectively).

Conclusions

The conus medullaris level changed postoperatively in the patients with severe scoliosis. Overall, the postoperative degree of correction of the coronal curve was higher in the change group than that in the non-change group. The degrees of correction of the coronal curve and lumbar lordosis were related to the spinal cord level change after scoliosis correction.     

Scoliosis may be the first symptom of the tethered spinal cord

Background:

Tethered cord syndrome (TCS) is a progressive clinical entity that arises from abnormal spinal cord tension. Scoliosis may be a unique symptom in TCS. The aim of this study is to investigate prognosis after releasing the filum terminale in scoliosis due to TCS with/without findings in magnetic resonance imaging (MRI) and to draw attention to the importance of somatosensorial evoked potentials (SSEP) on the differential diagnosis of idiopathic scoliosis versus scoliosis due to TCS with normal appearance of filum terminale and conus medullaris.

Materials and Methods:

Eleven female and seven male patients with progressive scoliosis were included in the study. They were evaluated radiologically, SSEP and urodynamical studies. Preoperative and postoperative anteroposterior full spine X-rays were obtained for measuring the Cobb''s angle. MRI was performed in all cases for probable additional spinal abnormalities. All patients underwent filum terminale sectioning through a L5 hemilaminectomy. The resected filum terminale were subjected to histopathological examination.

Results:

The mean Cobb angle was 31.6° (range 18°–45°). Eight patients (44.45%) had a normal appearance of filum terminale and normal level conus medullaris in MRI, but conduction delay and/or block was seen on SSEP. In the histopathological examination of filum terminale dense collagen fibers, hyaline degeneration and loss of elastic fibers were observed. Postoperatively none of the patients showed worsening of the Cobb angle. Three patients showed improvement of scoliosis.

Conclusion:

In TCS presented with scoliosis, untethering must be performed prior to the corrective spinal surgery. Absence of MRI findings does not definitely exclude TCS. SSEP is an important additional guidance in the diagnosis of TCS. After untethering, a followup period of 6 months is essential to show it untethering helps in stopping the progress of the scoliotic curve. In spite of non progression (curve stopped lesser than 45°) or even improvement of scoliosis, there may be no need for major orthopedic surgical intervention.     

Long-term follow-up of a case of aneurysmal bone cyst in the lumbar spine

Background context

Aneurysmal bone cyst (ABC) in the spine is relatively rare, so little is known about the natural history of the disease.

Purpose

The purpose of this study was to describe a spinal ABC that was followed for an extended period from lesion enlargement to spontaneous regression.

Study design

Case report.

Methods

A 63-year-old woman had a 1-year-long history of mild low back and bilateral leg pain without any significant neurologic deficits caused by lumbar spinal stenosis. At her first visit to our hospital, magnetic resonance imaging (MRI) showed a small cystic lesion on the left side of the L5 vertebral body. The patient's clinical symptom progression and MRI and computed tomography evaluations were reported for >13 years.

Results

After 6 years, the cystic lesion enlarged significantly and extended into the left pedicle and transverse process of the L5 vertebra. The lesion was diagnosed as an ABC based on multilocular cysts with fluid-fluid levels on MRI and bony septations on computed tomography. Thirteen years after the first visit, the lesion regressed spontaneously without a clear reason, such as biopsy or fracture, and most of the lesion was replaced by fatty marrow. The patient's symptoms stabilized without neurologic deterioration during the follow-up period.

Conclusions

Although spinal ABC is an expandable cystic lesion, we should consider that such a lesion in an elderly patient could spontaneously regress.     

Acute spinal subdural hematoma with hemiplegia after acupuncture: a case report and review of the literature

Background context

Subdural spinal hematoma (SDH) is a very rare entity; however, it can lead to serious complications resulting from injuries to the spinal cord and roots. Although acupuncture has been a popular method for the management of pain control, we encountered the first case of SDH after acupuncture.

Purpose

The purpose of this case report was to present the first case of subdural hematoma after acupuncture and the reasons for the risks of blind cervical acupuncture.

Study design

A case report and review of the previous literature are presented.

Methods

A 69-year-old man complained of progressive weakness in the right upper and lower extremities 2 hours after acupuncture on the cervical spine and back. The diagnosis was delayed because of unilateral weakness, and the symptom was initially misinterpreted as a transient ischemic attack because of no sensory change and pain and normal findings of two brain magnetic resonance imaging (MRI).

Results

Cervical MRI 36 hours after onset revealed acute hematoma from the C3–C5 level; hematoma showed an isointensity on T1-weighted image (WI) with the preservation of epidural fat and a hypointensity on T2WI. A decompressive surgery was scheduled to perform within 2 days after the cervical MRI scan because of a previous anticoagulation therapy, but the patient refused it. Finally, 9 days after the onset, surgical decompression and removal of hematoma were performed. Three months postoperatively, the patient had fully recovered demonstrating fine hand movement and good ability to walk up and down the stairs.

Conclusions

Our study indicates that it is essential to perform cervical MRI when a patient does not show an improvement in the neurologic deficit and has a negative brain MRI after acupuncture. In addition, blind acupuncture if not correctly practiced may be harmful to the cervical structures.     

The conus medullaris ratio: A new way to identify tethered cord on MRI

Purpose

Approximately 25% of patients with anorectal malformation have tethered cord. The traditional way of determining conus medullaris level on magnetic resonance imaging (MRI) relies on counting vertebrae, which may be challenging due to vertebral numeric variation, segmentation anomalies, as well as transitional vertebral body anatomy. The purpose of this study was to utilize more reliable anatomic landmarks (foramen magnum, conus termination, and the upper limit of the iliac crest) to establish a consistent ratio that may differentiate patients with normal and low-lying conus.

Primary Chemotherapy in Patients with Nonseminomatous Germ Cell Tumors of the Testis and Biological Disease Only After Orchiectomy

Purpose

We assessed the efficacy of primary chemotherapy in patients with nonseminomatous germ cell tumors of the testis and elevated serum tumor markers as the only evidence of disease after orchiectomy.

Materials and Methods

We analyzed the outcome of 20 patients with biological disease only who received cisplatin-based (16) or carboplatin-based (4) chemotherapy as primary treatment following orchiectomy.

Results

Serum tumor markers returned to normal levels in all 20 patients. One patient required subsequent surgery for recurrent retroperitoneal mature teratoma. Two patients experienced a relapse with active disease, 1 of whom died of progressive germ cell tumor. Of the patients 19 remained free of disease 18 to 116 months after the end of treatment.

Conclusions

Since results with primary retroperitoneal lymph node dissection suggest that elevated serum tumor markers usually reflect systemic metastases rather than retroperitoneal disease, primary chemotherapy seems to be the most appropriate strategy to consider in patients with biological disease only following orchiectomy.     

Acute transverse myelitis at the conus medullaris level after rabies vaccination in a patient with Behçet's disease

Case report:

A 25-year-old man with Behçet''s disease was admitted because of weakness of the lower limbs and difficulty in urination. He had received a rabies vaccination 2 months previous because he had been bitten by a dog.

Findings:

Clinical and laboratory findings supported acute transverse myelitis. A hyperintense lesion and expansion at the level of conus medullaris was detected on spinal magnetic resonance imaging.

Conclusion:

Although neurologic involvement is one of the main causes of mortality and morbidity in Behçet''s disease, the factors that aggravate the involvement of the nervous system are still unclear. Vaccination may have been the factor that had activated autoimmune mechanisms in this case. To our knowledge, involvement of the conus medullaris in Behçet''s disease after rabies vaccination has not been reported.     

The use of spinal angiography in the management of posterior mediastinal tumors: Case series and review of the literature

Introduction

Resection of inferiorly located posterior mediastinal tumors can be complicated by their proximity to the artery of Adamkiewicz (AKA). Although uncommon, intraoperative injury to the AKA may result in paraparesis or paralysis secondary to spinal cord ischemia. The use of preoperative spinal angiography may serve as a useful adjunct to the surgeon in guiding extent of resection of the tumor to avoid injury to this critical artery.

Methods

After IRB approval (H-31712), three patients, from 2008 to 2011, with lower posterior mediastinal tumors were identified. Their charts were reviewed for information concerning preoperative imaging, operative details, and postoperative neurologic complications. The literature regarding imaging of the AKA, cases of injury in pediatric patients, and recommendations for treatment after its injury were reviewed.

Results

One patient, who did not have preoperative spinal angiography, developed transient paresis lasting 6 weeks after posterior mediastinal tumor resection. Two patients underwent preoperative spinal angiography with successful localization of the AKA. In both cases, the patients subsequently underwent posterior mediastinal tumor resection without injury to the artery and without postoperative neurologic sequelae.

Conclusions

Preoperative spinal angiography may serve as a useful adjunct in the evaluation of children with inferior posterior mediastinal tumors in order to delineate the relationship of the artery of Adamkiewicz to the tumor for the purpose of guiding surgical resection.     

Contemporary Management of Postchemotherapy Testis Cancer

Context

Some controversy still exists regarding the management of testis cancer following chemotherapy for disseminated disease.

Objective

To review the available literature concerning the management of postchemotherapy testis cancer.

Evidence acquisition

A Medline search was conducted to identify original and review articles, as well as guidelines addressing the management of testis cancer following first-line chemotherapy. Keywords included germ cell tumor, testis cancer, retroperitoneal lymph node dissection, and chemotherapy. The most relevant articles were critically reviewed with the consensus of all the collaborative authors, who have expertise in the management of germ cell tumors (GCTs).

Evidence synthesis

Approximately one-third of patients who undergo chemotherapy for metastatic GCTs have residual retroperitoneal disease. All patients with residual masses ≥1 cm after chemotherapy for nonseminomatous GCTs should undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) because of the risk of mature teratoma in 40–45% of cases and of viable GCT in 10–15% of cases. Patients who obtain a complete serologic remission and radiographic residual <1 cm after chemotherapy have a 6–9% risk of relapse. Patients with a completely resected teratoma in only the PC-RPLND specimen have a >90% chance of cure, while patients with viable GCTs should be considered for additional therapy, depending on the percentage of viable tumor. In patients with disseminated seminoma, postchemotherapy masses <3 cm may be safely observed, while patients with masses >3 cm should be evaluated with positron emission tomography (PET)/computed tomography 2 mo after completion of chemotherapy, with very selective administration of PC-RPLND. Late relapse occurring >2 yr after chemotherapy is rare, and surgery remains the mainstay of therapy in cases of resectable masses independent of tumor markers. There is still controversy on whether high-dose chemotherapy confers a survival benefit compared with conventional-dose chemotherapy in the salvage setting. Surgery should always be considered for resectable masses following salvage therapies or in chemoresistant disease to maximize chance of cure.

Conclusions

Patients with advanced GCTs can achieve long-term disease-free survival when chemotherapy is combined with expert and judicious resection of residual disease. PC-RPLND is recommended for residual masses >1 cm identified on postchemotherapy imaging in nonseminomatous GCT and possibly for PET-positive residual disease ≥3 cm in treated seminomas.     

Mature spinal teratoma associated with thickened filum terminale

A 30-year-old man presented with an intradural spinal teratoma with thickened filum terminale manifesting as urinary and sexual disturbances, and low back pain persisting for 4 years. Spinal magnetic resonance imaging revealed thickened filum terminale containing a heterogeneously enhanced intradural lesion extending from the L-3 to L-4 levels and in contact with the conus medullaris. The filum terminale was incised and the tumor was totally resected. The histological diagnosis was mature teratoma consisting of three germ cell layers. The patient's complaints had completely resolved 6 months later.