One-stage resected case of dumbbell type tumor of the posterior mediastinum

We reported a dumbbell type tumor of the posterior mediastinum. The patient was an asymptomatic 40-year-old male. An abnormal shadow in the right lower lung field was pointed out in a mass survey. We recognized a dumbbell type tumor in the posterior mediastinum by chest CT and MRI. The tumor invaded the intervertebral canal through the spinal foramen. It was most clearly seen by MRI myelography. Operation was performed with the patient in a prone position and with an L-shaped skin incision of the back and 11th intracostal thoracotomy and Th11 laminectomy. The dumbbell type tumor was completely removed by this operation. The pathological diagnosis was Schwannoma. The post operative course was good. The one-stage operation is useful for dumbbell type tumors of the posterior mediastinum.     

显微手术切除及椎管固定融合治疗高颈段椎管哑铃型肿瘤

目的探讨显微手术切除高颈段椎管哑铃型肿瘤及椎管固定融合的方法及效果。方法回顾性分析11例高颈段椎管哑铃型肿瘤患者的临床资料,其中ToyamaⅡ型6例,Ⅲ型4例,Ⅴ型1例。均行显微手术切除,其中远外侧入路3例,颈后正中入路8例。同时行椎管固定融合6例。结果本组全切10例,次全切除1例。术后病理学诊断为神经纤维瘤9例,脊膜瘤2例。术后症状明显改善9例,改善2例,无感染及死亡病例。随访10例,平均时间27个月（3个月～3年）,患者的症状和神经功能均有不同程度的改善,无颈椎不稳及后凸畸形。结论高颈段椎管哑铃型肿瘤显微手术切除并椎管固定融合能明显改善症状,安全性好,并发症少。     

Spinal-thoracic dumbbell meningioma: a case report.

STUDY DESIGN: Total excision of a large dumbbell cervicothoracic intra- and extraspinal meningioma that had grown into the posterior mediastinum is described. This excision involved a two-step neurosurgical-thoracosurgical procedure within a short interval. OBJECTIVES: To document that the described laminectomy and thoracotomy techniques are adequate, safe, and effective for the treatment of this intra- and extraspinal meningioma lesion. SUMMARY OF BACKGROUND DATA: The management of intra- and extraspinal dumbbell tumors is based on anecdotal reports of mostly neurinomas, and thus remains a controversial issue. Even large series of spinal meningiomas lack adequate information on how best to treat large cervicothoracic meningiomas. METHODS: The authors have modified standard techniques used for resection of spinal and mediastinal tumors, respectively, adapting them for a large, invasive dumbbell meningioma in a 72-year-old lady. The patient initially underwent laminectomy and microsurgical excision of the intraspinal tumor portions encasing vascular structures. A week thereafter, a thoracotomy was performed, and the mediastinal tumor portions were removed completely. RESULTS: Restitution was remarkably good. The patient, who had been unable to walk on her own, regained some mobility. At this writing, she was able to walk considerable distances without support. There was no evidence of tumor recurrence during a follow-up interval of 3 years. CONCLUSIONS: The authors recommend a two-staged procedure for complete excision of a large spinal-thoracic meningioma. Even in elderly patients with major neurologic deficits, an impressive recovery can be achieved with such lesions.     

Anterior approach for dumbbell type cervical neurinoma

A one-stage anterior approach was performed in four patients for total removal of dumbbell type neurinoma at the cervical level. In each case, the neurinoma compressed the spinal cord in the cervical canal, developed anteriorly through the intervertebral foramen, and compressed the vertebral artery. A conventional cervical anterior approach at the tumor site was performed, followed by confirmation of the tumor located outside the spinal canal. After identification of the vertebral artery, corpectomy was carried out and the extradural component of the tumor was resected. In cases with a portion of the tumor located also within the dura mater, the dura mater was opened for removal of the intradural tumor. We found the anterior approach to be effective for the total removal of some kinds of cervical dumbbell type neurinomas.     

Cervical extradural en-plaque meningioma

A 22-year-old woman presented with a very rare extradural en-plaque spinal meningioma manifesting as right hemiparesis and gait disturbance. Magnetic resonance imaging revealed a well-enhanced lesion extending from the C-1 to C-5 vertebral levels, compressing the cord dorsally. Computed tomography revealed a slightly enhanced mass with calcification in the spinal canal, advancing in all directions except anteriorly. Surgery could not completely remove the part of the tumor that had progressed laterally. The histological diagnosis was cervical extradural en-plaque meningioma. Postoperatively, there was remarkable improvement in the patient's symptoms. Successful treatment of this type of tumor requires the development of a combined surgical and radiosurgical approach.     

Bilateral and symmetric C1–C2 dumbbell ganglioneuromas associated with neurofibromatosis type 1 causing severe spinal cord compression

Background ContextGanglioneuromas are rarely located in the cervical region compressing the spinal cord. Only two cases of bilateral and symmetric dumbbell tumor have been reported previously.PurposeThe purpose of the study was to present an additional case with bilateral and symmetric dumbbell ganglioneuromas of the cervical spine as part of multiple ganglioneuromas of the spine in a patient with neurofibromatosis type 1 (NF-1).Study DesignThe study design was a case report.MethodsA 15-year-old boy with NF-1 presented with a 6-month history of progressive tetraparesis. Magnetic resonance imaging showed voluminous bilateral and symmetric dumbbell masses at the C1–C2 level severely compressing the spinal cord. The spinal cord was also indented by a dumbbell mass at the left C3–C4 level. A systemic imaging survey of the patient showed numerous asymptomatic foraminal and extraforaminal tumors at all neuroforamina of the spine.ResultsThe result was found to be surgical decompression of the spinal cord by subtotal resections of bilateral tumors at the C1–C2 level and unilateral tumor at the left C3–C4 level alleviated patient symptoms. Histopathological diagnosis was ganglioneuroma for all resected tumors.ConclusionMultiple ganglioneuromas, particularly bilateral and symmetric dumbbell tumors, are extremely rare but could be associated with NF-1.     

A primary meningioma of the lumbar spine with neck metastasis

Context: Approximately 25% of all primary spinal cord tumors are meningiomas, and 80% of these tumors occur in the thoracic region. Few meningiomas of the lumbar spine have been presented. Extracranial metastasis of meningioma occurs extremely rare, only in about 0.1% of meningiomas. Even metastasis, the sites are seldom seen in deep soft tissue. We reported a woman original meningioma in the lumbar spine with distal deep neck metastasis.Findings: A 59-year-old patient suffered from severe right drop foot, numbness, and radicular pain for the previous 6 months. Computed tomography (CT) disclosed a huge, macrolobulated retroperitoneal soft-tissue lesion with a size of 14.9 × 10.8 × 17.7 cm. Magnetic resonance imaging (MRI) further revealed a solid spinal intracanal tumor with moderate enhancement involving the right paraspinal region at the L2∼L5 level and the right iliac fossa. A meningioma was diagnosed with histological proof. Four months later, another metastatic meningioma in her left neck. She was managed conservatively without neurologic dysfunction.Conclusions: To the best of our knowledge, such a large meningioma of the lumbar spine has not previously been reported in the literature. In this study, we demonstrated a rare spinal meningioma located in the lumbar spine primarily with secondary soft tissue metastasis.     

颈椎管肿瘤Asazuma分型对手术入路选择的意义

目的探讨颈椎管哑铃形神经鞘瘤的手术治疗方法及Asazuma分型在手术入路选择中的临床价值。方法总结我院2004年2月至2007年3月收治的13例颈椎管哑铃形肿瘤患者的临床表现、影像学特征、手术方式及手术前后患者脊髓神经功能改善情况,术前按照Asazuma分型进行评估,选择合适的手术入路,观察临床疗效,评估其临床应用价值。结果13例患者术前均经CT和MRI检查作出临床诊断,2例Ⅰ型,1例Ⅱa型,2例Ⅲa型,2例Ⅲb型,1例Ⅴ型,1例Ⅵ型采用后方入路,2例Ⅱc型采用前方入路,2例型采用前后联合入路。其中肿瘤完全切除11例（84.6%）,大部切除2例（15.4%）。3例患者术中同时切除宿主神经根。10例行内固定和植骨融合术。13例随访3个月至3年,平均16个月。所有患者术后临床症状及神经功能均有明显恢复。结论颈椎哑铃形椎管内肿瘤有较高的误诊、漏诊率,MRI检查对明确病变性质和位置有重要意义。Asazuma分型对颈椎管哑铃形神经鞘瘤的手术入路选择具有指导意义。     

Coexistence of intracranial and spinal meningiomas--report of two cases.

The authors report two rare cases of multiple meningiomas in both the intracranial and spinal regions. A 64-year-old female presented with a right sphenoidal ridge meningioma and a cervical extramedullary meningioma. Tumor histology was transitional and vacuolated types, respectively. The tumors were removed successfully in two stages, craniotomy then laminectomy 3 months later. A 62-year-old female presented with a right sphenoidal ridge meningioma (meningotheliomatous type) which was totally removed. An extramedullary spinal meningioma became symptomatic 33 months later, which was also removed totally. The meningiomas in the first case had different subtypes, but immunohistochemical characteristics including microcyst formation were similar. The second case had meningiomas of the same subtype with similar characteristics, but different fibrous septum development. Multiple meningiomas, even in different compartments of the central nervous system, may have common characteristics.     

Malignant intraventricular meningioma with spinal metastasis through the cerebrospinal fluid

A 67-year-old man developed a malignant meningioma of the right lateral ventricle at the trigone, for which he underwent total removal of the tumor and local irradiation. Six months after the operation, a spinal tumor developed and subtotal removal of the tumor was made. The spinal tumor was considered to be a metastasis via the cerebrospinal fluid in view of its histologic identity with the primary tumor, histologic findings of malignancy, absence of von Recklinghausen's disease, and lack of tumor attachment to the dura.     

Recurrent calcified spinal meningioma detected by plain radiograph

STUDY DESIGN: A case report of a patient presenting with a rare calcified spinal meningioma that recurred and became symptomatic 33 years after initial surgery was performed. OBJECTIVES: To demonstrate a calcified recurrent spinal meningioma visible on a plain radiograph. The present case is discussed in conjunction with a review of previous cases of calcified spinal meningioma. SUMMARY OF BACKGROUND DATA: Meningioma is a common spinal tumor that has a favorable prognosis if resected completely. Microscopic calcification is frequently found in spinal meningiomas because of psammoma bodies. However, calcified meningiomas in the spinal canal that can be detected on a plain radiograph are uncommon. To the authors' knowledge, there have been no previous reports of recurrent spinal meningioma with calcification visible on a plain radiograph. METHODS: A patient experienced difficulty in walking and was diagnosed as having a spinal meningioma. Laminectomies and a total tumor excision were performed. Histologically, the tumor was diagnosed as a psammomatous meningioma. The tumor recurred and became symptomatic 33 years after the initial operation. The tumor was detected on a plain radiograph, appearing as a calcified tumor at the same thoracic level as the site of the initial operation. The recurrent tumor was completely removed, and a histologic examination showed huge psammoma bodies with calcification, but without ossification. RESULTS: Preoperative paraplegia improved after the surgery, and she was able to walk with a crutch. The patient was discharged from the hospital. CONCLUSIONS: The recurrent psammomatous meningioma contained clusters of calcified psammoma bodies, resulting in a hard tumor that was visible on a plain radiograph.     

Spinal melanotic schwannoma: report of a case

A case of spinal dumbbell shaped melanotic schwannoma was reported. A 58-year-old housewife had a 3-months history of progressive gait disturbance. She also complained of mild backache and numbness in both legs. Her family history was not remarkable. When examined on admission, October 10, 1982, mild weakness of both legs with spasticity and sensory impairment below the level of T10 dermatome without sacral sparing were evident. Her deep tendon reflexes were hyperactive on both sides and plantar responses were extensor bilaterally. Sphincteric disturbance was not significant. The function of her cranial nerves was intact. She had neither cutaneous lesions, abdominal mass nor organomegaly. Thoracic plain X-rays revealed erosion of the right side vertebral body and pedicle of the 10th thoracic vertebra. Myelography disclosed a complete block at the same level by an epidural mass. On CT-myelogram, soft tissue density mass compressing the thoracic cord was apparent in the right epidural space of the spinal canal which extended to the paravertebral region through the right intervertebral foramen. Partial destruction of the body and the right side pedicle was easily recognized. Laminectomy from T9 to T11 exposed a large extradural mass which was encapsulated, elastic soft and pigmented in nature. The tumor was dumbbell shaped and extended to the right paravertebral region through the intervertebral foramen. Costotransversectomy was performed to excise the mass entirely. Following the total removal of the tumor, internal fixation was carried out by means of Harrington instrumentation with methylmethacrylate.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cervical spinal extradural meningioma: Case report

Extradural meningiomas account for approximately 7% of all spinal meningiomas and are most commonly located in the thoracic spine. Although rare, they should be included in the differential diagnosis of an extradural contrast-enhancing mass. Prognosis depends greatly on the extent of surgical resection. If considered safe, complete resection should be attempted to decrease the risk of recurrence. We report a case of spinal epidural meningioma diagnosed in an elderly woman complaining of right cervicobrachial pain of several years duration, associated with diffuse paresthesia and permanent numbness of her right index finger. The surgical removal of the tumor was incomplete because of the deep lateral extension of the lesion.     

后路椎板切除、椎弓根内固定治疗上颈椎哑铃形肿瘤

目的探讨后路椎板切除、椎弓根内固定治疗上颈椎哑铃形肿瘤的方法和疗效。方法对15例PUTHⅠ、Ⅱ、Ⅲ、Ⅴ型上颈椎哑铃形肿瘤患者行后路椎板切除摘除肿瘤,同时行椎弓根内固定植骨融合术。结果患者均获得随访,时间2个月~5年。术后神经功能Frankel分级:9例D级恢复至E级,3例C级恢复至D级,1例C级、1例D级及1例E级术后无改变。术后3例出现脑脊液漏,2例行腰大池引流、1例抬高床尾引流后好转;2例出现单侧肢体肌力减弱,1例出现霍纳综合征,均经康复治疗后好转。1例复发,行二次手术治疗。13例疼痛较术前有明显改善或消失,2例无明显变化。结论后路椎板切除暴露摘除肿瘤,同时行椎弓根内固定植骨融合术治疗PUTHⅠ、Ⅱ、Ⅲ、Ⅴ型上颈椎哑铃形肿瘤,可彻底切除肿瘤病灶,解除颈脊髓及神经根压迫,重建上颈椎稳定性。     

Extracalvarial meningioma--report of a case (author's transl)

A case of extracalvarial meningioma was reported. 75-year-old man was admitted to our department on November 11, 1974 because of a slowly growing tumor in the right frontoparietal area. The tumor was ovoid and 15x13 cm in size, protruding 5 cm above the skin level, and covered by the normal scalp. Neurological and electroencephalographic examination were negative. Spinal tap showed an opening pressure of 90 mm of water and clear CSF with 62 mg/dl of protein content. Plain roentgenogram and laminagram of the skull revealed both osteolytic and osteoblastic change in the outer and inner table of the skull just beneath the tumor. A right external carotid angiography disclosed a homogeneous extracalvarial tumor stain supplied by the superficial temporal artery and draining into the superficial temporal vein. A right carotid angiogram showed a 1 cm thick avacular area. The segmentally occluded superior sagittal sinus was displaced inward together with bridging collateral channels. Radiologically these picture corresponded to "intracranial non-globoid shape or avascular meningioma" discussed by Huckman et al. The tumor was well-circumscribed, encapsulated and loosely adherent to the periosteum and the skull except for a small portion through which the tumor was communicated with its intracranial part. Histological examination revealed that it was a typical endotheliomatous meningioma. This case should be allocated to the transitional or intermediate type between Lopez II and III type. In the schematical presentation (Fig. 6) we tried to readjust the rather confusing concept and classification of the extracalvarial meningioma.     

A case of angiomatous meningioma near the geniculate ganglion

A 57-year-old male was admitted with pulsatile tinnitus and hearing disturbance of the right ear and right peripheral facial palsy. Otological examination revealed a pulsatile red mass in his right ear and right conductive hearing disturbance. CT and MRI showed the mass lesion at his right middle fossa near the geniculate ganglion. Right external carotid angiogram disclosed a tumor stain fed by the middle meningeal artery. The tumor was removed via a combination of subtemporal and transmastoidal approaches. Histologically, this tumor was diagnosed as angiomatous meningioma partly with meningotheliomatous meningioma. Meningioma in this region is very rare. We discussed its clinical and radiological characteristics in comparison with chemodectoma and facial neurinoma at the geniculate ganglion.     

Surgical consideration of the intraspinal component in extradural dumbbell tumors

BACKGROUND: The dumbbell tumor is considered a distinct group of tumors of the spinal nerve sheath owing to its intriguing clinical and radiological characteristics. More than half of dumbbell tumors are completely restricted to the extradural space, although preoperative MRI in some cases suggests the presence of intradural/extradural tumors. The aim of this retrospective investigation is to elucidate the clinical features and to suggest the surgical strategy to reduce the operating time and prevent additional complications in extradural type. METHODS: The medical records and radiological studies of 7 consecutive cases (4 male, 3 female, mean age 40.4 years) who underwent removal of the intraspinal component of their extradural dumbbell tumors between January 1996 and December 2005 were analyzed. Diagnosis and preoperative evaluation were performed with MRI and myelogram/CTs. RESULTS: The relationship of the tumor mass to dural sac in preoperative MRIs was so indistinct as to suggest an intradural mass in 5 cases. We found that extradural portion was covered with an attenuated dura and that the dural ring was invaginated into the intradural portion in these cases. Therefore, the author began with the epidural removal of the intraspinal and extraspinal component, followed by carefully extracting the intradural-like mass. CONCLUSIONS: In conclusion, we suggest that invagination of the dural ring is the anatomical feature that may be confused with an intradural/extradural tumor during operations for extradural dumbbell tumors. Initial epidural mass removal, extraction of intradural/extradural tumors subsequent to dural opening, and affirmation of presence of intradural tumor remnant could save time during dumbbell tumor surgery.     

Minimally invasive resection of extradural dumbbell tumors of thoracic spine: surgical techniques and literature review

Purpose

Dumbbell-shaped thoracic tumors represent a distinct type of tumor and involve in both the spinal canal and the posterior thoracic cavity. Successful treatment for the tumors depends on gross total resection (GTR) via an open laminectomy and facetectomy or transthoracic transpleural approach. In this case series, we report our experiments with minimally invasive method for the removal of extradural dumbbell thoracic tumor and present related literature review.

Methods

We retrospectively reviewed two patients with dumbbell-shaped thoracic tumors who underwent minimally invasive resection and unilateral transforaminal thoracic intervertebral fusion (TTIF) through unilateral paraspinal muscle approachwith a spotlight expandable tubular retractor. Clinical data, tumor characteristics, and outcomes were analyzed.

Results

Two patients underwent successful minimally invasive treatment of their spinal neoplasms. There were no procedure-related complications. The efficacy in terms of neurological recovery, pain improvement and operative variables (length of incision, operative duration, blood loss, and hospital stay) was better when compared with prior published studies. Postoperative CT image demonstrated complete resection of dumbbell tumor in the patients. The solid fusion was obtained after 3 months follow-up and there was no failure of internal fixation.

Conclusion

If the medial border of intracanal component of extradural dumbbell tumor is near the midline of canal and the pedicles of adjacent vertebrae to tumor are intact, minimally invasive resection of tumor through unilateral paraspinal muscle approach combined with unilateral TTIF is good choice.

     

A case of dumbbell neurogenic tumor in the posterior mediastinum

We have recently experienced a dumbbell tumor that developed in the posterior mediastinum in a 64-year-old male. The patient suffered from dorsalgia one year and a half previously. Chest X-ray examinations revealed a well-defined boundary in the right posterior mediastinum. Myelography followed by computerized tomographic scanning (CT) revealed that the tumor developed in a paravertebral area linked with a vertebral canal through an intervertebral foramen and destructed a rib in growing in the paraspinal muscular layer. Longitudinal incision of about 10 cm was made downward from immediately above the first thoracic spinous process, and the chest was opened by posterolateral incision extending into the muscles of the back in an arc shape. The tumor was entirely excised by additional laminectomy. Since malignant schwannoma was diagnosed histologically, Linac X-ray of 50 Gray was given. The patient is now enjoying his healthy daily life with no postoperative complication 2 years after operation. Myelography followed by CT was proved to be quite useful in evaluating a relationship between the tumor and the spinal cord in the diagnosis of this disease.     

Dumbbell C2 schwannomas involving both sensory and motor rootlets: report of two cases

OBJECTIVE AND IMPORTANCE: Intradural-extradural dumbbell C2 schwannomas are rare. This report concerns two such cases with the intradural compartment located ventral to the spinal cord and involving both sensory and motor rootlets. CLINICAL PRESENTATION: One patient was a 57-year-old woman with sensory disturbances in the right extremities and hyperreflexia in the left extremities. The other patient was a 73-year-old man who presented with tetraparesis, walking disability, atrophy of the nuchal and bilateral shoulder muscles, and pain in the right C2 dermatome. INTERVENTION: The extradural component of the tumor was removed first; next, the intradural component was removed successfully via the posterior approach combined with a C1-C2 laminectomy. The patients experienced symptomatic improvement without further deficits except for sensory impairment of the C2 dermatome in one of the patients. CONCLUSION: Intradural-extradural dumbbell C2 schwannomas can be satisfactorily managed with a posterior approach. Removal of the extradural component and opening of the dural ring of the C2 nerve root are necessary for safe extraction of the intradural ventrally located component after debulking. These tumors may arise extradurally within the nerve sheath, extend intradurally and ventrally toward the spinal cord, and involve both sensory and motor rootlets.