Clinical and radiological presentation of spinal epidural haemangiomas: clinical series in a tertiary care centre during a 10-year period

Purpose

Haemangiomas are very frequent benign spinal tumours. However, pure epidural location is extremely rare. At present, only 52 cases have been reported in the literature during the last 10 years. We proposed to analyse clinical and radiological features of this rare entity treated in a tertiary care centre over the last 10 years.

Methods

A study of a retrospective surgical series (2002–2012) was conducted. The clinic’s electronic database was searched for “spinal” and/or “vertebral haemangiomas”, which were treated by surgery and/or vertebroplasty. Clinical, radiological and histopathological data were analysed.

Results

In total, the series comprised 30 spinal haemangiomas. There were 6 epidural (20 %), 17 vertebral (57 %) and 7 intradural lesions (23 %). There were four men and two women, mean age 28.3 years, with epidural lesions. One patient presented with localised back pain only, two with radiculopathy and focal neurological deficit, two with radiculopathy only and one with isolated focal neurological deficit, respectively. The onset of symptoms was progressive in four cases over weeks to months and sudden in two cases. Preoperative MRI imaging revealed features of meningioma, neurinoma or metastasis.

Conclusion

Epidural haemangiomas are extremely rare spinal lesions. They may mimic more common spinal tumours clinically and radiologically. The usual treatment is gross total resection confirming the diagnosis histologically.     

Spinal epidural angiolipomas: a rare cause of spinal cord compression. A report of 8 cases and review of the literature

Extradural spinal angiolipomas are rare benign tumors containing vascular and mature adipose elements. We report 8 cases of spinal epidural angiolipomas in 6 females and 2 males. In 7 cases, the clinical manifestation was a progressive spinal cord compression and one case had a regressive paraparesis mimicking a multiple sclerosis. In the 8 cases, the localization was thoracic with an extradural complete type of contrast block in 2 cases and partial in 5 cases. The myelo-CT achieved in 7 cases and the magnetic resonance imaging done at our last case revealed a fat-containing epidural tumor. The tumors were removed in all cases through a laminectomy with a successful outcome after an average of 9 years (range: 6 months-12 years). Sixty-seven similar cases in the international literature are reviewed. A total of 75 cases have been studied: 45 women and 30 men with a mean age of 46.3 years (range: 6-73), presenting a progressive spinal cord compression in 68 cases and in 7 cases a regressive paraparesis mimicking a multiple sclerosis. Myelography shows an extradural compression of the thecal sac. MRI is nowadays the imaging modality of choice for the diagnosis of these lesions. The surgical removal often easy of the epidural spinal angiolipomas permit a fast recovery. The etiopathogenesis of this process is still controversial between the dysembryogenetic and malformative hypothesis.     

Spontaneous dorsal epidural haematoma: Usefulness of magnetic resonance imaging and importance of operative treatment even in cases with complete paraplegia

Summary Spontaneous epidural haematomas are rare at any level of the spinal canal. The radiological diagnosis is usually made by myelography and in a few reported cases by computed tomography (CT).We describe a patient in which the final diagnosis was possible only with Magnetic Resonance Imaging (MRI). Surgical evacuation resulted in partial recovery of an already four days existing complete paraplegia.It is stressed that MRI is the most useful examination to differentiate haematomas from other spinal epidural lesions and that an operative evacuation of a spinal epidural haematoma is indicated even if the patient comes after a complete paraplegia has developed.     

Solitary spinal epidural cavernous angioma: report of nine surgically treated cases and review of the literature

Purpose

We intend to report the largest series of spinal epidural cavernomas (SEC), discuss their clinical features, imaging characteristics, surgical findings, outcome analysis and compare them with similar reports in the literature.

Methods

Among the cases of spinal tumors treated surgically by the authors, there have been nine cases of SEC’s. All the data were collected prospectively and the cases have been followed after surgery up to the time of this analysis.

Results

There were six female and three male patients with the ages ranging between 13 and 74 years. The lesions were located in the thoracic spine (4 cases), lumbar spine (4 cases) and one at the sacral level. Clinical presentations included acute spinal pain and paraparesis in two, low back pain and radiculopathy in five, and slowly progressive myelopathy in the other two cases. The lesion was iso-intense with the spinal cord in T1W images and hyperintense in T2W images and showed strong homogeneous enhancement after contrast medium injection in most of our cases. In the presence of hemorrhage inside the lesion, it was hyperintense in both T1W and T2W MR sequences as in our case 6. In the single case presenting with acute hemorrhage, epidural hematoma was the only finding, our case 1. Complete surgical removal was achieved in all our cases, and confirmed by postoperative MRI.

Conclusion

SEC is hard to be differentiated from other epidural spinal lesions before intervention but should be considered in the list of differential diagnosis regarding its favorable outcome.     

Delayed epidural hematoma after spinal surgery: a report of 4 cases

Symptomatic postoperative epidural hematoma is a rare and potentially devastating complication of spinal surgery. The overwhelming majority of reported cases have occurred in the immediate postoperative period. A recent publication defined the clinical entity of delayed postoperative epidural spinal hematoma as neurologic deterioration due to an epidural hematoma occurring at least 3 days after the index procedure. Only 2 such cases have been reported in the lumbar spine to date. Four cases of delayed postoperative spinal epidural hematoma were identified over a 6-year period among the spine surgeons at a single large academic institution. Each case involved the lumbar spine. The details of each patient's initial surgery, presentation, and hospital course were then gathered from a retrospective chart review. The 4 patients presented are unusual in their delayed symptomatic presentations of postoperative spinal epidural hematoma. Despite the longer time to onset, however, our patients exhibited many of the characteristics common to cases that presented in the acute postoperative period. The spine surgeon must remain vigilant for the possibility of postoperative spinal epidural hematoma in at-risk patients, even weeks after the original surgical procedure.     

Spinal angiolipomas revisited: Two case reports

Summary Approximately 60 cases of spinal angiolipomas have been described in the medical literature. Extradural tumours predominate. Lesions with a bony component, the infiltrating subgroup, were reported in 10 patients. Intradural angiolipomas were found three times. Several excellent review articles are available, but a systematic comparison of the characteristics of the two major varieties, infiltrating and non-infiltrating spinal extradural angiolipomas, has not so far been made.The authors operated on two patients with spinal angiolipomas and found one of them the infiltrating and the other the non-infiltrating type. Then, they proceeded to a review of all publish cases of infiltrating angiolipomas. With a knowledge of recently reported data on the subject the authors compared essential clinical features of both varieties of tumours.They share identical clinical characteristics. Differences found in age, sex or location were not statistically significant. Mode of onset and signs and symptoms present on admission were essentially similar. As could be anticipated, removal was more often complete in non-infiltrating tumours, but outcome was good or fair in more than 85% of cases in both groups. Involvement of bone by spinal angiolipomas does not imply a worsening in the prognosis.     

Lumbar spinal angiolipoma: case report and review of the literature

Spinal angiolipomas are extremely rare benign tumors composed of mature lipomatous and angiomatous elements. Most are symptomatic due to progressive spinal cord or root compression. This article describes the case of a 60-year-old woman who presented with a 6-month history of low back pain radiating to her right leg. The pain was multisegmental. The condition had worsened with time. Lumbar magnetic resonance imaging revealed a dorsal epidural mass at L5 and erosion of the lamina of the L5 vertebra. Laminectomy was performed, and an extradural tumor was totally excised. Neuropathologic examination identified it as a lumbar spinal angiolipoma. There was no evidence of recurrence in follow-up 12 months later. This rare clinical entity must be considered in the differential diagnosis for any spinal epidural lesion.     

Langerhans cell histiocytosis with multiple spinal involvement

To stress the clinical and radiologic presentation and treatment outcome of Langerhans cell histiocytosis (LCH) with multiple spinal involvements. A total of 42 cases with spinal LCH were reviewed in our hospital and 5 had multifocal spinal lesions. Multiple spinal LCH has been reported in 50 cases in the literature. All cases including ours were analyzed concerning age, sex, clinical and radiologic presentation, therapy and outcome. Of our five cases, three had neurological symptom, four soft tissue involvement and three had posterior arch extension. Compiling data from the eight largest case series of the spinal LCH reveals that 27.2% multiple vertebrae lesions. In these 55 cases, there were 26 female and 29 male with the mean age of 7.4 years (range 0.2–37). A total of 182 vertebrae were involved including 28.0% in the cervical spine, 47.8% in thoracic and 24.2% in the lumbar spine. Extraspinal LCH lesion was documented in 54.2% cases, visceral involvement in 31.1% and vertebra plana in 50% cases. Paravertebral and epidural extension were not documented in most cases. Pathological diagnosis was achieved in 47 cases including 8 open spine biopsy. The treatment strategy varied depending on different hospitals. One patient died, two had recurrence and the others had no evidence of the disease with an average of 7.2 years (range 1–21) of follow-up. Asymptomatic spinal lesions could be simply observed with or without bracing and chemotherapy is justified for multiple lesions. Surgical decompression should be reserved for the uncommon cases in which neurologic compromise does not respond to radiotherapy or progresses too rapidly for radiotherapy.     

Myopericytoma of the thoracic spine: a case report and review of literature

Background contextMyopericytoma is a recently proposed term to describe a group of tumors originating from perivascular myoid cells. The tumor is most commonly located in the subcutaneous tissues and dermis of the extremities. Myopericytoma involving the skeletal system is a very rare entity, with only two such cases previously reported in literature.PurposeTo present only the third reported case of myopericytoma of the spine along with a review of literature.Study designCase report with and review of literature.MethodsWe report the case of a 50-year-old woman who presented with pain in the back with gradual onset of paraparesis. Magnetic resonance imaging showed ill-defined signal changes in the body and posterior elements of the vertebrae with epidural soft tissue mass encasing the spinal cord.ResultsThe patient underwent excision of the lesion with spinal fusion followed by a short course of radiotherapy. The patient recovered functional power after surgery, and at 32-month follow-up, there is no radiological evidence of recurrence of the lesion.ConclusionsMyopericytoma should be considered in the differential diagnosis of lytic lesions of the spine. Surgery is curative; however, a short course of chemotherapy or radiotherapy may be required to prevent recurrent disease in case of incomplete tumor excision.     

Chronic spontaneous spinal epidural hematoma – a rare cause of cervical myelopathy

Spontaneous spinal epidural hematoma (SSEH) is a rare entity. SSEH occurring anterior to the spinal cord in the cervical region with spontaneous improvement is even more rare. One such rare case is reported. A 19-year-old male presented with a 2-month history of neck pain and weakness of the upper and lower limbs without sensory deficit. Magnetic resonance imaging (MRI) showed features of anteriorly located cervical epidural hematoma. As the patient had started improving by the time he sought neurosurgical consultation, he was treated conservatively, and he improved over a period of 2 months. This case illustrates that, though rare, chronic spontaneous spinal epidural hematoma should be entertained in the differential diagnosis of cervical cord compression. Spontaneous resolution of spinal epidural hematomas is known to occur, and in properly selected cases, surgical intervention may not always be necessary.     

Cavernous angiomas of the spinal district: surgical treatment of 11 patients

Cavernous angiomas, also called cavernous malformations or cavernomas, are vascular hamartomas accounting for 3–16% of all angiomatous lesions of the spinal district. Although histologically identical, these vascular anomalies may exhibit different clinical behavior and radiological features, depending on their location, hinting at different managements and therapeutic approaches. The authors report 11 cases of symptomatic spinal cavernous angiomas diagnosed and surgically treated over the past 18 years. Age of patients ranged from 15–75 years; males outnumbered females. Three patients had vertebral cavernous malformations, secondarily invading the epidural space; two had pure epidural lesions; two patients had intradural extramedullary lesions, and four intramedullary lesions. Surgical removal was completely achieved in four patients with intramedullary lesions, in two with subdural extramedullary lesions, and in one with a pure epidural lesion. Subtotal excision of another one epidural and three vertebral cavernous angiomas was followed by radiotherapy. There was no morbidity related to surgery; the mean follow-up was 2 years. The outcome was excellent in two cases, good in six, and unchanged in the other three. The authors discuss the different modalities of treatment of these vascular lesions variously placed along the spine.     

Hematogenous pyogenic facet joint infection.

STUDY DESIGN: Retrospective. OBJECTIVES: To determine the incidence, clinical presentation, diagnostic laboratory values, imaging characteristics, and optimal treatment of hematogenous pyogenic facet joint infections. SUMMARY OF BACKGROUND DATA: There are 27 documented cases of hematogenous pyogenic facet joint infections. Data regarding incidence, clinical presentation, diagnosis, and treatment response are incomplete because of the paucity of reported cases. METHODS: This is a retrospective study of all cases of hematogenous pyogenic facet joint infection treated at one institution. Data from previous publications were combined with the present series to identify pertinent clinical characteristics and response to treatment. RESULTS: A total of six cases (4%) of hematogenous pyogenic facet joint infection were identified of 140 cases of hematogenous pyogenic spinal infection at our institution. Combining all reported cases reveals the following: The average patient age is 55 years. Ninety-seven percent of cases occur in the lumbar spine. Epidural abscess formation complicates 25% of the cases of which 38% develop severe neurologic deficit. Erythrocyte sedimentation rate and C-reactive protein are elevated in all cases. Staphylococcus aureus is the most common infecting organism. Magnetic resonance imaging is accurate in identifying the septic joint and associated abscess formation. Percutaneous drainage of the involved joint has a higher rate of success (85%) than treatment with antibiotics alone (71%), but the difference is not significant (P = 0.37). CONCLUSIONS: Hematogenous pyogenic facet joint infection is a rare but underdiagnosed clinical entity. Facet joint infections may be complicated by abscess formation in the epidural space or in the paraspinal muscles. Uncomplicated cases treated with percutaneous drainage and antibiotics may fare better than those treated with antibiotics alone. Cases complicated by an epidural abscess and severe neurologic deficit should undergo immediate decompressive laminectomy.     

Spinal hematoma: a literature survey with meta-analysis of 613 patients

Spinal hematoma has been described in autopsies since 1682 and as a clinical diagnosis since 1867. It is a rare and usually severe neurological disorder that, without adequate treatment, often leads to death or permanent neurological deficit. Epidural as well as subdural and subarachnoid hematomas have been investigated. Some cases of subarachnoid spinal hematoma may present with symptoms similar to those of cerebral hemorrhage. The literature offers no reliable estimates of the incidence of spinal hematoma, perhaps due to the rarity of this disorder. In the present work, 613 case studies published between 1826 and 1996 have been evaluated, which represents the largest review on this topic to date. Most cases of spinal hematoma have a multifactorial etiology whose individual components are not all understood in detail. In up to a third of cases (29.7%) of spinal hematoma, no etiological factor can be identified as the cause of the bleeding. Following idiopathic spinal hematoma, cases related to anticoagulant therapy and vascular malformations represent the second and third most common categories. Spinal and epidural anesthetic procedures in combination with anticoagulant therapy represent the fifth most common etiological group and spinal and epidural anesthetic procedures alone represent the tenth most common cause of spinal hematoma. Anticoagulant therapy alone probably does not trigger spinal hemorrhage. It is likely that there must additionally be a "locus minoris resistentiae" together with increased pressure in the interior vertebral venous plexus in order to cause spinal hemorrhage. The latter two factors are thought to be sufficient to cause spontaneous spinal hematoma. Physicians should require strict indications for the use of spinal anesthetic procedures in patients receiving anticoagulant therapy, even if the incidence of spinal hematoma following this combination is low. If spinal anesthetic procedures are performed before, during, or after anticoagulant treatment, close monitoring of the neurological status of the patient is warranted. Time limits regarding the use of anticoagulant therapy before or after spinal anesthetic procedures have been proposed and are thought to be safe for patients. Investigation of the coagulation status alone does not necessarily provide an accurate estimate of the risk of hemorrhage. The most important measure for recognizing patients at high risk is a thorough clinical history. Most spinal hematomas are localized dorsally to the spinal cord at the level of the cervicothoracic and thoracolumbar regions. Subarachnoid hematomas can extend along the entire length of the subarachnoid space. Epidural and subdural spinal hematoma present with intense, knife-like pain at the location of the hemorrhage ("coup de poignard") that may be followed in some cases by a pain-free interval of minutes to days, after which there is progressive paralysis below the affected spinal level. Subarachnoid hematoma can be associated with meningitis symptoms, disturbances of consciousness, and epileptic seizures and is often misdiagnosed as cerebral hemorrhage based on these symptoms. Most patients are between 55 and 70 years old. Of all patients with spinal hemorrhage, 63.9% are men. The examination of first choice is magnetic resonance imaging. The treatment of choice is surgical decompression. Of the patients investigated in the present work, 39.6% experienced complete recovery. The less severe the preoperative symptoms are and the more quickly surgical decompression can be performed, the better are the chances for complete recovery. It is therefore essential to recognize the relatively typical clinical presentation of spinal hematoma in a timely manner to allow correct diagnostic and therapeutic measures to be taken to maximize the patient's chance of complete recovery. Electronic Supplementary Material is available if you access this article at http://dx.doi.org/10.1007/s10143-002-0224-y. On that page (frame on the left side), a link takes you directly to the supplementary material. Electronic Publication     

Gingival Fibroma: An Emerging Distinct Gingival Lesion with Well-Defined Histopathology

Gingival growths, barring a few are mostly reactive and seldom exhibit significant true neoplastic potential. The common etiology is local irritation from dental plaque/calculus, trauma as well as medication-related overgrowth. Such lesions are easily distinguishable and categorized into diagnoses such as pyogenic granuloma, peripheral ossifying fibroma, etc. We present a previously undescribed, but commonly encountered, reactive gingival growth with unique histologic features and suggest the diagnostic term “gingival fibroma.” An IRB approved retrospective review of the University of Florida Oral Pathology Biopsy Service encompassing years 2010–2019, was performed to select cases. Demographics, clinical data, and microscopic diagnoses were recorded and analyzed. Four board-certified oral and maxillofacial pathologists agreed upon and established the diagnostic criteria. These are: a prominent fibromyxoid stroma, variable cellularity, a whorled or storiform pattern of arrangement of the cellular elements, lack of significant inflammation or vascularity, and complete absence of calcification, and/or odontogenic islands. A total of 60 cases met all criteria and were included in the study. Age range in years was 14–87 with the mean at 45.11 years. A striking female predilection (90%) was noted. Approximately 62% of cases were reported on the maxillary gingiva, followed by 38.3% in the mandibular gingiva. Majority, 66.7% were in the anterior incisor region followed by 11.7% in the canine/first premolar areas. All lesions were submitted as excisional biopsy, and 4 cases recurred within 2–3 years of excision. In all cases, lesional tissue appeared to extend to the surgical base of the specimen. We present 60 cases of a histologically unique entity occurring exclusively on the gingiva and introduce the diagnostic term “Gingival Fibroma” for these lesions. Further studies with adequate clinical follow-up may help understand the exact clinical behavior of these lesions.     

Radiation-induced cavernoma of the central nervous system

Central nervous system radiation-induced cavernoma (RIC) is a rare entity. We report one case with a review of the literature. This case illustrates the following features: mean age of 11.7 years at time of radiation and mean latency period of nine years for these RIC, which are often numerous (38%), and located in the field of the craniospinal radiation therapy. This nosological entity belongs to the spectrum of radiation-induced lesions, and requires a long-term MRI follow up in patients who underwent cranial radiation therapy.     

Epidural varicosis as a rare cause of acute radiculopathy with complete foot paresis--case report and literature review

INTRODUCTION: Lumbar epidural varicosis presenting with radiculopathy is a seldom anticipated condition. An uncommon case of symptomatic enlargement of epidural veins mimicking lumbar disc herniation led us to perform a literature review to elucidate aetiopathological and diagnostic considerations as well as treatment options of this intraspinal pathology. METHODS: The case of a 40-year-old woman with acute sciatia accompanied by a complete paresis of foot elevation and extension caused by enlarged epidural veins is described. A literature survey (Medline 1960-2005) was conducted to uncover further cases of symptomatic epidural varicosis. RESULTS: The literature review revealed only 75 published cases of symptomatic epidural varices which is generally judged as a rare cause of radiculopathy. Different models for the origin of enlarged epidural veins have been proposed. Enlargement may occur primary or secondary to a herniated disc or compressive lesions in the spinal cord. In some cases obstruction or occlusion of the inferior vena cava due to pregnancy or deep vein thrombosis are suspected to increase the pressure of the epidural venous plexi via collateral pathways. MRI has been reported to be of high value in demonstrating the dilated epidural vein, but the findings might be misinterpreted as herniated nucleus pulposus material. Coagulative ablation and/or excision of enlarged epidural veins is recommended and produces good long-term results in cases without extraspinal vessel pathology. CONCLUSION: Enlargement of epidural veins with compression of lumbar nerve roots can mimic the clinical signs of disc herniation or spinal stenosis, even when accompanied by neurological disorders. Although rare, lumbar epidural varicosis should be appreciated as a possible cause of radiculopathy and diagnosed before surgery. Apart from intraspinal abnormalities causing dilatation of epidural veins, stenosis or occlusion of the extraspinal venous drainage system should be considered.     

Thoracolumbar spinal angiolipoma demonstrating high signal on STIR imaging: a case report and review of the literature

BackgroundAngiolipomas are rare benign tumors, accounting for 0.14% to 1.2% of all tumors of the spinal axis with vascular and fatty histological features. Spinal angiolipoma (SAL) is most commonly found in the thoracic region and has high signal on contrast enhanced fat-saturated T1-weighted imaging. Although the international literature is extensive, there are few cases reported in United States.ObjectiveTo present a case of SAL located in the thoracolumbar region without high signal on contrast enhanced fat-saturated T1-weighted imaging and to review previously reported cases.Study design/MethodsCase report and review the literature.ResultsMagnetic resonance imaging obtained in a 68-year-old man with a long history of lumbago showed a heterogeneous mass (T10–L1) hyperintense on T1-weighted imaging but not enhancing on suppression fat sequences, suggesting epidural hematoma. Surgical excision of the lesion was performed, and SAL was diagnosed and confirmed by pathology. The patient became asymptomatic.ConclusionsThe predominance of either vascular or fatty components inside the tumor might alter the expected results on magnetic resonance imaging with suppression fat sequences.     

Spinal epidural empyema

Spinal epidural empyema is a very rare entity occurring with an estimated incidence of 1 per 10,000 hospital admissions. This condition has a reputation for presenting as a diagnostic challenge resulting in late diagnosis and delayed treatment. However, the cornerstones of treatment are prompt diagnosis and early treatment to prevent permanent paralysis and high mortality. We present a cluster of nine cases presenting to the neurosurgery unit over a 3-year period and discuss their relevant features in view of the most recent literature. The diagnosis of spinal epidural empyema was made with gadolinium-enhanced MRI in eight of nine cases. Staphylococcus aureus was isolated as the causative pathogen in all cases. All patients were treated with antibiotics. Eight patients had surgery for debridement and spinal decompression. One patient was treated successfully with antibiotics alone.     

Spinal extradural angiolipoma: a case report]

This 60-year-old man had been well until four years prior to admission, when he developed slowly progressive weakness of the lower extremities. On admission he was found to have a spastic paraparesis, sensory disturbance below the level of T10 and mild sphincter dysfunction. Conventional myelography and CT myelography demonstrated an epidural mass located from T5 to T8 vertebral level. MRI revealed that the epidural mass was fusiform and markedly enhanced by the contrast medium. Laminectomy was performed and a fibrous tumor red in color was subtotally removed. Histological findings were consistent with those of angiolipoma. Angiolipoma is a rare tumor in the central nervous system and is regarded as a clinical entity different from a spinal lipoma. Occurrence of angiolipoma in the central nervous system has been reported in 40 cases in the world literature. Thirty nine cases of them occurred in the spinal canal, especially in the dorsal epidural space of the thoracic region. The fusiform shape demonstrated in this case might also be characteristic of angiolipoma in this region.