脊髓髓内肿瘤的显微手术治疗

目的:评估脊髓髓内肿瘤的手术疗效,了解影响预后的因素。方法:回顾分析42例显微手术治疗的髓内肿瘤患者的临床资料,颈髓28例,颈胸交界6例,胸髓5例,圆锥3例。结果:肿瘤全切30例,次全切8例,部分切除4例。无手术死亡。随访3~36个月,病情较术前改善者24例,稳定者13例,加重5例。术前神经功能障碍严重的患者,术后恢复差。3例星形细胞瘤患者术后8~16个月内死亡。结论:脊髓髓内肿瘤在显微镜下大多可手术全切或次全切,并保留正常的脊髓功能,改善或稳定病情。手术应在神经功能加重前进行。恶性胶质瘤的手术效果及预后仍不满意。     

Intrinsic spinal cord tumor resection

SPINAL CORD TUMORS are more frequently detected than in the past, because of progress in neuroradiology. Many neurosurgeons must now decide how to treat such lesions. The recent neurosurgical literature contains many case reports, few series, and different strategies. This article describes the surgical method I have developed in a period of 15 years, with Georges Fischer in Lyon, on the basis of experience with more than 260 patients and 300 operations. The standard treatment is complete resection whenever possible, but we must learn when and where to stop to preserve the quality of life. I have several useful strategies, which are explained in this report. For gliomas (ependymomas and astrocytomas), I favor a midline approach; for most vascular tumors (such as hemangioblastomas and cavernomas), however, I prefer to proceed from the point at which the lesion is observed through the microscope and to dissect the lesion in one piece. Meticulous nonbleeding surgery and experience are the keys to success.     

Microsurgical resection of solitary intramedullary spinal cord metastases

Two cases of solitary intramedullary spinal cord metastasis treated primarily by surgical excision are presented. It has been generally thought that appropriate management for the rare metastasis within the spinal cord is radiation and corticosteroids. The excellent palliative results obtained in our patients suggest that, in selected cases, surgical removal is technically feasible and can be of considerable benefit to the patient.     

脊髓髓内肿瘤的显微外科治疗

目的 探讨显微手术治疗脊髓髓内肿瘤临床疗效.方法 回顾分析我院2005年6月至2009年6月显微外科手术切除15例脊髓髓内肿瘤的临床资料.全切除12例,次全切除及部分切除3例.室管膜瘤8例均全切;星形细胞瘤3例,全切除2例,部分切除1例;脂肪瘤2例次全切除;血管母细胞瘤2例全切除.结果 术后随访平均2年,症状消失9例,好转3例,无变化2例,1例星形细胞瘤复发,症状加重.结论 对脊髓髓内病变应早期诊断,显微手术治疗仍可取得较好疗效.     

Dorsal cervical spinal arachnoid cyst (Type III) presenting with dorsal column dysfunction: A case report

Context: Spinal arachnoid cysts are usually asymptomatic and discovered incidentally. Expansion of the cyst, whether acute, subacute or chronic, leads to neural compression resulting in radicuopathy and/or myelopathy.

Findings: This case report is of a patient who presented primarily with posterior column dysfunction,subacute in onset and rapidly progressing. Images of the cervical spine showed a dorsal arachnoid cyst, causing significant cord compression and signal changes in the cord, with no scalloping of the vertebrae.

Conclusion: The author explains the mechanism of rapid expansion of an asymptomatic spinal arachnoid cyst, causing neural compression leading to fast progression of neurological deficits. The dorsal location of the cyst, explain the absence of radiculopathy, which is a common presenting feature of ventrally located intradural arachnoid cyst.     

Isolated spinal cord sarcoidosis mimicking an intramedullary tumor

A case of cervical intramedullary sarcoidosis and its uncommon magnetic resonance imaging with contrast medium are reported. Spinal cord sarcoidosis is very rare. It is difficult to diagnose intramedullary sarcoidosis without a previous diagnosis of systemic sarcoidosis or other apparent symptom. The patient had subacute myelopathy. Contrast-enhanced images revealed intense focal enhancement of the C6-7 cervical cord. The preoperative diagnosis was an intramedullary tumor. Subtotal resection was performed after intraoperative frozen section study was interpreted as malignant lymphoma. Subsequent pathologic examination of the biopsied specimens revealed spinal cord sarcoidosis. After surgery, steroid therapy was performed, but the patient's symptoms hardly improved. Even if imaging study and intraoperative frozen section show neoplasm, the first surgery should be limited to decompressing the cord and biopsy in cases of suspected sarcoidosis.     

Implantation of laminotomy electrodes for spinal cord stimulation in spinal anesthesia with intraoperative dorsal column activation

OBJECTIVE: To optimize the technique of implanting laminotomy plate electrodes for spinal cord stimulation and to minimize the discomfort of the patients during surgery. This operation is often performed while the patient is under local anesthesia, which is very stressful for the patient, or under general anesthesia, which precludes the use of test stimulation. An alternative approach is to perform the implantation with a spinal anesthetic and to examine whether stimulation-induced paresthesiae can still be evoked to guide the positioning of the electrode. METHODS: Spinal anesthesia was induced by bupivacaine (12.5-20 mg), which produced complete motor block and anesthesia up to a midthoracic level. After a single-level laminotomy (thoracic vertebrae 9-11) a four-pole plate electrode was inserted into the epidural space. Stimulation was applied with commonly used parameters, and the electrode was positioned so that the paresthesiae covered the painful region. RESULTS: In 19 patients (20 procedures) with different forms of neuropathic pain, implantation of laminotomy plate electrodes could be performed under spinal anesthesia without problems. In all patients, it was possible to evoke paresthesiae, the distribution of which could be reproduced postoperatively. The paresthesia thresholds during surgery were only moderately higher than those recorded after implantation (mean, 3.1 versus 2.1 V, respectively). During an interview after the intervention, no patient reported that he or she had experienced surgery as painful or uncomfortable. CONCLUSION: Implantation of laminotomy electrodes can be performed conveniently with spinal anesthesia because it minimizes discomfort for the patient and enables the use of intraoperative test stimulation to guide the positioning of the electrode. In spite of the total motor block and anesthesia, paresthesiae representing the activation of the dorsal columns can be evoked and are well perceived, and the thresholds are not abnormally high. This observation supports the notion that the subarachnoidal anesthetic agent acts predominantly on the spinal rootlets rather than on the spinal afferent pathways.     

Surgical treatment for intramedullary spinal cord melanocytomas

Spinal meningeal melanocytomas are rare lesions that are histologically benign and can behave aggressively, with local infiltration. The authors present their experience with intramedullary spinal cord melanocytomas consisting of 3 cases, which represents the second largest series in the literature. A retrospective chart review was performed following identification of all spinal melanocytomas treated at the author's institution, based on information obtained from a neuropathology database. The charts were reviewed for patient demographics, surgical procedure, clinical outcome, and long-term tumor progression. Three patients were identified in whom spinal melanocytoma had been diagnosed between 1989 and 2006. The patients' ages were 37, 37, and 48 years, and the location of their tumor was C1-3, T9-10, and T-12, respectively. All 3 had complete resection with no adjuvant radiotherapy during follow-up periods of 16, 38, and 185 months, respectively. One patient demonstrated a recurrence 29 months after resection and the other 2 patients have demonstrated asymptomatic recurrences on imaging studies obtained at 16 and 38 months following resection. With these cases added to the available literature, the evidence strongly suggests that complete resection is the treatment of choice for spinal melanocytomas. Even with complete resection, recurrences are common and close follow-up is needed for the long term in these patients. Radiation therapy should be reserved for those cases in which complete resection is not possible or in which there is recurrence.     

Non-dysraphic intramedullary spinal cord lipoma

True intramedullary spinal cord lipomas are extremely rare. Two cases of intramedullary spinal cord lipoma are presented. The patients did not exhibit any form of spinal dysraphism. The patients presented with gait difficulty, upper limb weakness, sphincter disturbance, dysesthesias and neck pain. The tumors were removed sub-totally and the neurological grade improved postoperatively in one of the patients.     

Isolated intramedullary spinal cord cysticercosis

We report a case of intradural, intramedullary, spinal cord neurocysticercosis at dorsal 10-11 (D10-11) level in a mentally retarded male. A 38-year-old, mentally retarded male presented with weakness and stiffness in both the lower limbs and waist since one year. Magnetic resonance imaging revealed a D10-D11 intradural space occupying lesion with cord compression. Intraoperatively, the tumor was grayish white, soft, cystic, and intramedullary with a well-defined plane with surrounding cord tissue. Gross examination revealed a cystic lesion of 1.5×1×0.8 cm, with a whitish nodule of 0.3 cm in diameter. The cyst wall was thin, shiny, and translucent. Microscopic examination revealed cysticercous cyst. Spinal neurocysticercosis should be considered in differential diagnosis of spinal mass lesion in patients residing in endemic area such as India.