Spinal tumors

Imaging and surgical outcomes of spinal tumors in 18 dogs and one cat

Clinical and magnetic resonance imaging (MRI) findings, histological appearances and surgical outcomes of 18 dogs and one cat with spinal tumors are presented. Medical records of the cases admitted for spinal disorders were reviewed, and cases of spinal tumors that were diagnosed by MRI and confirmed by histological examination were included in this study. T1 weighted, T2 weighted and contrast enhanced T1 weighted images were taken and interpreted to evaluate the spinal tumors. The tumors were diagnosed as: meningioma (n = 6), ependymoma (n = 1), nerve sheath tumor (n = 4), metastatic spinal tumor (n = 3), osteosarcoma (n = 2), osteoma (n = 1), rhabdomyosarcoma (n = 1), and nephroblastoma (n = 1). Thirteen cases underwent surgical operation and the remaining six cases were euthanized at the request of the owners. The neurological status of the surgical cases did not deteriorate, except for one dog that showed ependymoma in the early period after the operation. These results indicate the potential for surgical gross total tumor removal of vertebral tumors to provide better quality of life and surgical collection of histological specimens for definitive diagnosis. For effective case management, dedicated MRI examination is important to accurate evaluation of the spinal tumors, and surgical treatment is useful for extradural and intradural-extramedullary spinal tumors.

Spinal diffusion tensor tractography for differentiation of intramedullary tumor-suspected lesions

BACKGROUND AND PURPOSE

Primary MRI diagnosis of spinal intramedullary tumor-suspected lesions can be challenging and often requires spinal biopsy or resection with a substantial risk of neurological deficits. We evaluated whether Diffusion Tensor Imaging (DTI) tractography can facilitate the differential diagnosis.

MATERIALS AND METHODS

Twenty-five consecutive patients with an intramedullary tumor-suspected lesion considered for spinal surgery were studied with a Diffusion-weighted multi-shot read out segmented EPI sequence (RESOLVE). White matter tracts ("streamlines") were calculated using the FACT algorithm and visually co-registered to a T2-weighted 3D sequence. The fused images were assessed concerning spinal streamline appearance as normal, displaced or terminated. Definite diagnosis was verified by histological analysis or further clinical work-up.

RESULTS

All patients with normal appearing streamlines (n=6) showed an acute inflammatory demyelinating pathology in the further clinical work-up. In 10 patients streamline displacing lesions were found from which 5 patients underwent a surgical treatment with histologically confirmed low-grade tumors like ependymomas and pilocytic astrocytomas. In nine patients streamlines were terminated, from which 6 patients received a histology proven diagnoses with a more heterogenous spectrum (3 cases of high grade tumor, 1 case of low grade tumor with intralesional hemorrhage and 2 cases with gliosis but no tumor cells).

CONCLUSION

Using multi-shot DTI spinal tractography acute inflammatory lesions can be differentiated from other tumorous intramedullary lesions. The entity diagnosis of spinal tumors seems to be more challenging, primarily due to the variety of factors like invasivity, expansion or intralesional hemorrhage.

Idiopathic Transverse Myelitis Mimicking an Intramedullary Spinal Cord Tumor

The differential diagnoses for spinal cord lesions include spinal tumors and inflammatory processes. The distinction between these pathologies can be difficult if solely based on imaging. We report for the first time to our knowledge a case of idiopathic transverse myelitis (ITM) mimicking a discrete cervical spinal lesion in a 66-year-old man who presented with gait instability and neck pain. The patient's symptoms failed to resolve after an initial course of steroid therapy. Surgical biopsy confirmed the diagnosis of ITM. Subsequent treatment with dexamethasone resulted in complete resolution of the symptoms as well as the intramedullary enhancement. ITM is most common in the cervical and thoracic spine, spanning 3-4 spinal segments. It usually occupies more than 50% of the cross-sectional area of the spinal cord and tends to be central, uniform, and symmetric. It exhibits patchy and peripheral contrast enhancement. These criteria are useful guidelines that help distinguish ITM from neoplastic spinal lesions. A decision to perform biopsy must take into consideration the patient's clinical symptoms, the rate of progression of neurological deficits, and the imaging characteristics of the lesion. Surgical biopsy for questionable lesions should be reserved for patients with progressive neurological deficits refractory to empirical medical therapy.

Periosteal chondroma with spinal cord compression in the thoracic spinal canal: a case report

Periosteal chondroma is a very unusual cartilaginous neoplasm of the spinal canal. We herein report a case of periosteal chondroma in a 41-year-old male who presented with gait disturbance and paresthesia of both lower extremities. Magnetic resonance (MR) images showed an extradural mass which caused compression of the spinal cord at the T5/6 level. The mass showed iso-signal intensity on T1-weighted images, high signal intensity on T2-weighted images, and nodular and peripheral rim enhancement on post-contrast T1-weighted images. Computed tomography (CT) images showed a mass with punctate calcifications and extension into the left T5/6 neural foramen. MR and CT images showed extrinsic cortical bone erosion of the posterior inferior body of T5 and superior pedicle of T6, bone remodeling with overhanging margins, and sclerosis adjacent to the tumor. The patient underwent a complete excision of the mass by left T5/6 hemi-laminectomy and exhibited complete resolution of his symptoms. Histopathologic examination revealed periosteal chondroma. Tumor recurrence was not recorded during the 18-month follow-up period.

Advanced Neuroimaging in the Evaluation of Spinal Cord Tumors and Tumor Mimics: Diffusion Tensor and Perfusion-Weighted Imaging

Spinal cord tumors are an important component of pathologic diseases involving the spinal cord. Conventional magnetic resonance (MR) imaging only provides anatomical information. MR diffusion tensor imaging (DTI) and MR perfusion-weighted imaging (PWI) may detect microstructure diffusion and hemodynamic changes in these tumors. We review recent application studies of MR DTI and PWI in spinal cord tumors. Overall, MR DTI and MR PWI are promising imaging tools that are especially useful in improving differential diagnosis between spinal cord tumors and tumor mimics, preoperative evaluation of resectability, and providing assistance in surgical navigation.

Red flags presented in current low back pain guidelines: a review

OBJECTIVE

The purpose of this study was to identify and descriptively compare the red flags endorsed in guidelines for the detection of serious pathology in patients presenting with low back pain to primary care.

METHOD

We searched databases, the World Wide Web and contacted experts aiming to find the multidisciplinary clinical guideline in low back pain in primary care, and selected the most recent one per country. We extracted data on the number and type of red flags for identifying patients with higher likelihood of serious pathology. Furthermore, we extracted data on whether or not accuracy data (sensitivity/specificity, predictive values, etc.) were presented to support the endorsement of specific red flags.

RESULTS

We found 21 discrete guidelines all published between 2000 and 2015. One guideline could not be retrieved and after selecting one guideline per country we included 16 guidelines in our analysis from 15 different countries and one for Europe as a whole. All guidelines focused on the management of patients with low back pain in a primary care or multidisciplinary care setting. Five guidelines presented red flags in general, i.e., not related to any specific disease. Overall, we found 46 discrete red flags related to the four main categories of serious pathology: malignancy, fracture, cauda equina syndrome and infection. The majority of guidelines presented two red flags for fracture ('major or significant trauma' and 'use of steroids or immunosuppressors') and two for malignancy ('history of cancer' and 'unintentional weight loss'). Most often pain at night or at rest was also considered as a red flag for various underlying pathologies. Eight guidelines based their choice of red flags on consensus or previous guidelines; five did not provide any reference to support the choice of red flags, three guidelines presented a reference in general, and data on diagnostic accuracy was rarely provided.

CONCLUSION

A wide variety of red flags was presented in guidelines for low back pain, with a lack of consensus between guidelines for which red flags to endorse. Evidence for the accuracy of recommended red flags was lacking.

Coexistence of intervertebral disc herniation with intradural schwannoma in a lumbar segment: a case report

Background

Lumbar intervertebral disc herniation and spinal tumor are major pathologies that may cause back pain and radiculopathy. Neurological symptoms resulting from disc herniation and intradural spinal tumor together, however, are very rare.

Case presentation

We report a case of lumbar disc herniation which coexists with intradural schwannoma at the same spinal level in a 67-year-old man. The patient presented with persistent low back pain, sciatica, and weakness of the lower limbs. Contrast lumbar spine magnetic resonance (MR) imaging clearly delineated an intradural lesion and an extradural herniated disc at L3/4 level. Using a single posterior approach, both pathologies were addressed. Pathological studies confirmed the intradural lesion was schwannoma.

Conclusion

The case report highlights a rare concomitance of two symptomatic pathologies in a lumbar spine, which deserves clinical attention. Complete history, careful physical examination, and investigative measures, such as contrast MR imaging, are helpful to establish throughout diagnoses. 

Therapy for thoracic lumbar and sacral vertebrae tumors using total spondylectomy and spine reconstruction through posterior or combined anterior-posterior approaches

The present study aimed to analyze the indications, feasibility, safety and clinical effects of total spondylectomy and spine reconstruction through posterior or combined anterior-posterior approaches for thoracic lumbar and sacral vertebrae tumors. Between December 2009 and May 2012, 10 patients with thoracic lumbar and sacral vertebrae tumors were retrospectively analyzed. Different surgical indications and approaches were used according to the affected segments, the extent of lesion involvement and the specific pathology results. One-stage posterior or combined anterior-posterior total spondylectomy and reconstruction was used for the treatment of complicated thoracic lumbar and sacral vertebral malignant tumors and invasive benign tumors. The duration of surgery, levels of intraoperative blood loss and transfusions, and the clinical effects were observed. The average surgical duration was 6.8 h (range, 4.8-12 h), with an average blood loss level of 3,200 ml (range, 1,500-10,000 ml) and an average transfusion level of 2,500 ml. During the average 15 months (range, 3-29 months) follow up, two patients succumbed and one patient experienced tumor recurrence. Neither tumor reoccurrence nor metastasis was observed in all other patients. Personalized surgical indications and approaches according to the affected segments, the extent of lesion involvement and the specific pathology results would aid in the reduction of pain, the improvement of nerve function and the reduction of tumor recurrence.

Imaging diagnosis and the role of endovascular embolization treatment for vascular intraspinal tumors

Intraspinal tumors comprise a large spectrum of neoplasms, including hemangioblastomas, paragangliomas, and meningiomas. These tumors have several common characteristic imaging features, such as highly vascular mass appearance in angiography, hypointense rim and serpentine flow voids in MRI, and intense enhancement after intravenous contrast administration. Due to their rich vascularity, these tumors represent a special challenge for surgical treatment. More recently, the surgical treatment of intraspinal vascular tumors has benefited from the combination of endovascular techniques used to better delineate these lesions and to promote preoperative reduction of volume and tissue blood flow. Endovascular embolization has been proven to be a safe procedure that facilitates the resection of these tumors; hence, it has been proposed as part of the standard of care in their management.

A rare case of intramedullary 'whorling-sclerosing' variant meningioma

A 52-year-old man with a seven-year history of progressive weakness, gait problems, and pain in his extremities presented with subacute worsening of his symptoms. Examination revealed weakness in all four extremities, increased tone, hyperreflexia, and sensory deficits. MRI of the cervical spine showed an area of signal abnormality and abnormal enhancement within the cervical cord at the C5–C6 level. The patient initially underwent biopsy followed a few days later by a debulking surgery. Postoperatively, the patient showed improvement in strength as well as ambulation. Intraoperatively, the lesion was confirmed to be intramedullary without any dural attachments. Histopathological examination revealed an extensively hyalinized tumor with sparse collections of cells that were immunopositive for both cytokeratin and GFAP, and immunonegative for EMA and progesterone receptor. This is an unusual pattern of expression, with cytokeratin immunopositivity suggesting a meningioma and GFAP immunopositivity suggesting a glioma. Considering the combination of extensive hyalinization with cytokeratin positivity the tumor was thought to be most consistent with a hyalinized meningioma with GFAP positivity. GFAP-positive meningiomas are rare, and these include the recently described ‘whorling-sclerosing’ variant. Only three cases of this tumor have been previously reported, all of which were intracranial. This is the first reported case of an intramedullary whorling-sclerosing meningioma.

Features and Outcome of Surgical Management of Spinal Tumors in a Cohort of Nigerian Patients

OBJECTIVE

There is a dearth of information on operated cases of spinal tumors in patients in sub-Saharan Africa. The objective of this study was to evaluate the histologic pattern, anatomic distribution, and extent and outcome of surgery of Nigerian patients with spinal tumors.

METHODS

This retrospective study comprised a cohort of Nigerians who underwent surgery for spinal tumors. Data obtained included patient demographics, duration of symptoms, anatomic location, imaging findings, Frankel grading before and after surgery, and type and outcome of surgery. Univariate analysis was performed, and results were compared with results from other parts of the world.

RESULTS

There were 59 patients (male-to-female ratio 1:1.1) with a bimodal age distribution. The highest (20.34%) incidence was seen in the 20-29 age group. More than half (58.06%) of the patients presented with a duration of symptoms of at least 6 months (duration of symptoms was >12 months in 35.48%). Motor deficit was present in 97.73% of patients at presentation. Functional grading was Frankel A in 38.10% of patients, Frankel C in 26.19%, Frankel B in 16.67%, Frankel D in 16.67%, and Frankel E in 2.38%. The tumors were mostly in the thoracic region (65.45%), and 58% were extradural in location. Gross total tumor excision was performed in 50.88% of the cases, and subtotal resection was performed in 24.56%. Spinal stabilization was performed in 17.86% with spinous process wiring and vertical strut being the most common method of stabilization (80%) among this group. Metastasis was the most common histologic tumor type (23.21%). Meningioma accounted for 12.50% of tumors, and ependymoma, astrocytoma, and hemangioma each accounted for 7.14%. The most common source of metastasis was the prostate (38.46%). Postoperatively, 45% of patients improved neurologically, 52.5% remained the same, and 2.5% deteriorated. There was no perioperative mortality.

CONCLUSIONS

Metastasis was the most common histologic type of spinal tumor in this study, and the most common location was extradural. The outcome was satisfactory in most cases with neurologic function remaining the same or improving after surgery in most patients.

Primary bone tumors of the spine revisited: A 10-year single-center experience of the management and outcome in a neurosurgical department

OBJECTIVE

To report a large clinical series of primary bone tumors of the spine (PBTS) and review the current concepts of management.

MATERIALS AND METHODS

We retrospectively analyzed a clinical series of PBTS treated over the last decade (2004-2014) in the spine unit of a large European tertiary care center. Every PBTS was identified from an electronic medical-record system. Analysis comprised medical records and clinical imaging. Overall survival and outcome was measured using the Glasgow Outcome Scale (GOS) at six weeks, six months and one year postoperatively. Surgical management and adjuvant/neoadjuvant strategies were analyzed. A thorough review of the current literature was performed.

RESULTS

A total of 79 patients were included. Of these, 44 (55.7%) were male. The age ranged from 9 to 90 years (mean 55), and most patients were adults (93.6%). Local pain was the most common symptom and was present in 91.1% of the patients. The majority of the tumors occurred in the thoracic spine (52 patients, 65.8%). Overall 86% (68 patients) of PBTS were classified as malignant and at the time of diagnosis, 7 patients (8.9%) presented with non-spinal metastasis. The most common histologic types were hematopoietic tumors (72.2%), followed by chondrogenic ones (12.7%). Within hematopoietic tumors, plasmacytoma was the most frequent type (49 patients, 62%). In 12 patients (15.2%) recurrences were seen during the follow-up period. Overall mean survival of benign PBTS was 100%, malignant non-hematopoietic PBTS 50% and, malignant hematopoietic PBTS 84% at one year, respectively. At six weeks and one year after the initial surgery, 79% and 54% of the patients presented a GOS >3, respectively.

CONCLUSION

PBTS were almost exclusively seen in adults. Malignant tumors were markedly more frequent than benign tumors, with hematopoietic tumors being the most common type. For PBTS, early surgery is important in order to restore spinal stability and decompress the spinal cord. This allows pain reduction and prevention of neurological deficits.

Analysis of 5-aminolevulinic acid-induced fluorescence in 55 different spinal tumors

OBJECT

Subtotal resection (STR) of spinal tumors can result in tumor recurrence. Currently, no clinically reliable marker is available for intraoperative visualization of spinal tumor tissue. Protoporphyrin IX (PpIX) fluorescence induced by 5-aminolevulinic acid (5-ALA) is capable of visualizing malignant gliomas. Fluorescence-guided resections of malignant cerebral gliomas using 5-ALA have resulted in an increased rate of complete tumor removal. Recently, the application of 5-ALA has also been described in the first cases of spinal tumors. Therefore, the aim of this observational study was to systematically investigate 5-ALA-induced fluorescence characteristics in different spinal tumor entities.

METHODS

Three hours before the induction of anesthesia, 5-ALA was administered to patients with different intra- and extradural spinal tumors. In all patients a neurosurgical resection or biopsy of the spinal tumor was performed under conventional white-light microscopy. During each surgery, the presence of PpIX fluorescence was additionally assessed using a modified neurosurgical microscope. At the end of an assumed gross-total resection (GTR) under white-light microscopy, a final inspection of the surgical cavity of fluorescing intramedullary tumors was performed to look for any remaining fluorescing foci. Histopathological tumor diagnosis was established according to the current WHO classification.

RESULTS

Fifty-two patients with 55 spinal tumors were included in this study. Resection was performed in 50 of 55 cases, whereas 5 of 55 cases underwent biopsy. Gross-total resection was achieved in 37 cases, STR in 5, and partial resection in 8 cases. Protoporphyrin IX fluorescence was visible in 30 (55%) of 55 cases, but not in 25 (45%) of 55 cases. Positive PpIX fluorescence was mainly detected in ependymomas (12 of 12), meningiomas (12 of 12), hemangiopericytomas (3 of 3), and in drop metastases of primary CNS tumors (2 of 2). In contrast, none of the neurinomas (8 of 8), carcinoma metastases (5 of 5), and primary spinal gliomas (3 of 3; 1 pilocytic astrocytoma, 1 WHO Grade II astrocytoma, 1 WHO Grade III anaplastic oligoastrocytoma) revealed PpIX fluorescence. It is notable that residual fluorescing tumor foci were detected and subsequently resected in 4 of 8 intramedullary ependymomas despite assumed GTR under white-light microscopy.

CONCLUSIONS

In this study, 5-ALA-PpIX fluorescence was observed in spinal tumors, especially ependymomas, meningiomas, hemangiopericytomas, and drop metastases of primary CNS tumors. In cases of intramedullary tumors, 5-ALA-induced PpIX fluorescence is a useful tool for the detection of potential residual tumor foci.

Cystic spinal schwannomas: A short series of six cases. Can we predict them preoperatively?

Background:

Spinal schwannomas are benign tumors arising from the spinal nerve root sheaths and are the commonest intradural extramedullary spinal tumors. Though cystic changes in schwannomas are well described, predominantly cystic schwannomas are uncommon lesions and form a different spectrum of conditions as compared with the commonly seen intradural extramedullary solid lesions.

Case Description:

We present a case series of six patients with spinal intradural extramedullary cystic schwannomas. Two patients had uniloculated cystic schwannomas, two patients had multi-loculated cystic lesions with thick walls and intralesional septations, and two patients had giant cystic schwannomas, one of which had an extradural extension. We report two cases in which preoperative radiological dilemma was encountered and discuss the differential diagnoses of this uncommon entity.

Conclusion:

Cystic spinal schwannomas may be confused with other cystic lesions in the spine, differentiating them preoperatively is important and in this regard, contrast-enhanced magnetic resonance imaging plays a vital role. Frozen section histopathology should be used to identify them at surgery. It is important to detect these lesions at surgery, as total excision is possible and almost always results in good long-term neurological outcome.

Intradural schwannoma complicated by lumbar disc herniation at the same level: A case report and review of the literature

Intradural tumours of the spine are usually benign and have a good prognosis, if they are diagnosed and removed early. Lumbar disc herniation is a common cause of chronic, acute, or recurrent lumbar radiculopathy. However, to date, there have been no reports of progressive neurological deficiencies due to the co-existence of two significant pathologies contributing to intradural and extradural compression. The current study reports the rare case of a patient with simultaneous extradural and intradural compression of the nerve root due to co-existent intervertebral disc herniation and an intradural schwannoma at the same level. A 71-year-old female suffering from lower back pain and radiating pain of the right lower extremities was admitted to Busan Korea Hospital (Busan, Korea). Magnetic resonance imaging revealed lumbar disc herniation at L4–5 and a mass occupying the intradural space at the same level of the compressed dural sac. Using the posterior approach, surgical excision of the two pathologies was performed. Pathological diagnosis confirmed schwannoma and the symptoms markedly improved.

Magnetic resonance image findings of primary intradural Ewing sarcoma of the cauda equina: case report and review of the literature

BACKGROUND CONTEXT

Involvement of the cauda equina in Ewing sarcoma (ES) is extremely rare, and only few cases are reported in literature. However, ES of cauda equina shares some neuroradiological features with other neoplasms that can involve the intradural space. Therefore, differential diagnosis with other tumors of cauda equina should be considered by neuroradiologists and neurosurgeons to provide appropriate treatment.

PURPOSE

To present a rare case of intradural extramedullary primary ES.

STUDY DESIGN

Case report.

METHODS

We report a case of a 44-year-old woman presenting with the rapid onset of cauda equina syndrome. Radiological analysis showed multiple intradural masses, extending from L1 to S3 level. After radical surgery, lesions were histologically defined as ES. We present a literature review, analyzing magnetic resonance image (MRI) features of primary intradural ES of the cauda equina.

RESULTS

Four cases of primitive ES arising from the cauda equina have been reported in the literature.

CONCLUSIONS

Because of the low number of reported cases, it is not possible to describe pathognomonic MRI findings for intradural ES of the cauda equina. However, few tumors show similar MRI features. Therefore, despite its rarity, intradural ES should be taken into account in the differential diagnosis of spinal tumors involving cauda equina.

An overview of the role of cancer stem cells in spine tumors with a special focus on chordoma

Primary malignant tumors of the spine are relatively rare, less than 5% of all spinal column tumors. However, these lesions are often among the most difficult to treat and encompass challenging pathologies such as chordoma and a variety of invasive sarcomas. The mechanisms of tumor recurrence after surgical intervention, as well as resistance to radiation and chemotherapy, remain a pervasive and costly problem. Recent evidence has emerged supporting the hypothesis that solid tumors contain a sub-population of cancer cells that possess characteristics normally associated with stem cells. Particularly, the potential for long-term proliferation appears to be restricted to subpopulations of cancer stem cells (CSCs) functionally defined by their capacity to self-renew and give rise to differentiated cells that phenotypically recapitulate the original tumor, thereby causing relapse and patient death. These cancer stem cells present a unique opportunity to better understand the biology of solid tumors in general, as well as targets for future therapeutics. The general objective of the current study is to discuss the fundamental concepts for understanding the role of CSCs with respect to chemoresistance, radioresistance, special cell surface markers, cancer recurrence and metastasis in tumors of the osseous spine. This discussion is followed by a specific review of what is known about the role of CSCs in chordoma, the most common primary malignant osseous tumor of the spine.

Conus medullaris and cauda equina tumors: clinical presentation, prognosis, and outcome after surgical treatment: clinical article

OBJECT

Intradural cauda equina and conus medullaris tumors (CECMTs) are rare. Only a few large clinical series exist to date. Therefore, clinical symptoms, surgical complications, and outcomes are poorly understood. The aim of the present study was to evaluate outcome after surgery of CECMTs and to identify the factors associated with a worse clinical prognosis based on the results of a series with sufficiently high number of cases.

METHODS

All cases of intradural CECMTs treated surgically at the authors' department between March 2006 and May 2012 were retrospectively evaluated. Arachnoid cysts and multifocal tumors were excluded. Sixty-eight adult patients met the inclusion criteria (35 female and 33 male patients; median age 56 years). Follow-up data were available for 72% (n = 49) in a median period of 9 months.

RESULTS

Overall, 18 tumors were located intramedullary and 50 extramedullary. The majority were nerve sheath tumors (n = 27), ependymomas (n = 17), and meningiomas (n = 9). The most common preoperative symptom was pain. The rate of new transient postoperative impairment was 18% (n = 12), and new permanent deficits were observed in only 6% (n = 4). Overall neurological improvement was achieved in 62%. The reversibility of preoperative symptoms was related to the interval between the time of symptom onset and the time of surgery and to the presence of preoperative neurological deficits. Surgery of ependymoma and carcinoma metastases was associated with a higher rate of morbidity.

CONCLUSIONS

Intradural CECMTs present as a group of tumors with varying histological features and clinical symptoms. Symptomatic manifestation is usually unspecific, mimicking degenerative lumbar spine syndromes. Despite a significant risk of transient deterioration, early surgery is advisable because more than 94% of patients maintain at least their preoperative status and more than 60% improve during follow-up. The reversibility of preoperative symptoms is related to the duration between symptom onset and surgery and to the presence of preoperative neurological deficits. The prognosis for recovery from cauda equina or conus medullaris syndrome is less favorable than for other deficits. Surgery of ependymoma is associated with a higher morbidity rate than other benign entities.

Advanced MR diffusion tensor imaging and perfusion weighted imaging of intramedullary tumors and tumor like lesions in the cervicomedullary junction region and the cervical spinal cord

Differential diagnosis between intramedullary tumors and tumor-like lesions (TLL) in the cervicomedullary junction region and cervical spinal cord is important, sometimes clinical dilemma on conventional MR imaging and empirical treatment. We evaluated advanced MR diffusion tensor imaging (DTI) and perfusion weighted imaging (PWI) in 25 patients, including 12 with intramedullary tumors and 13 with TLL in the cervicomedullary junction region and cervical spinal cord. We found that mean fractional anisotropy value of tumors was significantly lower than the value found in TLL, and the mean trace apparent diffusion coefficient and peak height values of tumors were significantly higher (P < 0.05). The receiver operating characteristic curve analysis showed that peak height was better than any of the other imaging parameters, with a sensitivity of 90.9% and specificity of 80% using a cutoff value of 4.523 to differentiate between tumors and TLL. In conclusion, the MR DTI and PWI could be useful in differentiating between intramedullary tumors and TLL in the cervicomedullary junction region and cervical spinal cord.

A case of intradural osteosarcoma of the spine

BACKGROUND CONTEXT

Intradural-extramedullary spinal tumors and extradural osteosarcomas are both rare entities. Only one case of primary intradural-extramedullary osteosarcoma of the spine has been previously reported. This is the second reported case.

PURPOSE

To describe a case of primary intradural-extramedullary osteosarcoma of the spine associated with rapid clinical deterioration.

STUDY DESIGN

Case report of a 70-year-old woman who presented with a constellation of neurologic symptoms.

METHODS

Review of patient files, radiographic studies, surgical images, histopathology, and relevant literature.

RESULTS

The patient underwent tumor debulking but exhibited rapid, postsurgical, functional deterioration and died within 6 weeks. This case and the only previous case of its kind both occurred in individuals with a remote history of iophendylate (Myodil) myelogram.

CONCLUSIONS

Primary intradural-extramedullary extraosseous osteosarcoma of the spine is an exceedingly rare entity with no established management approach. Iophendylate myelography may be implicated in the etiology of this tumor type.

Myelopathy due to calcified meningiomas of the thoracic spine: minimum 3-year follow-up after surgical treatment

Object

Calcified meningiomas are an uncommon type of meningioma. This study details the clinical features, treatment, and follow-up of 11 calcified meningiomas treated from 2002 to 2009, for the purpose of providing general information, describing the skill required for the surgery, and detailing the imaging study of these tumors.

Methods

Between 2002 and 2009, 11 patients underwent surgery for the treatment of calcified meningiomas. All were treated by the same group of doctors at the same institution, including surgery and rehabilitation after surgery. The minimum 3-year (> 36 months) follow-up data from the 11 patients were detailed. Neurological function was evaluated twice, based on the Frankel scale and Japanese Orthopaedic Association scoring system. The first evaluation occurred before surgery and the second 3 years after surgery.

Results

In 3 cases, the Frankel score decreased by 1 level. In a comparison of the duration of preoperative symptoms, age, degree of canal stenosis, and intraoperative blood loss, it was found that the greater the degree of canal stenosis, the poorer the outcome of the patient. Calcified meningiomas were more likely to adhere to the nerves and dura, a finding that might explain the high incidence of neurological dysfunction and CSF leakage after surgery.

Conclusions

Calcified meningiomas are the most rare of all meningiomas. It appears that a greater degree of canal stenosis can lead to a poorer outcome. Computed tomography scans and MRI with contrast enhancement are recommended for intraspinal tumors before surgery to exclude the possibility of calcification. For calcified meningiomas, precise tumor resection, dura repair during surgery, and medical care after surgery are important for achieving an acceptable outcome.

Cauda equina tumor surgery: how I do it

BACKGROUND

Tumors of the cauda equina usually require surgery due to their impingement on neighboring nerve roots, often resulting in pain and neurological deficits.

METHOD

The Authors first give a brief introduction on cauda equina tumors, followed by a description of the surgical anatomy, and then develop the microsurgical technique. In particular, tricks to avoid complications are presented, underlining the importance of intraoperative neuromonitoring.

CONCLUSION

Both microsurgical technique and neuromonitoring are important in cauda equina tumor surgery, the goal of which is to achieve complete resection while at the same time preserving neurological function.

Delay in diagnosis of primary intradural spinal cord tumors

Background:

It has been our impression in recent years that there is a significant delay in diagnosis (DID) of patients in Israel harboring intradural spinal cord tumors (IDSCTs). DID can lead to irreversible deficits and unnecessary suffering. Our goal was to identify the incidence and the specific reasons for DID of IDSCTs in patients operated upon at our institution.

Methods:

A retrospective record review, with additional telephone survey, of 101 patients operated upon at our institute between the years 1996 and 2009 was conducted. The patients who were not diagnosed locally and those who were diagnosed during routine spinal imaging studies as part of their basic disease check-up were excluded. Accordingly, neurofibromatosis and medical tourist patients were excluded.

Results:

The clinical presentation of IDSCTs in our study was similar to the descriptions given in previous reports. The average age was 41.9 ± 23.3 years. Most tumors were ependymomas, astrocytomas, and schwannomas. The most common symptoms were motor or sensory disturbance, back pain, walking disturbance, and sphincter control deficit. The median time to diagnosis was 12.0 ± 37.0 months (range 3 days to 20 years). We found DID in 82.2% of the cases. 62.4% of the cases were defined as “unreasonable delay.” The most common reasons for DID were “classical symptoms with a wrong diagnosis” and “delayed imaging.”

Conclusions:

Based on the results of this study, the incidence of unreasonable delays in diagnosis of primary IDSCTs in Israel is very high. In order to shorten the time to diagnosis, primary and secondary care physicians need to increase their awareness of symptoms that may be associated with these lesions. We hereby offer feedback for care providers, relevant to the diagnostic workup of these patients. Such a feedback must be delivered by neurosurgeons to the community they are serving.

Magnetic resonance imaging characteristics of primary intraspinal peripheral primitive neuroectodermal tumour

PURPOSE

The purpose of our study was to describe the salient magnetic resonance imaging (MRI) findings in primary intraspinal peripheral primitive neuroectodermal tumour (PNET).

METHODS

A retrospective review of the clinical and MRI images of 7 pathologically proven cases of intraspinal peripheral PNETs was performed. The various parameters, such as vertebral level of involvement; tumour location, size, focality, and margin; signal intensity of the lesion; the presence of hemorrhage or calcification; any signal voids; assessment of the adjacent cord for cord compression; cord dilatation; the presence of paraspinal tissue mass; or vertebral or other bony changes, were analysed.

RESULTS

All 7 patients had lesions in the thoracolumbar region. Three patients had extradural lesions, 4 had intradural extramedullary lesions, and none had intramedullary lesions. Six lesions were well circumscribed. Only 1 patient had multifocal involvement. All lesions were of hypointense or isointense signal on T1-weighted imaging, whereas all but one were hyperintense on T2-weighted imaging. Lesions enhanced heterogeneously except 1 intradural extramedullary lesion, which enhanced homogeneously. A paraspinal mass was noticed in 2 patients. Vertebral collapse was present in 1 patients.

CONCLUSION

Intraspinal peripheral PNETs are rare spinal tumours. Although imaging characteristics are not specific, a focal circumscribed lesion in a young individual at the intramedullary, extramedullary intradural, or extradural spinal location that shows hypointense and hyperintense signal on T1- and T2-weighted images, respectively, requires PNET to be considered in the differentials.

Management of Thoracal and Lumbar Schwannomas Using a Unilateral Approach without Instability: An Analysis of 15 Cases

Study Design

Retrospective case series.

Purpose

The objectives of this study were to determine and discuss the surgical planning of patients who underwent operations following diagnoses of thoracal and lumbar spinal schwannomas. We also aimed to discuss the application of unilateral hemilaminectomy for the microsurgery of schwannomas.

Overview of Literature

Schwannomas are located in different regions and sites. These differences require several surgical approaches. Unilateral laminectomy without stabilization of the spine provides a more minimally invasive removal of the tumor.

Methods

In this retrospective study, 15 patients with spinal schwannomas were evaluated with regards to age, sex, onset history, neurological findings, tumor locations, McCormick scale, surgical procedure, and operational results. The lateral approach provides exposure of intradural structures and posterior paraspinal regions. Extensions of tumors cause problem for the surgeon in terms of approach, resectability of the tumor, and stability of the spine. Gross total resection was achieved in all cases, and none of the patients necessary required a fusion procedure.

Results

Five patients were males and 10 were females. The age interval was 29-65 years. The tumor was located in the lumbar region in 9 patients, in the thoracic region in 2 patients, and in the thoracolumbar junction in 4 patients. The intradural lesions were removed by laminectomy and the extradural lesions were resected with hemilaminectomy. The paramedian route was used to explore the extraspinal part of the tumor. Costotransversectomy was for the thoracic region. Subtotal resection was performed in 1 patient. Patient symptoms recovered gradually in the postoperative period.

Conclusions

Resection of giant schwannomas is challenging and usually requires a different approach. We describe the complete resection of complex dumbbell or paraspinal schwannomas of the thoracic and lumbar spine by unilateral hemilaminectomy.

Delayed onset of paresis in rats with experimental intramedullary spinal cord gliosarcoma following intratumoral administration of the paclitaxel delivery system OncoGel

OBJECT

Treatment options for anaplastic or malignant intramedullary spinal cord tumors (IMSCTs) remain limited. Paclitaxel has potent cytotoxicity against experimental intracranial gliomas and could be beneficial in the treatment of IMSCTs, but poor CNS penetration and significant toxicity limit its use. Such limitations could be overcome with local intratumoral delivery. Paclitaxel has been previously incorporated into a biodegradable gel depot delivery system (OncoGel) and in this study the authors evaluated the safety of intramedullary injections of OncoGel in rats and its efficacy against an intramedullary rat gliosarcoma.

METHODS

Safety of intramedullary OncoGel was tested in 12 Fischer-344 rats using OncoGel concentrations of 1.5 and 6.0 mg/ml (5 μl); median survival and functional motor scores (Basso-Beattie-Bresnahan [BBB] scale) were compared with those obtained with placebo (ReGel) and medium-only injections. Efficacy of OncoGel was tested in 61 Fischer-344 rats implanted with an intramedullary injection of 9L gliosarcoma containing 100,000 cells in 5 μl of medium, and randomized to receive OncoGel administered on the same day (in 32 rats) or 5 days after tumor implantation (in 29 rats) using either 1.5 mg/ml or 3.0 mg/ml doses of paclitaxel. Median survival and BBB scores were compared with those of ReGel-treated and tumor-only rats. Animals were killed after the onset of deficits for histopathological analysis.

RESULTS

OncoGel was safe for intramedullary injection in rats in doses up to 5 μl of 3.0 mg/ml of paclitaxel; a dose of 5 μl of 6.0 mg/ml caused rapid deterioration in BBB scores. OncoGel at concentrations of 1.5 mg/ml and 3.0 mg/ml paclitaxel given on both Day 0 and Day 5 prolonged median survival and preserved BBB scores compared with controls. OncoGel 1.5 mg/ml produced 62.5% long-term survivors when delivered on Day 0. A comparison between the 1.5 mg/ml and the 3.0 mg/ml doses showed higher median survival with the 1.5 mg/ml dose on Day 0, and no differences in median survival or BBB scores after treatment on Day 5.

CONCLUSIONS

OncoGel is safe for intramedullary injection in rats in doses up to 5 μl of 3.0 mg/ml, prolongs median survival, and increases functional motor scores in rats challenged with an intramedullary gliosarcoma at the doses tested. This study suggests that locally delivered chemotherapeutic agents could be of temporary benefit in the treatment of malignant IMSCTs under experimental settings.

Histopathologic and immunohistochemical profile of spinal glioblastoma: a study of six cases

Spinal intramedullary glioblastomas are uncommon tumors and are known to have a very poor prognosis. Only a few studies in the literature have described their histopathological characteristics. We describe the detailed histopathological and immunohistochemical profiles of six cases of spinal glioblastoma. Most of the tumors were located in the cervical or cervicothoracic region. The majority of the patients were young adults (mean age 34.8 years), presenting with a short duration of symptoms of 2 months or less. Their histopathological features were similar to cerebral glioblastoma. Diverse vascular changes like microvascular proliferation, sprouting angiogenesis, sclerosed and thrombosed vessels, along with field necrosis were prominent findings. All tumors were positive for GFAP and negative for EMA. The MIB-1 labeling index was very high (mean 16.7 ± 3.2%). Five out of six tumors were immunoreactive for p53 protein, and only two showed over-expression of EGFR protein. The predominant expression of p53 in these young patients suggests that spinal glioblastomas are similar to secondary glioblastoma in the cerebral hemispheres, despite the short duration of symptoms in them and vascular changes that are similar to those noted in primary glioblastoma. These observations support the fact that spinal glioblastomas are heterogeneous tumors underlined by complex molecular pathways. Nevertheless, inactivation of the p53 tumor suppressor pathway could play a major role in the genesis of these neoplasms.

MR perfusion-weighted imaging may help in differentiating between nonenhancing gliomas and nonneoplastic lesions in the cervicomedullary junction

PURPOSE

To evaluate the ability of dynamic susceptibility-weighted contrast-enhanced magnetic resonance (MR) perfusion imaging (DSC-PWI) in distinguishing between nonenhancing gliomas and nonenhancing, nonneoplastic lesions in the cervicomedullary junction region.

MATERIALS AND METHODS

This retrospective study involved eight patients with nonenhancing gliomas in the medulla oblongata and eight patients with nonenhancing nonneoplastic lesions. The relative cerebral blood volume (rCBV) ratios, peak heights, and percentage of signal intensity recovery derived from time-signal intensity curves of these nonenhancing lesions were compared.

RESULTS

The mean peak height of nonenhancing gliomas was significantly higher than the value of their reference regions of interest (ROIs). In contrast, mean peak height of nonneoplastic lesions was significantly lower than their reference ROIs. The mean peak height and mean maximal rCBV ratio of nonenhancing gliomas were significantly higher than those of nonenhancing, nonneoplastic lesions (P<0.05). There was no significant difference with regard to percentage of signal intensity recovery between the two groups.

CONCLUSION

DSC-PWI could be a useful adjuvant tool to differentiate between nonenhancing gliomas and nonenhancing, nonneoplastic lesions in the cervicomedullary junction region.

Intradural tumor and concomitant disc herniation of cervical spine

We report a rare patient of a simultaneous extradural and intradural compression of the cervical spinal cord due to co-existent intervertebral disc herniation and an intradural schwannoma at the same level. The intradural lesion was missed resulting in recurrence of myelopathy after a surprisingly complete functional recovery following anterior cervical discectomy. Retrospectively, it was noted that the initial cord swelling noticed was tumor being masked by the compression produced by the herniated disc. A contrast magnetic resonance imaging scan is important in differentiating intradural tumors of the spinal cord. A high index of suspicion is often successful in unmasking both the pathologies.

Clinical presentation, histology, and treatment in 430 patients with primary tumors of the spinal cord, spinal meninges, or cauda equina

OBJECT Patients having a primary tumor of the spinal cord, spinal meninges or cauda equina, are relatively rare. Neurosurgeons encounter and treat such patients, and need to be aware of their clinical presentation, tumor types, treatment options, and potential complications. The purpose of this paper is to report results from a series of 430 patients with primary intraspinal tumors, taken from a larger cohort of 9661 patients with primary tumors of the CNS. METHODS Extensive information on individuals diagnosed (in the year 2000) as having a primary CNS neoplasm was prospectively collected in a Patient Care Evaluation Study conducted by the Commission on Cancer of the American College of Surgeons. Data from US hospital cancer registries were submitted directly to the National Cancer Database. Intraspinal tumor cases were identified based on ICD-O-2 topography codes C70.1, C72.0, and C72.1. Analyses were performed using SPSS. RESULTS Patients with primary intraspinal tumors represented 4.5% of the CNS tumor group, and had a mean age of 49.3 years. Pain was the most common presenting symptom, while the most common tumor types were meningioma (24.4%), ependymoma (23.7%), and schwannoma (21.2%). Resection, surgical biopsy, or both were performed in 89.3% of cases. Complications were low, but included neurological worsening (2.2%) and infection (1.6%). Radiation therapy and chemotherapy were administered to 20.3% and 5.6% of patients, respectively. CONCLUSIONS Data from this study are suitable for benchmarking, describing prevailing patterns of care, and generating additional hypotheses for future studies.

Magnetic Resonance Imaging for Spinal Cord Tumors

This paper discusses spinal cord tumors including imaging characteristics with emphasis on magnetic resonance imaging and advances in treatment. This is a retrospective study of 20 cases patients with neoplasms arising from the spinal cord. All of our cases were explored by magnetic resonance imaging (1.5T) using T1-weighted imaging (Spin Echo), T2-weighted imaging (Spin Echo) and T1-weighted imaging with Gadolinium administration. Pain is the earliest symptom, characteristically occurring at night when the patient is supine. Ependymoma were observed in 11 cases. Astrocytoma was noted in five cases. Other uncommon tumors were identified in four cases: oligodendroglioma (n=1), epidermoid cyst (n=1), hemangioblastoma and metastasis (n=1). In MRI most tumors are isointense or slightly hypointense compared to the normal cord signal with homogenous or irregular enhancement. We describe the characteristic magnetic resonance findings and differential diagnosis of spinal cord tumors. Spinal cord lesions comprise approximately 2–4% of all central nervous system neoplasms. Magnetic resonance imaging plays a central role in the imaging of spinal cord neoplasms.

Short-term progressive spinal deformity following laminoplasty versus laminectomy for resection of intradural spinal tumors: analysis of 238 patients

OBJECTIVE

Gross total resection of intradural spinal tumors can be achieved in the majority of cases with preservation of long-term neurological function. However, postoperative progressive spinal deformity complicates outcome in a subset of patients after surgery. We set out to determine whether the use of laminoplasty (LP) vs laminectomy (LM) has reduced the incidence of subsequent spinal deformity following intradural tumor resection at our institution.

METHODS

We retrospectively reviewed the records of 238 consecutive patients undergoing resection of intradural tumor at a single institution. The incidence of subsequent progressive kyphosis or scoliosis, perioperative morbidity, and neurological outcome were compared between the LP and LM cohorts.

RESULTS

One hundred eighty patients underwent LM and 58 underwent LP. Patients were 46 +/- 19 years old with median modified McCormick score of 2. Tumors were intramedullary in 102 (43%) and extramedullary in 102 (43%). All baseline clinical, radiographic, and operative variables were similar between the LP and LM cohorts. LP was associated with a decreased mean length of hospitalization (5 vs 7 days; P = .002) and trend of decreased incisional cerebrospinal fluid leak (3% vs 9%; P = .14). Following LP vs LM, 5 (9%) vs 21 (12%) patients developed progressive deformity (P = .728) a mean of 14 months after surgery. The incidence of progressive deformity was also similar between LP vs LM in pediatric patients < 18 years of age (43% vs 36%), with preoperative scoliosis or loss of cervical/lumbar lordosis (28% vs 22%), or with intramedullary tumors (11% vs 11%).

CONCLUSION

LP for the resection of intradural spinal tumors was not associated with a decreased incidence of short-term progressive spinal deformity or improved neurological function. However, LP may be associated with a reduction in incisional cerebrospinal fluid leak. Longer-term follow-up is warranted to definitively assess the long-term effect of LP and the risk of deformity over time.

Intraspinal primitive neuroectodermal tumor: imaging findings in six cases

PURPOSE

To retrospectively review CT and MRI findings in a series of six intraspinal primitive neuroectoderal tumors and to find out their radiological features.

METHODS

CT and MRI of six patients with surgically and pathologically proved intraspinal primitive neuroectoderal tumor were retrospectively reviewed. The tumor location, morphological features, signal intensity, calcification, contrast enhancement characteristics, involvement of paraspinal soft tissues and adjacent bony structures were assessed.

RESULTS

Of six patients, four had extradural lesions and two had intradural, extramedullary lesions. Most lesions were well defined and manifested heterogeneous iso- or hypo-intense signal on T1-weighted imaging and hyper-intense signal on T2-weighted imaging and moderate attenuation on CT, and were heterogeneously enhanced after contrast enhancement. The lesion extending through the intervertebral foramen with a large paraspinal soft tissue mass formed was found in four patients and vertebral bone involvement was seen in four patients.

CONCLUSIONS

Although imaging findings are not specific of intraspinal primitive neuroectoderal tumor, this diagnosis could be suggested when MR imaging depicts an intradural, extramedullary or extradural large well-circumscribed mass which extends out from intervertebral foramen and invades paraspinal soft tissues or vertebral bones in a young patient.

[Spinal tumors]

Spinal tumors can be intramedullary, intradural (within the meninges), or extradural (between the meninges and the bones), or they may extend secondary to the spine from other locations. Vertebral hemangioma represents the most common benign tumor of the spine. Metastases, lymphoma, and multiple myeloma are the most frequent malignant spinal tumors. Primary osseous tumors of the spine, in contrast, are rare conditions but may demonstrate typical imaging findings. For the differential diagnosis, the patient's age, the topographic localization of the mass, and morphologic features of the lesion as depicted by computed tomography and magnetic resonance imaging play important roles.