INTRASPINAL TUMORS IN INFANTS AND CHILDREN; REVIEW OF 115 CASES

Pediatric Extramedullary Epidural Spinal Teratomas: A Case Report and Review of the Literature

Background

Teratomas in the pediatric population are most commonly found in the sacrococcygeal region. Pediatric intraspinal teratomas, however, are an exceedingly rare central nervous system (CNS) neoplasm. The clinical presentation of these intraspinal neoplasms can vary significantly and thus can be difficult to identify in infants less than one year of age where verbal expression and motor development are still lacking. Case Description. A 7-month-old, previously healthy male presented with a thoracic scoliosis and an asymptomatic right midupper thoracic spinal prominence present since birth. MRI revealed an extensive heterogenous mass in the right epidural space from T5-T6 and the right paravertebral space, resulting in severe spinal stenosis. Outcome. Complete resection of the tumor, including a three-level neurotomy, was achieved by posterior decompression/laminectomy. The final tumor was consistent with a mature teratoma. The surgical resection was performed without any immediate complications.

Conclusions

Extramedullary epidural teratomas are exceptionally rare tumors in the pediatric population. Clinical presentation can be ambiguous, particularly in an infant. MRI was useful in suggesting a teratoma as a potential diagnosis and for postoperative surveillance for recurrence. However, histopathological analysis remains the gold standard for definitive diagnosis. Surgical resection is the mainstay of treatment, especially in the setting of cord compression and progressive loss of motor function. Close follow-up is crucial to monitor for progressive spinal deformity or recurrence.

Extensive spinal epidural immature teratoma in an infant: case report

Here, the authors present an extremely rare case of an extensive spinal epidural teratoma (SET) in an infant and provide a review of the cases in the literature. In this report, the authors focused on the clinical manifestation and management of extensive SET. A 64-day-old girl presented with severe dyspnea and paraparesis caused by a large thoracic mass. Imaging studies revealed that the mass originated from the epidural space of the thoracic spine and extended from C7 to L1. The tumor extended bilaterally through the intervertebral foramina and formed a large posterior mediastinal mass. The tumor was partially resected via laminotomy after an emergency thoracotomy. The remnant grade I immature teratoma grew rapidly. After a re-laminotomy and bilateral thoracotomy, the residual tumor stopped growing. However, the patient's paraparesis improved very little, and her scoliosis progressed gradually. Therefore, SET should be included in the differential diagnosis when an infant patient with paraparesis of the lower extremities is encountered. Timely diagnosis, aggressive treatment, and close monitoring are of critical importance to successful recovery in such patients.

Upper Lumbar Mature Cystic Teratoma: A Case Report

BACKGROUND

Intradural extramedullary spinal teratoma (IEST) is a rare condition in adults, with a male predominance. It is commonly associated with spinal dysraphism, lumbar puncture, and previous spinal surgery. This case is a 37-year-old male diagnosed with a mature cystic IEST without dysraphism or previous surgical interventions.

CASE DESCRIPTION

The patient's symptoms included a lumbar backache that progressed to the toes, as well as the anterior region of both thighs. Subsequently, he could not walk for >3 minutes and experienced saddle paresthesias, heaviness, and numbness in both lower limbs. The teratoma was diagnosed by magnetic resonance imaging (MRI), which showed a mixed signal intensity mass with a fatty component in the conus medullaris at the L1-L2 level. The treatment strategy included total surgical excision of the teratoma, followed by histopathological examination, at which the mass was diagnosed as a mature cystic teratoma. On postoperative follow-up, the patient reported urinary and fecal incontinence. Neurologic examination of both the lower limbs revealed hyperreflexia of the left knee and atrophy of the left calf muscles, but no residual mass at the site of surgery.

CONCLUSIONS

MRI is a standard tool for diagnosing IEST, but the diagnosis is confirmed by histopathological examination. Total surgical excision is the treatment of choice, but when adhesions to the neural tissue are present, subtotal excision should be attempted. The patient should be followed up with serial clinical and radiologic examinations to ensure the absence of residual mass at the site of surgery.

Surgical management of intradural spinal cord tumors in children and young adults: A single-center experience with 50 patients

BACKGROUND

Intradural spinal cord tumors (IDSCTs) in children and young adults are rare diseases. This present study is aimed to demonstrate our experience with a large series of children and young adults with IDSCT.

METHODS

A total of 50 patients aged <20 years with IDSCT treated in our department between 1990 and 2010 were included in the study. Clinical, histological, and radiological findings, treatment strategies, and clinical outcome were retrospectively assessed. Depending on the relation to the spinal cord, IDSCT were dichotomized into intramedullary SCT (IMSCT) and extramedullary SCT (EMSCT). The functional outcome was evaluated with the Frankel score assessing the longest available follow-up period.

RESULTS

Mean age was 10.3 years (range 6 months-19 years). IDSCT surgery was performed in 44 patients (88%). A common first symptom in patients with EMSCT was neck and back pain (41%), whereas monoparesis of arms (43%) were often seen in patients with IMSCT. The main duration of the symptoms was longer in patients with IMSCT. The postoperative functional outcome was generally comparable to the preoperative functional condition, while better for EMSCT (P < 0.01). The functional outcome at last follow-up correlated significantly with the preoperative Frankel score (P < 0.002).

CONCLUSION

Due to the mostly mild impact of the surgery on the functional outcome, the surgical treatment of IDSCT in children and young patients can be uniquely advocated.

Infected cervico-dorsal dermoid cyst with fluid - fluid level

We report a case of a 22-year-old female who was operated at the age of 3 months for cervico-dorsal swelling. She presented with gradual onset, progressively worsening dull aching pain in the cervico-dorsal region, 21 years following previous surgery. Magnetic resonance imaging showed intradural dermoid cyst with the fluid level. She underwent excision of the dermoid cyst with excision of the wall. The clinical profile, etiopathogenesis, radiological features, and management of intraspinal dermoid cysts are discussed in the light of current literature.

Intramedullary spinal epidermoid presenting after thoracic meningocele repair: case report

A 4-year-old girl with a history of thoracic meningocele repair at the age of 3 months presented with progressive myelopathy. An intramedullary thoracic epidermoid was identified on MRI. The patient underwent excision of the epidermoid and subsequently returned to neurological baseline. This case illustrates the potential for delayed development of intraspinal epidermoid after initial repair of a simple meningocele.

Mature teratoma of the spinal cord in adults: An unusual case

Intraspinal mature teratomas rarely occur in adults. The present study describes an unusual case of adult intradural mature teratoma, which was completely resected. A 22-year-old female presented with an intermittent pinching pain in the lower right shank that had lasted for three months. Magnetic resonance imaging (MRI) results indicated a multicystic mass extending from the T12 to L2 vertebrae, and the tumors were certified as teratomas by a histopathological examination. The level of pain experienced by the patient was improved following the surgery. The present study also compared the literature concerning adult intradural mature teratoma, summarized the basic clinical characteristics and theory of origin of adult intradural mature teratoma and reviewed the available treatments for this disease.

Spinal epidural teratoma: review of spinal teratoma with consideration on the pathogenesis: case report

BACKGROUND AND IMPORTANCE

Of the 170 cases of teratomas in the spinal canal reported in the English literature, only 13 were spinal epidural teratomas (SETs). We present a case of SET, review the characteristics of SETs in comparison with spinal intradural teratomas (SITs), and investigate the pathogenesis of spinal teratoma.

CLINICAL PRESENTATION

A 17-month-old boy visited our clinic with paraparesis. A multicystic mass was noted in the left epidural space from T8 to T10 and the left paraspinal area. Complete resection of the tumor, including the paraspinal portion, was accomplished by laminoplastic laminotomy. The tumor was well encapsulated and filled with heterogeneous contents. The tumor was suspected to originate from the left T9 root.

CONCLUSION

On histopathological examination, the tumor was found to be a mature teratoma. The clinical characteristics of SETs and SITs show similarities in age, male preponderance, location, associated anomalies, and pathology. SETs and SITs are probably 2 different types of a single disease entity. Pluripotent somatic cell from the Hensen's node and caudal cell mass is the probable origin of spinal teratoma. However, originating from misplaced primordial germ cell could not be excluded.

Intramedullary inclusion cysts of the cervicothoracic junction

✓Intramedullary inclusion cysts are extremely rare within the rostral spinal cord. In this case report the authors outline the clinical features and surgical treatment of one dermoid cyst and one epidermoid cyst of the cervicothoracic junction. The authors also include a relevant literature discussion regarding the treatment and the embryological origin of these lesions.

Lower urinary tract dysfunction in children with central nervous system tumours

The findings in 10 children with neuropathic vesicourethral dysfunction after the onset of a central nervous system tumour are presented. Eight had a spinal tumour and two a brainstem tumour. Bladder dysfunction occurred late in most children except in those with neoplastic infiltration of the conus and cauda equina. Moreover, tumour recurrence was often heralded by loss of bladder control before other neurological signs became obvious. Videourodynamics (VUD) showed various combinations of "filling" and "voiding" dysfunction in tumours extending from the pons to the cauda equina, whereas an isolated "filling" dysfunction was evident in the patient with a suprapontine tumour. Urinary incontinence and recurrent urine infection can be immensely distressing to children and their families, particularly when they have had to cope with the stress of diagnosis and treatment of the underlying tumour. Different management strategies, based on VUD findings, are discussed highlighting the impact these have on the children's quality of life.

Treatment of spinal cord tumors in children

BACKGROUND

A retrospective review was carried out of nine children under 17 years of age with a diagnosis of intramedullary tumor seen during the period 1989-1995. Six had astrocytomas; one each had an ependymoma, a PNET, and a choroid plexus papilloma. Five patients had back pain, 3 others had mild pareses and the ninth had incapacitating defects. Seven of the 9 were treated by subtotal extirpation of the lesion, and biopsy alone was performed in the other two. All tumors were low grade (grade I or II) and therefore radiation therapy (RT) was performed as the only postoperative treatment in 8 of the 9 children.

RESULTS

In February 1996, seven (77.8%) children were alive and two (22.2%) died of recurrent tumor (7 months and 5 years after diagnosis, respectively). Median follow-up was 3 years 4 months (range: 1 year 6 months to 7 years 3 months).

CONCLUSION

Surgical removal of intraspinal tumors provides the best hope of control, but spinal column deformity after laminectomy and irradiation is a serious long-term problem in children. Orthopedic supervision for the prevention of these deformities; e.g., by external immobilization, is mandatory.

Difficulties in diagnosing intrinsic spinal cord tumours

Thirteen children with intrinsic spinal cord tumours were seen between 1984 and 1995. In only one was this the presumptive diagnosis at referral, despite a high incidence of characteristic features. Eight had presented to their local paediatrician, four to local orthopaedic teams, and one to a general surgeon. Eleven had back pain. Eleven had either spinal curvature or change in gait. The interval between onset of symptoms and diagnosis ranged from one week to six years, with a mean of 17.5 months. In nine children symptoms had been present for four or more months. In nine, unrewarding investigations had been carried out. This paper highlights typical presenting features of these tumours and how earlier diagnosis can be achieved.

Acquired torticollis as the only presenting symptom in children with posterior fossa tumors

Acquired torticollis is a symptom of an underlying disorder. It requires a thorough, meticulous search for the cause, because some of the problems associated with torticollis, such as posterior fossa tumor, can be life-threatening.

Management of intramedullary tumours in children

Clinical presentation, diagnosis, surgical technique and results of 25 cases of intramedullary tumours in patients under 16 years of age are analyzed. Pre-operative spinal deformity was present in 9 patients. Surgery was performed in all. After multilaminectomy with preservation of the intervertebral joints, total removal of the lesion was achieved in 11 patients and subtotal removal in 14 others. After surgery, external immobilization lasting an average period of 5 years was instituted in all patients. Postoperative radiation therapy was performed in 11 cases (5 "high grade" astrocytomas, 5 ependymomas, 1 glioblastoma). There were 11 recurrences: 4 of which (2 ependymomas and 2 "low grade" astrocytomas) were treated surgically, 7 (5 "high grade" astrocytomas, 1 glioblastoma, 1 oligodendroglioma) with palliative radiation treatment. Six patients eventually developed postlaminectomy spinal deformities as diagnosed roentgenographically 6 to 50 months postoperatively. Of the 16 patients still alive, 7 did not present relevant neurological deficit, 1 presented a monoparesis, while the other 8 presented invalidating deficits. Surgical treatment did not differ from that employed in the intramedullary tumours in the adult: radical resection is indeed the optimal therapeutic origin. The risk of radiation therapy are greater in children: it is crucial to limit radiation therapy to only some histotypes. The incidence of spinal column deformity after multilevel laminectomy is greater in young patients. It is advisable to implement prevention of spinal deformities by postoperative external immobilization and constant follow-up so as to detect early changes of spinal stability.

Results of the combined treatment of paediatric intraspinal tumours

In this article 98 patients with paediatric intraspinal tumours are presented. All were evaluated according to their ages, sex, signs and symptoms. The patients also had radiological and histopathological studies; and the results of surgical, physical medicine and rehabilitation and of radiotherapy are discussed and compared with the results of patients reported in the literature.

Benign tumors and tumorlike conditions of the spine. Radiological features, treatment, and results

A series of 44 benign tumors and tumorlike conditions of the spine treated surgically between 1952 and 1982 is reported. We have focused on their radiodiagnosis, treatment, and long-term results. The radiologic features considered pathognomonic of skeletal tumors, and frequently found in tumors outside the spine, are less common in the spinal variety. In fact, the radiologic findings in spinal tumors are, as a rule, nonspecific. The long-term results in this series are considered satisfactory, despite two recurrences of a giant cell tumor and late malignant degeneration of an osteochondroma. The prognosis was good, and recurrence rare even after conservative excision of the lesion. More aggressive treatment is nonetheless recommended nowadays for giant cell tumors and osteoblastomas, even if vertebral stability has to be sacrificed and fusion performed, as this affords the best chance of permanent cure. Conservative excision without radiotherapy remains the treatment of choice for other benign tumors. Spinal instability is a serious risk especially in younger patients who have undergone radiotherapy and have residual neurological deficits. Provision should be made against this risk by planning a fixation procedure either in the same operation as ablative surgery or at a later stage.

Astrocytomas of the spinal cord in children and adolescents

The authors review 32 cases of spinal cord astrocytoma in patients under 20 years of age who were treated at the Mayo Clinic between 1955 and 1980. There was a 1.3:1 male to female ratio. Twenty patients were between 6 and 15 years of age at the time of diagnosis. The duration of symptoms prior to definitive diagnosis varied from 5 days to 9 years, with an average of 24 months. The most common symptoms were pain (62.5%), gait disturbance (43.7%), numbness (18.8%), and sphincteric dysfunction (18.8%). The most common neurological findings were a Babinski response (50.0%), posterior column sensory dysfunction (40.6%), and paraparesis (37.5%). A median follow-up period of 8.6 years (range 0.8 to 25.5 years) revealed that the survival time diminished with increased histological grade of the astrocytoma (p less than 0.001). The development of postlaminectomy spinal deformities represented a serious postoperative complication. This occurred in 13 patients and was first recognized between 8 and 90 months postoperatively. Six deformities occurred following cervical laminectomy, and eight patients required at least one orthopedic procedure. It is crucial to follow these patients for an extended period of time to watch for postoperative spinal deformities.

Scoliosis: a rare manifestation of intrinsic tumours of the spinal cord in children

Three cases are described of apparent idiopathic scoliosis in childhood which were shown subsequently to be due to intramedullary spinal cord tumour. The possibility of this underlying lesion should be considered in any child who develops scoliosis without an obvious cause.