Complex split cord malformation with mediastinal extension of a teratoma and simultaneous ventral and dorsal bony spur splitting the cord

Cervicomedullary junction mature teratoma with pulmonary differentiation and diastematomyelia in an adult - A rare case

Background

Intradural extramedullary teratomas in the cervical or cervicomedullary region are rare in adults.

Case Description

We report a symptomatic, mature teratoma at the cervicomedullary junction in a 52-year-old Hispanic female who also has a type I diastematomyelia in the thoracolumbar spine. The patient underwent surgical resection of the lesion with the resolution of presenting symptoms. Histopathology of the lesion revealed a mature cystic teratoma with pulmonary differentiation.

Conclusion

We discuss the case along with a review of pertinent literature and considerations with regard to the diagnosis, etiology, prognosis, and management of this unusual pathology.

Dorsal bony spur in pediatric split cord malformations: eight-year experience from a tertiary care hospital

INTRODUCTION

Dorsal spurs in Type I split cord malformations (SCM-I) are infrequent findings. The pathogenesis of the same is debatable. The objective of this study is to analyze our experience with SCM-I patients having dorsal bony spurs.

METHODOLOGY

Retrospective analysis of SCM patients operated from 2010 to 2017 was performed. Their demographic profile, clinic-radiological features, operative findings, and outcome following surgery were recorded.

RESULTS

Twenty-four cases of Type I SCM harboring dorsal bony spurs were identified with mean age of 4.96 years. The commonest split site was lumbar, documented in 62.5%. Scoliosis was observed in 58.3%. Pre-operative neurological deficits were seen in 66.6% cases with asymmetric weakness of limbs seen in 16.6%. There was no new neurological deficit observed post-operatively.

CONCLUSIONS

This is the largest series of dorsal spurs occurring in SCM, reported in literature so far. Meticulous pre-operative evaluation and imaging are important to identify dorsal spurs for appropriate management and good clinical outcome. Differentiating dorsal spur from ventral spur is important as it has a bearing on surgical approach.

An Unusual Case of Split Cord Malformation with Simultaneous Ventral and Dorsal Bony Spur at a Single Site: A Technical Challenge

Split cord malformation (SCM) with simultaneous ventral and dorsal bony spur at a single site is an extremely rare entity with only one other case reported so far. We present a second such case in a 13-month-old female child, who presented with a skin dimple over the lumbar region with overlying hairy patch without any associated lower limb weakness or urinary complaints. Imaging demonstrated a complex Type I SCM with simultaneous ventral and dorsal bony spur at L4-L5 level. Intraoperatively, the patient was confirmed to have a Type Ic SCM with a ventrally based bony spur going dorsally to attach on the hypertrophied posterior arch of L4 and a dorsal spur going ventrally to attach on the L4 vertebral body. After meticulous microsurgical excision of the spur, the child was stable and developed no fresh neurological deficits. We discuss the relevant surgical implications and possible embryological mechanisms involved in such a complex SCM.

Split cord malformation types I and II: a personal series of 131 patients

PURPOSE

A personal series of 131 patients with split cord malformation (SCM) operated on is presented.

METHODS

Age, gender, symptoms and signs, radiological and operative findings, complications, associated anomalies, outcome, and pathological specimens were analyzed.

RESULTS

There were 88 girls (73 %) and 43 boys (27 %). The female predominance was slightly more remarkable in type I SCMs than in type II SCMs. The presenting symptoms can be summarized as skin lesions, spina bifida aperta, scoliosis or kyphoscoliosis, sphincter disturbance, foot deformities and weakness, and/or atrophy in the lower extremities. The ages of patients with neurological deficits and orthopedic deformities were significantly older than those without deficits (P = 0.030). The duration of symptoms was longer in the patients with neurological deficits and orthopedic deformities than that in those without deficits (P = 0.00095). In six patients, composite SCMs were present. Only one patient with a type II SCM did not have an associated spinal cord lesion. A type I SCM was more frequently encountered in patients with spina bifida (P < 0.0005). Transient postoperative complications were seen in 29 patients (22 %). There was no permanent complication. Retethered cord syndrome developed in five patients with a type I SCM.

CONCLUSIONS

The risk of neurological and orthopedic deficits increases with the age of the patient. The risk of permanent deficit after surgery is very low. The whole spine must be examined for additional lesions. All patients should be surgically treated when diagnosed, especially before the development of orthopedic and neurological manifestations, and all associated lesions should also be treated at the same session.

Complex forms of spinal dysraphism

INTRODUCTION

Spinal dysraphisms are a heterogeneous group of congenital malformations involving the bony component of vertebrae or spinal cord or both. Simple forms include the contiguous, solitary malformations such as myelomeningocele and diastematomyelia, and can be either aperta or occulta type.

MATERIAL

Complex forms include various types of spinal malformations occurring in combination, one type of malformations occurring at multiple levels in noncontiguous manner or spinal dysraphisms with other organ anomalies. Anomalous development in gastrulation, primary neurulation, and secondary neurulation stage in variable proportions give rise to these types of complex malformations. These cases can be diagnosed postnatally in early infancy by the strong clinical suspicion, supplemented by whole spinal axis and cranial magnetic resonance imaging (MRI) screening, to detect any occult spinal dysraphisms like split cord malformations, neurenteric cyst, lipoma, or cranial anomalies like Chiari malformations and hydrocephalus. Computed tomography and MRI are the gold standard to detect bony anomalies and cord malformations, respectively. Complex spinal dysraphisms, to our mind, should always be tried to be corrected in single operative stage, however, in case of ruptured defects, correction through multiple operations can be considered.

DISCUSSION

Overall, prognosis of complex forms of spinal dysraphism is poor in comparison to their simple forms and depends on preoperative neurological status and the nature of complex dyraphism. We discuss the classification, embryogenesis, investigation, and treatment protocol with review of literature of such complex anomalies.

Mature posterior fossa teratoma mimicking dermoid cyst

We describe a very rare case of mature posterior fossa teratoma in an adult who presented with clinico-radiological findings consistent with a dermoid cyst. A computed tomography scan showed a hypodense mass in the cistern magna with calcification and a sinus tract in the occipital bone. Magnetic resonance imaging revealed a hypo- to hyperintense mass without contrast enhancement. The intraoperative picture showed a dermal sinus and a cyst containing lipid, keratin and hair. Histopathological examination showed a tumor with components of all the three germ layers; thereby, a diagnosis of mature teratoma was made. The histopathological differentiation between teratoma and dermoid cyst is very valuable for ruling out the presence of immature/malignant or germinomatous components that would require further adjuvant therapies. Thus, we here present a rare case of posterior fossa teratoma mimicking dermoid cyst and emphasize the importance of histopathological differentiation between these entities.