Lumbar Intramedullary Epidermoid Following Repair of Sacral Myelomeningocele and Tethered Cord: A Case Report With a Review of the Relevant Literature and Operative Nuances

Recurrent lumbar intraspinal epidermoid cyst presenting as lower back pain, a case report

INTRODUCTION

Intraspinal Epidermoid Cyst (IEC) is a very-rare, yet one of the most benign tumors of the Central Nervous System (CNS). Very few cases of IEC were reported world-wide. Presentations depend on the location of the tumor with pain being the most common presenting symptom.

CASE PRESENTATION

A-35-year-old patient presented to the neurosurgical department for a regular follow up. Her history dates back to four years ago, when she first presented with back pain, which was later accompanied with fecal and urinary incontinence. Magnetic Resonance Imaging (MRI) showed a tumor at the level of L4-L5 which was surgically removed. Three years later, the patient presented to the clinic with similar symptoms. A repeat MRI showed a mass at L4-L5, which was surgically removed. Histological findings of both surgeries showed findings consistent with IEC. Currently the patient has no complaints.

CLINICAL DISCUSSION

IEC has various presentations. Our case presented with back pain, and urinary and fecal incontinence. Diagnosis depends on imaging and histology. MRI is the imaging modality of choice for those tumors in the CNS. Surgical removal is associated with high recurrence as a result of the suboptimal resection due to the strong adhesions between the capsule and the spinal cord.

CONCLUSION

Pain is the most common presenting symptom for IEC. Adjuvant radiotherapy, which should be implemented in the standard of care, is associated with a lesser degree of recurrence, in addition to regular follow-ups.

Surgical Strategy for Sacral Tumor Resection

PURPOSE

This study aimed to present our experiences with a precise surgical strategy for sacrectomy.

MATERIALS AND METHODS

This study comprised a retrospective review of 16 patients (6 males and 10 females) who underwent sacrectomy from 2011 to 2019. The average age was 42.4 years old, and the mean follow-up period was 40.8 months. Clinical data, including age, sex, history, pathology, radiographs, surgical approaches, onset of recurrence, and prognosis, were analyzed.

RESULTS

The main preoperative symptom was non-specific local pain. Nine patients (56%) complained of bladder and bowel symptoms. All patients required spinopelvic reconstruction after sacrectomy. Three patients, one high, one middle, and one hemi-sacrectomy, underwent spinopelvic reconstruction. The pathology findings of tumors varied (chordoma, n=7; nerve sheath tumor, n=4; giant cell tumor, n=3, etc.). Adjuvant radiotherapy was performed for 5 patients, chemotherapy for three, and combined chemoradiotherapy for another three. Six patients (38%) reported postoperative motor weakness, and newly postoperative bladder and bowel symptoms occurred in 5 patients. Three patients (12%) experienced recurrence and expired.

CONCLUSION

In surgical resection of sacral tumors, the surgical approach depends on the size, location, extension, and pathology of the tumors. The recommended treatment option for sacral tumors is to remove as much of the tumor as possible. The level of root sacrifice is a predicting factor for postoperative neurologic functional impairment and the potential for morbidity. Pre-operative angiography and embolization are recommended to prevent excessive bleeding during surgery. Spinopelvic reconstruction must be considered following a total or high sacrectomy or sacroiliac joint removal.