Clinical Features of Cauda Equina Tumors Requiring Surgical Treatment

Ancient Schwannoma Presenting at the Cauda Equina: A Report of a Rare Case

Ancient schwannoma is an uncommon variant of schwannoma. While many reports have presented defining histologic and clinical features of ancient schwannoma, there are only a very few cases in the literature, to our knowledge, of ancient schwannoma presenting at the cauda equina. The current report of ancient schwannoma presenting at the cauda equina adds to the literature and discusses the identification of specific histologic characteristics, the role of conservative medical management, surgical resection, and prognostication in this select subset of patients.

Lumbar Schwannoma as a Rare Cause of Radiculopathy in the Chiropractic Office: A Case Report

Cauda equina tumors are rare, slow-growing, and typically benign. These tumors present with low back pain resembling disc displacement with radiculopathy and thus may go undiagnosed for months. A 52-year-old, otherwise healthy man presented to a chiropractor with a one-year history of worsening low back pain radiating to the right lower extremity, rated an 8/10 in severity and aggravated by recumbency. Previously, his primary care physician had ordered radiographs revealing mild lumbar degenerative changes, prescribed a non-steroidal anti-inflammatory medication, and referred him to an orthopedist and physical therapist. There had been no change in symptoms. Upon examination by the chiropractor, the patient had neurologic deficits, and due to progressive worsening, the chiropractor recommended magnetic resonance imaging (MRI), which the patient deferred due to cost. The chiropractor initiated a trial of care, with initial success; however, the patient's symptoms recurred, and he consented to an MRI. MRI revealed an intradural extramedullary lumbar tumor, and the chiropractor referred the patient to an oncologist, who referred the patient to a neurosurgeon. The neurosurgeon surgically removed the mass, with a biopsy confirming a schwannoma. The patient had significantly improved six weeks after surgery. This case highlights a patient with chronic low back pain for whom a chiropractor identified a cauda equina tumor and referred him for further evaluation and surgery. Clinicians should consider night pain and persistent symptoms, despite conservative care, as red flags warranting further investigation in those with low back pain. Providers should refer for neurosurgical evaluation when clinical and radiological findings suggest a cauda equina tumor.

Resection of an Intradural Extramedullary Capillary Hemangioma in the Lumbar Spine

BACKGROUND AND IMPORTANCE

Capillary hemangiomas are space-occupying lesions that rarely affect the central nervous system. When they present within the spinal canal, they can cause insidious symptoms and threaten neurological function. In this study, we present a case of an intradural extramedullary capillary hemangioma of the lumbar spine, discuss our management strategy, and review the current literature. For the first time for this diagnosis, we also provide an operative video.

CLINICAL PRESENTATION

The patient is a previously healthy 40-year-old man who presented with complaints of progressive low back and leg pain, numbness, and intermittent subjective urinary incontinence. MRI revealed a discrete, homogenously enhancing intradural extramedullary lesion at L4. This lesion was resected by performing an L4 laminoplasty, which entails en bloc removal of the L4 lamina and then securing it back into place once the intradural resection and dural closure are completed. Histological analysis revealed a diagnosis of capillary hemangioma. The patient had full resolution of his symptoms postoperatively.

DISCUSSION

Definitive management of spinal capillary hemangiomas involves gross total resection and can be accomplished with laminoplasty. Because these benign tumors can be adherent to adjacent structures, intraoperative neuromonitoring is helpful adjunct to preserve neurological function for a good outcome.

CONCLUSION

Capillary hemangiomas rarely affect the spine but should be considered on the list of differential diagnoses of intradural lesions.

Ancient Schwannoma of the Cauda Equina: Our Experience and Review of the Literature

Ancient schwannomas (AS) are exceedingly rare variant of common schwannomas (CS). Only two cases involving the cauda equina region have been previously reported in literature. AS are typically associated with a higher histological degree of degenerative changes (Antoni B areas). It is of peculiar importance, according to our opinion, to outline that, because of their extremely slow growth (which explains the increase of the degenerative changes in respect to the CS) and their typical soft consistency in respect to their standard counterparts, AS usually imply an even better prognosis.

Tumor Occupation in the Spinal Canal and Clinical Symptoms of Cauda Equina Schwannoma: An Analysis of 22 Cases

STUDY DESIGN

Retrospective, radiological study.

PURPOSE

To determine the relationship between clinical symptoms and the extent of tumor occupation of the spinal canal by cauda equina schwannoma.

OVERVIEW OF LITERATURE

Little is known about the relationship between the size of tumors of the cauda equina and the manifestation of clinical symptoms. We analyzed this relationship by estimating the percentage of tumor occupation (PTO) in the spinal canal in cauda equina schwannomas and by correlating this parameter with the presence and severity of clinical symptoms.

METHODS

Twenty-two patients (9 men and 13 women; age, 19-79 years; mean age, 55.3 years) who were radiologically diagnosed with schwannomas of the cauda equina between April 2004 and July 2014 were retrospectively analyzed. PTO was measured in axial and sagittal magnetic resonance imaging slices in which the cross-sectional area of the tumor was the largest. Data regarding clinical symptoms and results of physical examinations were collected from patient medical records. PTO differences between symptom-positive and -negative groups were analyzed for each variable.

RESULTS

In the 4 cases in which tumor presence was not related to clinical symptoms, PTO was 5%-10% (mean, 9%) in axial slices and 23%-31% (mean, 30%) in sagittal slices. In the 18 cases in which symptoms were associated with the tumor, PTO was 11%-86% (mean, 50%) in axial slices and 43%-88% (mean, 71%) in sagittal slices. PTO in axial slices was significantly higher in the presence of Déjèrine symptoms and/or muscle weakness, a positive straight leg raise test, and a positive Kemp sign.

CONCLUSIONS

PTO >20% in axial slices and >40% in sagittal slices can be an indication of symptomatic cauda equina schwannoma.

Management of Pelvic Chondroblastic Osteosarcoma after Urgent Spinal Decompression - A Report of 2 Cases

Introduction:

Pelvic sarcoma presenting with neurologic symptoms is rare. Workup of neurological deficits, whether elective or emergent should address the possibility of a space occupying lesion including pelvic sarcoma. Poor biopsy technique and incomplete workup of musculoskeletal tumors results in misdiagnosis or major errors in 18% of biopsies. The sequelae of a suboptimal biopsy include local recurrence, a more extensive resection, or extremity amputation. Pelvic chondroblastic osteosarcoma presenting with neurological deficits has not been previously reported. We report two cases of chondroblastic osteosarcoma that were treated with urgent decompression of the lumbar spine due to neurologic symptoms.

Case presentations:

Our two cases, a 25 year old Hispanic female and 22 year old Hispanic male, both presented with neurologic changes due to a space occupying tumor in the lumbar spine and pelvis. Both underwent spinal decompression following incomplete workup. A repeat biopsy was required in both cases due to a questionable initial diagnosis. Once the diagnosis was confirmed, they underwent definitive resection and treatment that was more morbid due to the primary decompressions.

Conclusion:

We stress the importance of proper biopsy techniques as well as the need to complete a full preoperative staging workup prior to any surgical procedures involving musculoskeletal tumors. We review the current literature on lumbar chondroblastic osteosarcomas and review the issues surrounding biopsy of musculoskeletal tumors. Our cases underline the need for complete workup and correct biopsy techniques to ensure patients have the best chance at tumor free survival with minimal morbidity.

Intradural extramedullary cavernoma of a lumbar nerve root mimicking neurofibroma. A report of a rare case and the differential diagnosis

BACKGROUND CONTEXT

Intradural extramedullary (IDEM) cavernomas are rare vascular malformations. They are well-circumscribed dark berry-like lesions with a histologic appearance of sinusoidal vascular channels. Neurofibromas are the most common IDEM tumors, originating from all nerve elements and leading to firm enlargement of the affected nerve root. These lesions are completely different; however, they may involve the spinal nerve roots or the major nerve trunks. Any similarities in clinical findings are based on different pathophysiology.

PURPOSE

To present a rare resemblance of an IDEM cavernoma to a neurofibroma.

STUDY DESIGN

This is a case report with review of the literature focused on the differential diagnosis.

METHODS

A 79-year-old patient presented with acute sensorimotor disturbance from L2-S1 levels. The investigations showed an L2-L3 lesion occupying the canal. Findings resembled a neurofibroma and a surgical resection was decided.

RESULTS

The complete surgical resection revealed a vascular lesion originating from a nerve root. The histology confirmed an IDEM cavernoma. This is a unique case as such a clinical resemblance and a macroscopical appearance has not been reported for an IDEM cavernoma as yet. The patient showed full postoperative recovery from his initial symptoms.

CONCLUSIONS

Intradural extramedullary cavernoma is a rare cause of compression to spinal cord or nerve roots. Its manifestation characteristics are well defined and should always be part of the differential diagnosis. Intraoperative findings aid the diagnosis in nontypical cases before the final histology. The nontraumatic and nerve tissue sparing surgical resection warrants optimal postoperative results and excellent prognosis.

Cavernous angiomas of the cauda equina: clinical characteristics and surgical outcomes

Cavernous angioma (CA) is a rare hamartomatous vascular lesion, consisting of abnormal, dilated, and packed sinusoidal vascular channels without interposed nervous tissue. CAs of the cauda equina are exceedingly rare and have been previously reported in the literature as case reports. The aim of this study was to discuss the clinical presentation and the outcomes of microsurgery for these rare lesions. We retrospectively reviewed the records of 10 patients who underwent microsurgery for CAs of the cauda equina. All patients had performed pre- and postoperative magnetic resonance imaging (MRI). CAs of the cauda equina generally exhibited mixed intensity on T₁- and T₂-weighted images. Contrast-enhanced T₁-weighted images showed heterogeneous enhancement. The hemosiderin ring which surrounded the cauda equina CA was rare. Gross total resection was achieved in all cases. All patients were followed up, with a mean duration of 41.1 months. Long-term neurological function was improved in nine patients and remained stable in one patient. No recurrence was observed on MRI. CAs should be considered in the differential diagnosis of cauda equina tumors. Because of the excessive vascularity of CAs, en bloc resection is recommended. For symptomatic patients, early surgery should be performed before neurological deficits deteriorate.

Lower urinary tract symptoms: thinking beyond the urinary tract

We present a case of a 54-year-old man with progressive lower urinary tract symptoms over 12 months. Physical examination, urinalysis, serum biochemistry and ultrasound of the renal tract were all unremarkable. Flexible cystoscopy was normal. Urodynamic assessment revealed an overactive bladder of unknown aetiology. The patient went on to have an MRI of the lumbosacral spine which showed a spinal cord tumour of the conus medullaris. The patient underwent a laminectomy and resection of the tumour. Histology showed myxopapillary ependymoma of the spinal cord. This case highlights the need to consider the full spectrum of causes, urological and non-urological, in assessing a patient with voiding dysfunction.

Clinical features and surgical outcomes of primary cauda equina tumours

BACKGROUND

To identify clinical features, radiological findings and surgical outcomes of primary cauda equina tumours.

METHODS

A consecutive series of 64 operations in 60 patients with primary cauda equina tumours from April 1999 to May 2009 at one institution comprised the study. The cases were divided into tumours of neural sheath origin (TNS, n = 48) and tumours of non-neural sheath origin (TNNS, n = 22). We analysed pain intensity, neurological abnormalities, MRI findings, surgical extent and functional outcome.

RESULTS

The TNS group showed more leg pain (76 % vs. 44 %, p = 0.019) with higher intensity (6.1 ± 1.5 vs. 4.6 ± 1.9, p = 0.04). Motor weakness and bladder dysfunction were more common in the TNNS group (p = 0.028 and p = 0.00 in each). Flow voids of MRI were more frequently observed in TNNS (50 % vs. 4 %, p = 0.01). The TNS group achieved total removal in all operations compared with total removal in 77 % in the TNNS group (p = 0.001). The TNNS group showed higher recurrence rates (18 % vs. 0 %, p = 0.009). The TNS group showed higher improvement of JOA scores postoperatively (p = 0.049). Surgical complications were observed less frequently in the TNS group (19 % vs. 78 %, p = 0.000).

CONCLUSIONS

TNS differs from TNNS by causing more frequent leg pain, higher pain intensity and more frequent flow voids. TNS has better surgical outcomes than TNNS in terms of higher rates of total removal, fewer surgical complications, better functional outcomes and less recurrence.

Intradural cauda equina metastasis of renal cell carcinoma: a case report with literature review of 10 cases

STUDY DESIGN

Case report with literature review.

OBJECTIVE

To describe a rare case of intradural spinal metastasis from renal cell carcinoma (RCC) spread to the cauda equina, and to discuss the clinical features of metastatic RCC in the cauda equina from the data available in the literature.

SUMMARY OF BACKGROUND DATA

Intradural spinal metastasis is rare, representing 6% of all spinal metastasis. Indeed, intradural metastasis from a RCC to the cauda equina is extremely rare with previously only 9 case reports.

METHODS

A 68-year-old male presented with a 2-month history of worsening lower back pain radiating to both legs. The patient had undergone nephrectomy for the treatment of the clear cell RCC 16 years before admission. Magnetic resonance imaging showed a well-defined intradural extramedullary mass in the cauda equina at T12 to L1.

RESULTS

The pathological examination displayed metastatic clear cell RCC. Additional imaging studies showed no metastatic in other locations. The patient was discharged without neurological deficit and pain after the operation, and maintained an optimal condition for 2 years.

CONCLUSION

When a lesion of the cauda equina presents, intradural metastasis should be in the differential diagnosis in patients who had been previously treated for RCC although any other metastatic lesion was not observed.

LEVEL OF EVIDENCE

N/A.

Adult-onset NREM parasomnia with hypnopompic hallucinatory pain: a case report

We report the case of a 43-year-old woman presenting with nocturnal episodes of pain and screaming during sleep starting at age 30. There was no childhood or family history of parasomnia. The events had gradually become more frequent over the years, occurring in the first half of the night within 2 h of sleep onset. There were no triggers, and she had partial amnesia for the events. A diagnosis of adult-onset sleep terrors was made on clinical grounds and supported polysomnographically. Seizures and periodic limb movements were excluded as triggering factors. There was some mild sleep disordered breathing (predominantly non-desaturating hypopnea with a propensity for REM sleep of debatable significance). Imaging of the brain and spine and neurophysiological investigations ruled out lesions, entrapments, or neuropathies as possible causes of pain. Treatment (clonazepam, paroxetine, or gabapentin) was poorly tolerated and made no difference to the nocturnal episodes, while trazodone worsened them. This is the first report of hypnopompic psychic pain in association with a NREM parasomnia. We hypothesize that the pain may represent a sensory hallucination analogous to the more commonly recognized visual NREM parasomnia-associated hypnopompic visual hallucinations and that, as such, it may arise during arousal of the sensory neocortex as confabulatory response.

Surgical treatment of rare cauda equina tumours

BACKGROUND

Cauda equina tumours (CET) are rare and usually benign. Treatment of schwannomas and benign ependymomas, which are the most frequent histopathological types of CET, is now well established. However, management of other presumed histopathological types of CET is still a matter of debate. The aim of this study was to assess the incidence and the surgical treatment of rare CET.

METHOD

A retrospective study was carried out on 176 adult patients surgically treated for CET in our two departments from 1994 to 2010. We reviewed pre- and postoperative symptoms, magnetic resonance imaging aspects, surgical findings, outcome including operative neurological morbidity, local recurrence rate and operative mortality, and incidence of rare CET.

FINDINGS

Seventeen percent (30 patients) of CETs operated on were neither schwannomas nor benign ependymomas. Half of these cases were benign tumours, with paragangliomas being the most common. Two patients were in poorer clinical condition after surgery, one patient experienced a local recurrence, and one died following surgery, from the progress of his disease (Von Hippel-Lindau disease). The other half were malignant tumours, with metastases being the most common. One third of the patients were worsened by surgery, and the mortality rate was 1/3 at 8 months (1-27 months).

CONCLUSIONS

Roughly one in six CET were neither schwannomas nor benign ependymomas. This study demonstrated the efficiency of surgery for rare benign CET with a low local recurrence rate. Surgical treatment of rare malignant CET led to a high rate of increased postoperative neurological deficit in patients with a reduced life expectancy.

Relationships between pathology and pain severities: a review

The relationships between pathology severity and pain severity are reviewed using the literature available for humans. The aim is to help veterinary radiologists, physicians and pathologists recognise the disorders in which severity of a lesion is likely to be related to the severity of pain or to incipient pain. Specific features or lesions within the following conditions showed a relationship with pain score, which was usually assessed with a visual analogue scale: inflammation; pancreatitis; ileitis; mucositis; fasciitis; synovitis; arthritis; lower back pain; disc herniation; sciatica; scoliosis; myalgia; cancer; arteriosclerosis; skin ulcers; mastalgia; skin and oral neuropathies; endometriosis; hepatopathy and chronic pulp diseases of the teeth. As experience with magnetic resonance imaging grows, there will be further opportunities to look for quantitative relationships in humans between pathology and pain severities. This information will be useful to veterinarians and other people working with animals in evaluating pain in animals in their care.

Giant schwannoma of the cauda equina without neurological deficits -- case report and review of the literature

Schwannomas and ependymomas are the most frequent tumours of the filum terminale. Giant schwannomas, however, are very rare in this location with less than 30 cases reported in the literature, most of them presenting with preoperative neurological deficits. We present the case of a giant schwannoma in a 75-year-old lady extending from the level of lower D12 to upper L3 vertebra with low-back pain as the only symptom. Microsurgical removal of the tumour was accomplished via an L1-L2 laminotomy without permanent neurological deficits. Giant schwannoma of the cauda equina is a rare tumour with variable symptoms. Early diagnosis is crucial to obtain good postoperative results. Total removal without additional neurological deficits can be achieved by appropriate microsurgical techniques.

Clear cell ependymoma occurring in the cauda equina

The authors present a rare case of clear cell ependymoma that developed in the cauda equina. A 54-year-old man was admitted to hospital with intermittent lower back pain. A neurological examination conducted on admission revealed no sensory or motor disturbance. Deep tendon reflexes in both lower extremities were normal. Magnetic resonance images demonstrated a 1.0 cm-sized intradural mass at the filum terminale. Gross total resection was performed via total laminectomy of L1 and L2. The tumor was confirmed to be clear cell ependymoma by histopathologic examination. His symptom was relieved after surgery.

Intradural spinal metastasis to the cauda equina in renal cell carcinoma: a case report and review of the literature

STUDY DESIGN

Case description.

OBJECTIVES

To describe a case of intradural metastasis from a renal cell carcinoma (RCC) spread to the cauda equina, and review the pertinent medical literature.

SUMMARY OF BACKGROUND DATA

Intradural spinal metastasis is rare, accounting for 6% of all spinal metastases. Only 7 cases of intradural metastasis from a RCC to the cauda equina have been previously reported.

METHODS

A 41-year-old male presented with a 1-month history of severe back pain radiating to both legs. The patient underwent a right nephrectomy for treatment of a RCC 1-year before admission. Magnetic resonance imaging showed a well-demarcated, intradural extramedullary mass at the L2 vertebra.

RESULTS

After a total laminectomy, total excision of the tumor was achieved followed by rapid improvement of the back pain. The tumor was histologically verified as metastatic RCC, identical to that of a previous tumor specimen. The patient was asymptomatic on the 1-year follow-up.

CONCLUSION

Although the majority of cauda equina tumors are primary tumors, intradural metastasis should be considered before surgery in patients with previously treated RCC.

Capillary hemangioma of cauda equina: a case report

Background

Capillary hemangiomas of spinal nerve root, mostly affecting the cauda equina, are extremely rare.

Case presentation

A 20-year old man was presented with back pain, radiculopathy, and urogenital symptoms. Magnetic resonance images revealed an intradural extramedullary mass, isointense in T1-weighted and hyperintense in T2-weighted images, with noticeable post injection enhancement. The clinical and radiological findings simulated neurinoma.

However, a pinkish lesion was removed surgically and histopathological examination revealed lobules of capillary vessels separated by fibrous tissue, suggesting capillary hemangioma.

Conclusion

Although rare and sometimes indistinguishable from more common lesion, capillary hemangioma should be in differential diagnosis of any enhancing intradural extramedullary mass at the level of cauda equina or conus medullaris.

Primary filum terminale ependymoma: a series of 16 cases

Filum terminale ependymomas are slow growing tumors of the cauda equina with a high incidence in young adults. Although a complete microsurgical resection can lead to a cure, recurrence is not uncommon. Sixteen cases of filum terminale ependymomas treated at the Instituto de Neurologia de Curitiba were analyzed. Eleven patients were females and 5 males, their age ranging from 7 to 84 years. Symptoms and signs included lumbar pain (31.25%), radicular pain (56.25%) and neurological deficits (12.5%). In three cases, patients had previously undergone surgery in other hospitals. All were tested through MRI and were operated on. Two underwent a laminoplasty and 14 a laminectomy. The last 8 patients of this series had neuro-physiological monitoring during surgery. In all patients a total microsurgical resection was achieved. Histologically, 2 cases were cellular ependymomas and 14 cases myxopapillary ependymomas. There was no recurrence during a 2 to 84 month follow-up period.

Spinal cord tumors of the thoracolumbar junction requiring surgery: a retrospective review of clinical features and surgical outcome

PURPOSE

A retrospective review of medical records and imaging studies. To investigate characteristic clinical features and surgical outcomes of spinal cord tumors (SCTs) of the thoracolumbar junction (TLJ). The spinal cord transitions to the cauda equina in the TLJ. The TLJ contains the upper and lower motor neurons of the spinal cord and cauda equina. As a result, the clinical features of lesions in the TLJ vary, and these anatomical characteristics may affect surgical outcome.

MATERIALS AND METHODS

Pathological diagnosis, clinical features, neurological signs, and surgical outcomes were investigated in 76 patients surgically treated at our institute for SCTs arising from T11 to L2. The patients were divided into epiconus (T11-12, n=18) and conus groups (L1-2, n=58).

RESULTS

Patients in the epiconus group had hyperactive deep tendon reflexes (DTRs), while those in the conus group had hypoactive DTRs (p < 0.05). Nine patients were misdiagnosed with intervertebral disc diseases (IVDs) before correct diagnoses were made. It was impossible to definitively determine the exact cause of symptoms in four patients who had both SCTs and IVDs.

CONCLUSION

Among SCTs of the TLJ, the epiconus group displayed upper motor neuron syndrome and the conus group displayed lower motor neuron syndrome. SCTs of the TLJ were frequently misdiagnosed as IVDs due to symptomatic similarities. SCTs of the TLJ should be included in differential diagnosis of back and leg pain, and it is highly recommended that routine lumbar magnetic resonance imaging include the TLJ.

Faecal incontinence as presentation of an ependymomas of the spinal cord

Background

Spinal tumours and ependymomas in particular are rare causes of cauda equina syndrome that present with faecal incontinence.

Case presentation

We present a case of a 45 year old gentleman who presents to a colorectal clinic with incontinence. We then present a review of ependymomas with particular reference to the symptoms they cause as well a review of the neurophysiology of faecal continence.

Conclusion

Suspicion for non-colonic causes for faecal incontinence should arise when there is absence of other etiologic factors. Establishment of the diagnosis of spinal tumours is with neurological examination and MRI spine.

A Case Report of an Uncommon Cause of Cauda Equina Symptoms

OBJECTIVE

This case report discusses a patient who presented with right-sided buttock pain of apparently uncomplicated mechanical origin that was eventually diagnosed as a primary Ewing sarcoma/primitive neuroectodermal tumor of the sacrum.

CLINICAL FEATURES

A 32-year-old male full-time student presented for care with right-sided buttock pain.

INTERVENTION AND OUTCOME

After examination, the patient was referred to his general practitioner for urgent magnetic resonance imaging, the report revealed no explanation for the presenting symptoms. After further imaging and biopsy, an eventual diagnosis of Ewing sarcoma/primitive neuroectodermal tumor was reached. The patient died 12 months later.

CONCLUSION

This case highlights a nondiscal cause for cauda equina symptoms. It emphasizes potential diagnostic complexities that may present due to preconceptions based upon the probability of symptoms being related to a specific disease process.