Abstract
Neuroendocrine tumors (NETs) are benign tumors of the autonomic nervous system that rarely occur in the spinal canal. The gold standard treatment is gross total resection while preserving the patient’s neurologic functioning as complete surgical resection is curative. The surgical management of NETs could pose a challenge given their friable consistency, hypervascular nature, and proclivity to adhere to the cauda equina nerve roots.We present a case of a 62-year-old female with an incidental primary NET arising from the filum terminale internum, review the literature, and describe the surgical technique including the benefits of using an intraoperative ultrasound and some of the pitfalls of relying “blindly” on neuromonitoring. Early identification and disconnection of the tumor’s vascular pedicle, which usually runs through the cranial filum, devascularizes the tumor, prevents systemic complications from catecholamine release, and facilitates circumferential dissection off the en passage cauda equina nerve roots. Our patient remains neurologically intact and asymptomatic two years postoperatively and neuroimaging confirmed complete resection.
Highlights
Neuroendocrine tumors (NETs) or paragangliomas are rare tumors of neural crest origin that occur predominantly in the head and neck, mediastinum, adrenal gland and para-aortic ganglia, and very exceptionally in the spinal canal
A very small subset of these NETs arises from the filum terminale internum (FTI), and gross total resection (GTR) achieves the cure
We report a case of a NET of the FTI managed surgically with complete resection and discuss the surgical technique
Summary
Neuroendocrine tumors (NETs) or paragangliomas are rare tumors of neural crest origin that occur predominantly in the head and neck, mediastinum, adrenal gland and para-aortic ganglia, and very exceptionally in the spinal canal. A dedicated lumbar spine MRI (Figure 1) showed a vividly enhancing lumbar intradural tumor (Figures 1B, 1C) at the level of the L4 vertebral body, arising from and wrapping around the FTI (Figure 1A). She had no back pain or neurological complaints and was neurologically intact on exam. The tumor’s macroscopic appearance was unlike any other tumor in this region and hypervascular (Figure 2B) It was clearly sprouting from the filum terminale internum (Figures 2B, 2C) and had several en passage cauda equina roots wrapped on its capsule, including the left L5 nerve root. The patient remains asymptomatic at a two-year follow-up
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