Conus Medullaris Research Articles

Focal classic intradural extramedullary ependymoma near the conus medullaris: A case report and literature review

Rationale: To enhance clinicians’ comprehension of conus medullaris region ependymomas and elevate their diagnostic accuracy. Patient concerns: A 26-year-old female patient had 10 months of low back pain and right lower limb pain. Diagnoses: Lumbar magnetic resonance imaging (MRI) scan revealed a circular abnormal signal in the spinal canal at the level of L2. Pathological examination confirmed classic ependymoma. Interventions: The patient underwent tumor resection surgery. Outcomes: Postoperatively, the patient’s right lower limb soreness improved, and no new neurological deficits were observed. Lessons: Focal classic intradural extramedullary ependymomas near the conus medullaris are rare. Close follow-up with MRI of the craniospinal axis is necessary. Hormonal factors may influence the development of ependymomas in this unusual location. The appearance of these tumors on MRI and contrast-enhanced MRI scans is variable.

Investigation of intrafractional spinal cord and spinal canal movement during stereotactic MR-guided online adaptive radiotherapy for kidney cancer.

This study aimed to investigate the intrafractional movement of the spinal cord and spinal canal during MR-guided online adaptive radiotherapy (MRgART) for kidney cancer. All patients who received stereotactic MRgART for kidney cancer between February 2022 and February 2024 were included in this study. Patients received 30-42 Gy in 3-fraction MRgART for kidney cancer using the Elekta Unity, which is equipped with a linear accelerator and a 1.5 Tesla MRI. MRI scans were performed at three points during each fraction: for online planning, position verification, and posttreatment assessment. The spinal cord was contoured from the upper edge of Th12 to the medullary cone, and the spinal canal was contoured from Th12 to L3, using the first MRI. These contours were adjusted to the second and third MR images via deformable image registration, and movements were measured. Margins were determined via the formula "1.3×Σ+0.5×σ" and 95% prediction intervals. A total of 22 patients (66 fractions) were analyzed. The median interval between the first and third MRI scans were 38 minutes. The mean ± standard deviation of the spinal cord movements after this interval were -0.01 ± 0.06 for the x-axis (right-left), 0.01 ± 0.14 for the y-axis (caudal-cranial), 0.07 ± 0.05 for the z-axis (posterior-anterior), and 0.15 ± 0.08 for the 3D distance, respectively. The correlation coefficients of the 3D distance between the spinal cord and the spinal canal was high (0.92). The calculated planning organ at risk volume margin for all directions was 0.11 cm for spinal cord. The 95% prediction intervals for the x-axis, y-axis, and z-axis were -0.11-0.09 cm, -0.23-0.25 cm and -0.14-0.03 cm, respectively. Margins are necessary in MRgART to compensate for intrafractional movement and ensure safe treatment delivery.

High-grade astrocytoma with piloid features in the conus medullaris: a rare presentation of a new World Health Organization diagnosis. Illustrative case.

Neuroepithelial tumors with histological features of pilocytic astrocytoma (PA), increased mitotic activity with high-grade features of microvascular proliferation, and palisading necrosis have often been designated as anaplastic PAs. High-grade astrocytoma with piloid features (HGAP) was recently classified as its own entity by the World Health Organization (WHO) in 2021, after being grouped under anaplastic PA. This rare tumor typically arises in the cerebellum. The authors present the case of a patient with HGAP in the conus medullaris, a rare occurrence, with only 17 reported HGAP cases in other parts of the spinal cord. An 83-year-old female patient presented with progressive lower-extremity weakness over 2 weeks. Subsequent imaging revealed an intramedullary spinal cord mass near the conus. Histopathological analysis confirmed a neuroepithelial tumor. Chromosomal microarray revealed the diagnosis of HGAP, an exceedingly unusual tumor to be found near the conus. The tumor characteristics showed uniformly low cellularity and low proliferation of medium-sized ovoid cells with elongated nuclei, embedded in a loose pilocytic matrix. This report presents the case of a patient with HGAP in the conus medullaris, a new WHO diagnosis that needs to be included in the differential diagnosis for conus masses. https://thejns.org/doi/10.3171/CASE24390.

Hemorrhagic intramedullary spinal cord metastasis from renal cell carcinoma: a rare case 15 years after cured renal cell carcinoma. Illustrative case.

Renal cell carcinoma (RCC), the most common kidney cancer, often metastasizes to bones, lungs, liver, and the central nervous system. Intramedullary spinal metastasis from RCC is rare but can cause significant neurological deficits, necessitating prompt diagnosis and treatment through surgical intervention, radiotherapy, and immunotherapy. An 86-year-old man presented with progressive right lower-limb weakness and reduced sensation over 3 weeks. His medical history included a right nephrectomy for RCC 15 years earlier and L4-S1 spondylosis. Imaging identified a bleeding lesion in the conus medullaris at T11-12 and an incidental left kidney mass. Urgent surgical exploration led to a T12 laminectomy and en bloc removal of the lesion, which was confirmed as RCC metastasis. Postoperatively, the patient received focused radiotherapy and immunotherapy, showing significant motor and sensory improvement before dying 3 months later. This case underscores the importance of comprehensive diagnostic imaging for the accurate identification and characterization of spinal lesions. An interdisciplinary approach involving neurosurgeons, oncologists, radiologists, and pathologists is crucial for optimal treatment planning. Urgent surgical intervention can effectively address acute neurological deficits caused by intramedullary lesions. Additionally, adhering to postoperative care instructions, such as deep venous thrombosis prophylaxis, is vital to prevent fatal complications. https://thejns.org/doi/10.3171/CASE24349.

Do Not Forget the Spine MRI in Children With Arthrogryposis Multiplex Congenita: High Prevalence of Tethered Spinal Cord and Preliminary Clinical Findings Following Detethering.

Arthrogryposis multiplex congenita (AMC) encompasses congenital conditions with joint contractures in 2 or more joints. Patients with AMC may have scoliosis and neural axis malformations. The study aimed to determine the prevalence of tethered spinal cord (TSC), characterized by a low-lying conus medullaris, and secondarily, present preliminary findings following surgical untethering in children with AMC. Patients 18 years of age and younger with a diagnosis of AMC and a spine MRI were identified. The presence of a TSC was defined as a low-lying conus with termination at or below the lower third of the L2 vertebral body. A pediatric neurosurgeon and a pediatric orthopaedic surgeon independently reviewed MRIs. The medical records of patients with AMC who underwent untethering were examined to evaluate preoperative and postoperative clinical findings. The prevalence of TSC in our AMC patients was compared with published normative data using χ2 analysis. Forty-two of 105 AMC patients (40%) had TSCs. There was a greater percentage of patients with AMC and a TSC compared with the unaffected population (P<0.0001). Sixteen patients underwent detethering through filum terminale sectioning. Nine patients had preoperative neurological deficits in addition to their AMC. There were no postoperative complications. All patients had improvement in their bowel and bladder symptoms within 3 months after their detethering procedure. TSC is more prevalent in the pediatric population with AMC compared with those without AMC. MRI is recommended for all patients with AMC due to its high prevalence. Although not a benign procedure, surgical detethering may have potential benefits for children with AMC. Level IV-therapeutic study.

Treatment Strategies for Unknown Anatomic Pathology Ventriculus Terminalis Case Series: Single Center Experience

The ventriculus terminalis is a cavity in the conus medullaris, bounded by ependymal cells, associated with the central canal. It is an anatomical structure that is very rare in adults, with a limited number of surgical cases that have been reported in the literature. In children, it is regarded as a normal congenital variation, known to regress before five years of age, and very few symptomatic cases have been reported in both pediatric and adult populations. It is often asymptomatic in adults and is detected incidentally. Although potentially nonsignificant individually, symptoms can range from nonspecific low back pain to sphincter dysfunction and focal neurologic deficits. Our purpose is to discuss our management strategy in comparison to the existing literature. A retrospective review was conducted of all adult patients (aged 17 years and older) diagnosed with ventriculus terminalis who were referred to the hospital between 2010 and 2020. Clinical classification was made according to the classification defined by Batista. In addition, Ganau's classification was also used. Five patients were included in the study. The majority of these patients (n=4, 80%) were symptomatic at the time of diagnosis, with nonspecific back pain being the most common symptom (n=3, (60%). None of the patients required neurosurgical intervention during the follow-up period of 21.6±8.9 months, as there was no clinical deterioration observed. Ventriculus terminalis is a rare pathology that may develop de novo in adults, often remaining undiagnosed until the cyst enlarges, and can manifest with a wide spectrum of symptoms. When identified, it requires careful management, involving surgery when necessary and a conservative approach when appropriate.

SPIN-02 AN INTRAMEDULLARY MYXOPAPILLARY EPENDYMOMA: A RARE OCCURANCE IN THE CERVICO-THORACIC SPINE

Abstract BACKGROUND Spinal myxopapillary ependymomas are a rare variant of spinal ependymoma that are considered to occur exclusively in the conus medullaris and filum terminale. They account for about 13% of all spinal ependymomas and have a slight male predominance. Case presentation: We report a case of 38-year-old male, Muganda, that presented at the Neurosurgery department Mulago National Referral Hospital with progressive paresthesia and paraparesis, of the upper limbs and chronic neck pain for 2years. MRI showed an isointense lesion on TIWI extending from C4 to T2 levels and exhibited heterogenous enhancement on gadolinium administration. The lesion was hyperintense on T2WI with a syrinx above the tumor. A radiological diagnosis of an intramedullary neoplastic process was made with differentials of Ependymoma, Schwanomma, and Astrocytoma. The patient underwent posterior laminectomy, and the tumor was completely excised. He is currently under follow up by the Neurosurgery team. CONCLUSION This case underscores the rarity of intramedullary myxopapillary ependymomas highlighting diagnostic challenges and the critical role of tailored surgical interventions in managing rare spinal neoplasms.

ID: 344930 Targeting the Conus Medullaris with Closed Loop Stimulation for Chronic Pelvic Pain: A Case Series

ID: 344930 Targeting the Conus Medullaris with Closed Loop Stimulation for Chronic Pelvic Pain: A Case Series

A Case of the Anti-aquaporine-4 Antibody-negative Neuromyelitis Optica Spectrum Disorders Associated with Atopic Disease with High Concentration of Anti-IgE Autoantibody and HyperIgEemia

We report a 70-year-old male patient with the sero-negative neuromyelitis optica spectrum disorders (NMOSD) associated with atopic disease (AD). He was diagnosed with allergic rhinitis at the age of 20. When he was 61 years old, he subacutely developed orthostatic hypotension, bilateral optic neuritis, quadriparesis, urinary retention, and constipation. The laboratory results revealed allergen-specific IgE positivity for cryptomeria japonica and hinoki, hyperIgEemia, and Th (helper T cell) 1 dominance. The serological tests for autoantibodies revealed negative anti-aquaporine 4 antibody, and high concentration of anti-IgE autoantibody (anti-IgE AAb). Cerebrospinal fluid was negative for anti-myelin-oligodendrocyte glycoprotein antibody and glial fibrillary acidic protein antibody. Fluid-attenuated inversion recovery on brain magnetic resonance imaging (MRI) showed high signal intensities in bilateral cerebral deep white matter. T2 weighted image on spine MRI showed longitudinally extensive high signal intensities in the spinal cord, specifically involving C1 vertebral level to conus medullaris. Intravenous methylprednisolone (IVMP) and plasma exchange resulted in partial improvement. Following the onset of NMOSD, he had relapse of NMOSD four times. In each episode, IVMP was to be partially effective with anti-IgE AAb reduction. Anti-IgE AAb may be a reasonable clinical indicator of increased disease activity in the sero-negative NMOSD associated with AD.

Utility of routine mid-trimester fetal ultrasound scan in detecting filar cysts and follow-up outcomes.

To assess the value of routine mid-trimester fetal ultrasound scans in detecting FCs, as well as the related ultrasound and clinical follow-up outcomes. A retrospective analysis was conducted on 1064 fetuses who underwent standardized ultrasound screening during the mid-trimester. During the examination, high-frequency ultrasound was used to examine the fetal spine. Different frequency ultrasound probes were used to compare and analyze the detection rates of FCs. We conducted follow-up ultrasound observations on all FCs and conducted long-term follow-up observations in terms of the motor function of the children after birth. Among 1064 fetuses detected by ultrasound, a total of 910 fetuses were completely evaluated using high-frequency and low-frequency ultrasound, and 24 FCs were found. In all 24 cases of FCs, 7 cases were detected using low-frequency ultrasound, while high-frequency ultrasound detected all cases. There was a significant difference in the detection rates between the two groups (χ2 = 26.323, P = 0.000). Of all the 24 FCs, 21 cysts disappeared spontaneously (87.5%); one fetus was induced for abortion due to a concurrent cleft lip; after multiple ultrasound examinations, it was found that the cyst persisted in one fetus; one case was not followed up by ultrasound. There was no statistically significant difference in the start of sitting and crawling time between the control group and the FCs group. Routine mid-trimester fetal ultrasound scan detect FCs, particularly when high-frequency ultrasound probes were routinely applied. Most FCs detected by prenatal ultrasound spontaneously disappear and have no impact on the motor function of the fetus after birth (with the conus medullaris located at or above the L3 level). The shortest time interval from the detection to the disappearance of the cyst was 11days.

Spinal Teratoma with Recurrent Epileptic Episodes in Adults: A Case Report

Introduction: Spinal teratomas are rare, accounting for nearly 0.2–0.5% of all spinal tumors and 2% of all teratomas. Teratomas at the conus medullaris location do not inherently lead to epilepsy. However, potential epileptic seizures are caused when teratoma ruptures and the chemical stimulation of teratoma components enter the dural sac. Case Presentation: A 31-year-old Asian male patient suffering from epileptic onset and poor antiepileptic treatment was demonstrated. The spinal imaging examination was performed, and the patient suffered a space-occupying lesion within the conus medullaris related to spinal deformity, spinal embolism, etc. The autoimmune encephalitis spectrum revealed mGluR5 antibody IgG (+) 1:10 response. The patient stabilized after treatment with hormones and human immunoglobulin. Some hair and lipid droplets could be observed in the dural sac intraoperatively, and more hair and lipid-like material were present in the spinal cord. Postoperative pathology established the diagnosis as a conus medullaris teratoma in adults. Epileptic seizures stopped after surgery, and no additional seizures were reported during the 33-month follow-up period. Conclusions: Conus medullaris teratoma rupture in adults rarely causes epileptic seizures. For spinal deformity patients with unexplained epileptic symptoms, spinal MRI can be helpful in early diagnosis, and more appropriate treatment improves disease prognosis.

Incidence of Tethered Cord Syndrome in Pediatric Patients With Neurofibromatosis Type 1

ObjectiveThe link between Tethered Cord Syndrome (TCS) and Neurofibromatosis Type 1 (NF1) remains unclear. To date, only two studies have indicated a high occurrence of TCS in the pediatric NF1 patient population. Our study aims to ascertain the incidence of TCS among Chinese pediatric patients with NF1. MethodsA single-institution, 8-year retrospective analysis at a tertiary-level children's hospital was conducted for patients with NF1 who underwent surgery for TCS. The clinical features, imaging characteristics, genetic testing outcomes, and histopathological findings of pediatric NF1 patients with TCS were analyzed. ResultsDuring the study period, a total of 115 pediatric patients were diagnosed with NF1. Among these 115 NF1 patients, 11 individuals, accounting for 9.6% of the sample, were confirmed to have TCS. This rate of occurrence is significantly higher than the incidence rate of TCS in the general population, which stands at 0.17%. All 11 of the pediatric NF1 patients underwent surgery for TCS. Out of the 11 patients who were advised to have tethered cord release surgery, 4 (which is 36.4%) were girls, and the average age of these 11 patients was 8.6 years old, with ages ranging from 2 to 17 years old. The conus medullaris position of the 11 pediatric NF1 patients ranged from L1 to L2, and 10 of them (91%) had a filum terminale lipoma, characterized by high signal intensity on T1-weighted magnetic resonance (MR) images. Another patient was diagnosed with Occult Tethered Cord Syndrome (OTCS). All 11 pediatric NF1 patients exhibited symptoms associated with TCS, such as neuromotor dysfunction, abnormalities in urination, defecation, skeletal system abnormalities, or pain. Eight of the 11 pediatric NF1 patients had undergone genetic testing, which is a crucial part of the diagnostic process for NF1. The histopathological examination of the 11 pediatric NF1 patients who underwent surgery revealed that 10 patients had fatty infiltration of the filum terminale (FT), while the remaining patient exhibited fibrosis of the filum terminale (FT). ConclusionsIn the group of pediatric patients with NF1, the incidence of TCS, presenting to the pediatric neurosurgery clinic for any reason, is significantly higher than that of the general population. However, the pathophysiological relationship between NF1 and TCS is still not clear. It is essential to provide counseling to NF1 patients and their families about the symptoms of TCS to make sure they are aware and can seek the necessary care when needed. This underscores the importance of not only diagnosing NF1 but also staying alert for related conditions like TCS, which may have a higher occurrence in this demographic.

Understanding metastatic involvement of the conus medullaris: a systematic review of clinical presentations, diagnostic approaches, treatment options, and patient outcomes.

Metastasis to the conus medullaris (CM) is a rare but devastating condition. This systematic review aimed to evaluate the clinical presentation, diagnostic workup, treatment options, and outcomes of patients with CM metastasis. By synthesizing the available evidence, this study seeks to improve our understanding of this condition and inform clinical practice. A systematic review adhering to PRISMA guidelines analyzed literature on CM metastasis from 1997 to January 2024. Human studies in English were included, focusing on primary research articles. Screening criteria ensured a homogeneous study population, with data analyzed using SPSS 26 and assessed for quality using the JBI checklist. The study analyzed 88 patients with conus medullaris metastasis. Common symptoms included back pain (49.3%), sensory impairment (75%), and bladder dysfunction (60.3%). MRI was the primary diagnostic tool, revealing lesions above L1 (37%) or between L1 and L2 (29%). Treatment involved surgery with laminectomy, and combined therapy (surgery plus radiotherapy) in 81.3%. Postoperative outcomes showed improved motor function in 59.6% of patients, while combined therapy yielded better sensory and bowel/bladder function recovery. Median survival was 100 days. Metastasis to the conus medullaris is rare but significant. Surgical resection can improve motor function, while combined therapy (surgery plus radiotherapy) is effective in improving sensory manifestations and bowel/bladder functions. Despite these treatments, the median survival remains around 100 days, which is shorter compared to other types of intramedullary spinal cord metastases.

Neurosurgical Management of Rubinstein-Taybi Syndrome: An Institutional Experience

Introduction: Rubinstein-Taybi syndrome (RTS) is a rare genetic condition with a distinctive set of physical features. This case series reports a single institutional experience of RTS cases, highlighting the role of neurosurgery in the comprehensive management of RTS patients. Methods: A retrospective review of patients with genetically confirmed RTS presenting between 2010 and 2023 at Children’s Hospital of Pittsburgh was performed. Patient demographics, genetic profile, clinical symptoms, radiographic characteristics, and neurosurgical management were recorded for all patients. Results: Twenty-one patients (13 females, 8 males) aged 0 to 22 years presented for formal genetic counseling and diagnosis. Twenty patients (95%) had CREBBP pathogenic variants (RTS type 1), and 1 patient (5%) had EP300 pathogenic variants (RTS type 2). Ten patients (48%) had a low-lying conus medullaris, and 3 patients (30%) underwent subsequent spinal cord detethering. Four patients (19%) had a Chiari malformation, and three (75%) underwent Chiari decompression surgeries. One patient (5%) had Chiari-associated syringomyelia. Conclusions: RTS patients have an increased rate of tethered cord syndrome requiring detethering. The incidence of symptomatic Chiari I malformation requiring decompression has not been previously reported. The RTS series presented here demonstrates a high incidence of symptomatic Chiari I malformation in addition to tethered cord syndrome.

65. Low-lying conus medullaris and scoliosis in the pediatric patients with arthrogryposis

65. Low-lying conus medullaris and scoliosis in the pediatric patients with arthrogryposis

Diagnosis and management of a case of gestational trophoblastic neoplasia with lumbosacral metastases.

Gestational trophoblastic neoplasia (GTN) with spinal metastasis is rare with few documented cases worldwide. Few studies have explored chemotherapy combined with radiotherapy in the treatment of such cases. However, because of its rarity, there is still no standardized treatment regimen. A 34-year-old Gravida 1 Para 0 (0010) was diagnosed with GTN with metastasis to the lumbosacral spine, resulting in conus medullaris syndrome with lumbar radiculopathy. She presented with a 14-month history of amenorrhea, left lower extremity pain, and urinary and bowel retention. On examination, there was a 10.0 × 7.0 cm lumbosacral mass and atrophy of the left lower extremity. Transvaginal ultrasound showed a cul de sac mass, and diluted β-human chorionic gonadotropin (β-hCG) titer was markedly elevated at more than 1000 000 mIU/mL. Magnetic resonance imaging (MRI) of the lumbosacral spine showed an ill-defined sacral mass measuring 13.3 × 11.5 × 6.3 cm with spinal canal, bone, muscle, and nerve root involvement. She was treated with 10 cycles of EMACO and palliative radiotherapy with 10 sessions of 30 Gy of external beam radiation therapy directed toward the lumbosacral mass. Repeat MRI showed a decrease in size of the mass to 6.6 × 8.2 × 4.1 cm with concurrent decrease in β-hCG to 1.30 mIU/ml, and resolution of leg pain and urinary and bowel symptoms. She was declared to be in remission 3 months after the last cycle of EMACO.

The predictive value of intraoperative bulbocavernosus reflex monitoring for postoperative voiding function in patients with conus medullaris and cauda equina tumors: a retrospective single center study

BACKGROUND CONTEXTSurgical resection is the preferred treatment in most conus medullaris and cauda equina tumor (CMCET) cases. However, total resection is usually challenging to obtain and has a strong possibility of causing various complications if forcibly attempted. Intraoperative neurophysiological monitoring (IONM) has become a necessary adjunctive tool for CMCET resection. PURPOSEThe current study aimed to evaluate the application value of bulbocavernosus reflex (BCR) monitoring in CMCET surgery. STUDY DESIGNA retrospective clinical study. PATIENT SAMPLEThe medical records of patients who underwent CMCET resection by the same neurosurgical team at our hospital from September 2020 to June 2022 were retrospectively reviewed. IONM was conducted in all surgeries. According to inclusion criteria and exclusion criteria, ultimately, 105 patients were enrolled in the study. OUTCOME MEASURESThe voiding function was assessed before surgery, 1 month after, and 6 months after surgery using the Neurogenic Bladder Symptom Score (NBSS). If the NBSS obtained 1 month after surgery exceeds 9 points than that before surgery, it can be considered that the patient suffered new-onset postoperative voiding dysfunctions (PVDs). Moreover, if the NBSS could restored (less than 9 points higher than before the surgery) at 6 months after surgery, it was defined as a short-term PVD. Otherwise, it was defined as a long-term PVD. METHODSThe amplitude reduction ratios (ARRs) of bilateral BCR waveforms were calculated and compared between patients with PVDs and those without. The receiver operating characteristic curve analysis was subsequently applied to determine the cut-off value of the maximal and minimal ARRs for predicting PVDs. RESULTSThe maximal and minimal ARRs were significantly correlated with short-term and long-term PVDs (p<.001 for all comparisons, Mann-Whitney U test). The threshold values of maximal ARR for predicting short-term and long-term PVD were 68.80% (AUC=0.996, p<.001) and 72.10% (AUC=0.996, p<.001), respectively. While those of minimal ARR were 50.20% (AUC=0.976, p<.001) and 53.70% AUC=0.999, p<.001). CONCLUSIONSThe amplitude reduction of intraoperative bilateral BCR waveforms showed high predictive value for PVDs.

Intramedullary Metastases to Conus Medullaris: A Review of the Literature with a Case Illustration.

Introduction: Intramedullary metastases to the conus medullaris spinalis (IMCM) pose a rare problem in neurosurgical oncology and are usually encountered as a complicated clinical scenario in the setting of advanced systemic malignancy with poor overall survival. Despite the progress in interdisciplinary oncological care, their management remains complicated. Research Question: We performed a PRISMA-guided literature search to achieve a pooled analysis of all previously reported IMCM cases that contained detailed clinical data on this problem to investigate the currently employed management options and respective outcomes. We obtained a clinical vignette and performed a comprehensive narrative review of IMCM management. Materials and Methods: The PubMed/MEDLINE/Google Scholar, Cochrane and Embase databases were systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All relevant publications retrieved were subjected to full-text analysis in detail and pertinent information was extracted. Results: The most common systemic primary tumor site as the origin of IMCM was the lung, followed by the breast. Overall, the pooled median survival was 6 months (range 0.5-36 months). Patients who received both surgery and radiation therapy had the longest overall survival (OS) (mean 9.9 months) and those who received no oncological treatment (neither surgery nor adjuvant therapy) had the shortest OS (mean 3.6 months). In cases where surgical resection was performed as part of the treatment plan for metastases, those with partial tumor resection had a more favorable neurological outcome than patients who underwent aggressive gross total resection. Conclusions: Based on the results of our analysis, we find that diligent microsurgical resection (subtotal or total) followed by radiation therapy appears as an effective and suitable treatment in select patients with IMCM. When surgery is not feasible as part of the treatment algorithm, radiation therapy alone (conventional or radiosurgery) also appears to be a suitable treatment option that confers a benefit to the patient.

Novel Technologies to Address the Lower Motor Neuron Injury and Augment Reconstruction in Spinal Cord Injury.

Lower motor neuron (LMN) damage results in denervation of the associated muscle targets and is a significant yet under-appreciated component of spinal cord injury (SCI). Denervated muscle undergoes a progressive degeneration and fibro-fatty infiltration that eventually renders the muscle non-viable unless reinnervated within a limited time window. The distal nerve deprived of axons also undergoes degeneration and fibrosis making it less receptive to axons. In this review, we describe the LMN injury associated with SCI and its clinical consequences. The process of degeneration of the muscle and nerve is broken down into the primary components of the neuromuscular circuit and reviewed, including the nerve and Schwann cells, the neuromuscular junction, and the muscle. Finally, we discuss three promising strategies to reverse denervation atrophy. These include providing surrogate axons from local sources; introducing stem cell-derived spinal motor neurons into the nerve to provide the missing axons; and finally, instituting a training program of high-energy electrical stimulation to directly rehabilitate these muscles. Successful interventions for denervation atrophy would significantly expand reconstructive options for cervical SCI and could be transformative for the predominantly LMN injuries of the conus medullaris and cauda equina.

Topography of the medullary cone of Choloepus didactylus for locoregional anesthesia purposes.

Choloepus didactylus (two-toed sloth) is a Xenarthran mammal whose morphology has so far been little studied. Given the increasing number of sloths requiring clinical and surgical interventions,this lack of clarity regarding anatomical features and landmarks has had a negative impact on veterinary decision-making for this species. We therefore sought to describe the topography of the medullary cone (MC) of Choloepus didactylus in order to provide guidance to qualified professionals on the ideal access for locoregional anesthesia. In evaluating four specimens, radiographs and dissections revealed that Choloepus didactylus has three lumbar vertebrae and five sacral vertebrae. The lumbar intumescence is located between T14 and the cranial half of L2, the medullary cone is located between the caudal half of L2 and L3, with an average length of 2.26cm, and the cauda equina extends from S1 to S5. Based on these anatomical findings, we propose that the lumbosacral region would be the most suitable target for epidural anesthesia in Choloepus didactylus.