Epidural Tumor Research Articles

Tetrahedral silicon balloon for endoscopic skull base reconstruction

INTRODUCTION Advances in transnasal endoscopic approaches and the development of instrumentation and imaging technology have turned endoscopic endonasal surgery into the mainstay for treating inflammatory diseases and neoplasms involving the paranasal sinuses and skull base. The expanded endonasal approach (EEA) and its modifications provide access to the anterior skull base, planum, sphenoid, sella, clivus, cervical spine, and infratemporal fossa via the two nostrils. This approach enables endoscopic extradural and intradural tumor resection and skull base reconstruction in a single procedure. Technical advances in reconstruction methods and the development of vascularized locoregional flaps have improved our ability to seal the cranio-basal diaphragm after tumor extirpation. Use of a nasal septal flap (NSF) has reduced the rate of complications and allowed increasing numbers of patients with skull base neoplasms to undergo curative surgical resections by means of minimally invasive techniques. One drawback of this technique is the difficulty of stabilizing the multilayered reconstruction in place after its application. Currently, a 12-French Foley catheter latex balloon is used to support the multilayered reconstruction during the 1st week after surgery. The main disadvantages of this method are: 1) the balloon surface is spherical, thus providing inadequate support to the flat surfaces of the skull base; 2) decrease in the balloon’s volume due to frequent leaks may impair the support of the flap; 3) the latex balloon is weak and frequently bursts due to exposed bone chips; 4) inability to use this balloon in patients who are allergic to latex; and 5) it is inconvenient for patients because it interferes with their nasal breathing. An alternative support for skull base reconstruction that is free of these limitations is needed. In this report we describe a novel anatomically shaped graft stabilizer for endonasal skull base reconstruction.

Pure spinal epidural cavernous hemangioma

Pure epidural cavernous hemangiomas without bony involvement are rare, representing 4% of all spinal epidural tumors. Most of these are case reports and are easily misdiagnosed. Herein nine patients (male:female, 5:4, average age: 51 years) with symptomatic pure epidural spinal cavernous hemangioma between 2005 and 2011 were treated, and the clinical, radiological, and pathological records, treatment, and prognosis were discussed. All patients experienced a slowing progressive clinical course, except for one with intralesional hemorrhage. Clinical manifestations included back or radiating pain, sensorimotor deficits, and sphincters disturbance. Eight lesions were isointense on T1- and hyperintense on T2-weighted images with homogenously strongly enhancement and one was mixed signal with heterogeneous enhancement because of intratumoral hemorrhage. Hemilaminotomoy or laminotomy was performed and total resection was achieved. All patients experienced a gradual neurological improvement with no recurrence. Spinal epidural cavernous hemangioma is a benign vascular malformation that should be excluded in the diagnosis of epidural lesion. Total surgical resection is recommended and usually results in a good prognosis.

Intracranial hemorrhage following lumbar spine surgery

Intracranial hemorrhage is a serious but rare complication of spinal surgery, which can occur in the intracerebral, cerebellar, epidural, or subdural compartment. To describe patients with intracranial hemorrhage after lumbar spinal surgery and present clinical and diagnostic imaging findings. In this retrospective study, medical records of 1,077 patients who underwent lumbar spinal surgery in our tertiary referral neurosurgery center between January 2003 and September 2010 were studied. The original presentations of the patients before the surgical intervention were herniated lumbar disc, spinal canal stenosis, spondylolisthesis, lumbar spinal trauma, and lumbar spine and epidural tumor. The operations performed consisted of discectomy, multiple level laminectomy, stabilization and fusion, lumbar instrumentation, and lumbar spinal and epidural tumor resection. Four cases developed intracranial hemorrhage including acute subdural hematoma (one case), epidural hematoma (one case), and remote cerebellar hemorrhage (two cases). The clinical and diagnostic imaging characteristics along with treatments performed and outcomes of these four patients are described and the pertinent literature regarding post-lumbar spinal surgery intracranial hemorrhages is reviewed. Though rare, intracranial hemorrhage can occur following lumbar spinal surgery. This complication may be asymptomatic or manifest with intense headache at early stages any time during the first week after surgery. Dural tear, bloody CSF leakage, focal neurologic symptoms, and headache are indicators of potential intracranial hemorrhage, which should be considered during or following surgery and necessitate diagnostic imaging.

James Watson Kernohan (1896–1981): Frontiers in neuropathology

James Watson Kernohan (1896–1981): Frontiers in neuropathology

Intracranial Extramedullary Hematopoiesis in Beta-Thalassemia

Extramedullary hematopoiesis (EMH) represents tumor-like proliferation of hemopoietic tissue which complicates chronic hemoglobinopathy. Intracranial EMH is an extremely rare occurrence. Magnetic resonance imaging (MRI) offers a precise diagnosis. It is essential to distinguish EMH from other extradural central nervous system tumors, because treatment and prognosis are totally different. Herein, we report the imaging findings of beta-thalassemia in a 13-year-old boy complaining of weakness of left side of the body and gait disturbance; CT and MRI revealed an extradural mass in the right temporoparietal region.

Spinal Cord Compression by Thoracic Vertebral Hemangioma—A Case Report

A 68 year old with lower extremity numbness, vibratory sensation loss, coldness and burning of his feet, unsteady gait, frequent falls and a sensory level had an MRI demonstrating aT7 and T8 vertebral body/posterior element lesion with epidural extension, cord compression and foraminal extension (Figures 1-5). Decompressive laminectomy/resection confirmed vertebral hemangioma, a common benign neoplasm that typically remains asymptomatic, found incidentally in 10% of the population. Progressive vertebral body hemangiomas may cause cord or nerve root compression due to epidural tumor extension, expanded bone, hematoma or fracture. Radiographs demonstrate course vertical striations caused by thick trabeculae. CT in indolent lesions demonstrates fat density while compressive lesions demonstrate soft tissue density. Indolent lesions follow fat signal on MRI; symptomatic lesions are T1 isointense/T2 hyperintense. Work-up for aggressive hemangiomas includes angiography to determine vascularity, identify feeding/draining vessels and identify blood supply to the cord. Biopsy helps differentiate hemangioma, lymphoma, myeloma or metastasis. Management of symptomatic hemangiomas includes vertebroplasty for pain, radiation for pain, compression or pre-op and decompressive laminectomy for epidural disease. Embolization of feeding vessels may be performed pre-op or may be curative. Hemangioma causing cord compression and neurologic symptoms by extraosseous extension is much less common than benign hemangioma. Imaging features may suggest potential for progression.

The C2 ganglion sectioning epidural approach to craniocervical junction chordoma: A technical case report

In chordoma, complete surgical removal of the epidural tumor should be the first choice of treatment. Numerous surgical approaches to clival chordoma have been described: anterior approaches, lateral approaches, and posterolateral approaches. A multistaged operation with a combination of these approaches is generally performed. We used three approaches to remove a clival chordoma extending from the lower clivus anteriorly to the anterior perivertebral space and inferiorly to the C2 level. The epidural posterolateral approach through the vertebral artery (VA)-C2 interval space after resection of the C2 dorsal ganglion was the most effective. To our knowledge, the epidural posterolateral approach below VA, referred to as C2 ganglion sectioning epidural approach has not been reported as an independent approach in detail. We report a two-year-old girl with a lower clival chordoma which has been excised using C2 ganglion sectioning epidural approach.

Extradurale Tumoren

Approximately 50-60% of spinal tumors are extradural and depending on the origin and location are classified into tumors of the vertebrae, tumors of the epidural space and primarily extraspinal tumors growing into the spine. Presenting complaints include back pain and weakness as well as myelopathy and radiculopathy due to compression of the spinal cord or the nerve roots, respectively. Imaging of extradural tumors mostly requires both magnetic resonance imaging (MRI) and computed tomography (CT). Extradural masses and infiltration of the cord can be depicted by MRI and CT depicts osteolytic and osteosclerotic lesions and the extent of osseous involvement. Bone scintigraphy is often helpful in detecting metastases and characterizing osteoid osteomas.

Two-Stage Surgery for a Large Cervical Dumbbell Tumour in Neurofibromatosis 1: A Case Report

Spinal neurofibromas occur sporadically and typically occur in association with neurofibromatosis 1. Patients afflicted with neurofibromatosis 1 usually present with involvement of several nerve roots. This report describes the case of a 14- year-old child with a large intraspinal, but extradural tumour with paraspinal extension, dumbbell neurofibroma of the cervical region extending from the C2 to C4 vertebrae. The lesions were readily detected by MR imaging and were successfully resected in a two-stage surgery. The time interval between the first and second surgery was one month. We provide a brief review of the literature regarding various surgical approaches, emphasising the utility of anterior and posterior approaches. Neurofibromatosis 1, Dumbbell Neurofibroma, Spinal Tumour, Cervical Spine, Surgical Approach.

Minimally invasive transfrontal sinus approach to resection of large tumors of the subfrontal skull base

To review our favorable experience with a minimally invasive transfrontal sinus approach to tumors of the subfrontal region. Retrospective review in a tertiary care referral practice. Patients undergoing anterior skull base surgery by the senior author (Y.D.) were reviewed and transfrontal sinus approach patients selected for review. All cases of transfrontal sinus approaches to the base of the anterior cranial fossa from 2007 to 2011 were reviewed in a retrospective fashion. A total of 14 cases were noted. Male to female ratio was 10 to 4 with an average age of 58.2 years. The pathologies included: meningioma (n = 6), esthesioneuroblastoma (n = 3), squamous cell carcinoma (n = 3), adenocarcinoma (n = 1), and adenoid cystic carcinoma (n = 1). Five intradural and nine extradural dissections were performed. No major complications were noted, and no patients required conversion to a traditional transfacial approach or required the use of a craniotomy. Twelve patients underwent complete tumor removal, whereas two patients underwent subtotal tumor removal. Reasons for subtotal removal were not access related but rather tumor characteristic related (carotid artery wall involvement, optic chiasm involvement). Contraindication to this approach is the presence of a hypoplastic or aplastic frontal sinus. The minimally invasive transfrontal sinus approach to the subfrontal region provides ready expeditious access to the base of the anterior cranial fossa without the need for brain retraction, craniotomy or naso-orbital osteotomies. It represents an excellent alternative in the surgical access of both intra- and extradural tumors in this region of the skull base.

Image-Guided Thoracoscopic Resection of Thoracic Dumbbell Nerve Sheath Tumors

Surgical removal of dumbbell nerve sheath tumors (NSTs) remains challenging because these neoplasms occupy ≥ 2 spinal and extraspinal spaces. The presence of intraspinal extension, tumor dimension, and/or its location within the thoracic cavity have previously made the resection of these types of neoplasms difficult. To describe the feasibility of performing minimally invasive thoracoscopic surgery, as facilitated by an image guidance system (IGS), to achieve gross total resection of select dumbbell NSTs located in the thoracic spine. The 3 cases presented here contained small intraspinal or foraminal components. Preoperative symptoms included Horner syndrome and back and chest wall pain. We used IGS to help guide the complete thoracoscopic resection of select dumbbell NSTs, consisting of extradural, intraforaminal, and paravertebral tumor components, which previously would have been challenging with only a thoracoscopic approach. IGS provided continuous intraoperative anatomic orientation to achieve gross total resection in all 3 cases. All surgical and postsurgical outcomes were satisfactory; preoperative symptoms improved or resolved; and no adverse events were observed. Thoracic dumbbell NSTs that have small intraspinal or foraminal components could be resected thoracoscopically when facilitated by IGS. Image-guided thoracoscopic resection of such dumbbell tumors may not only improve the precision of resection, reduce recurrence, and avoid the need for spinal reconstruction but also obviate the need for more invasive or simultaneous posterior procedures. The IGS enhances the accuracy and safety of 2-dimensional thoracoscopic surgery and may reduce its learning curve.

Monoparesis of the leg caused by thoracic vertebral hemangioma: a case report

Monoparesis of the leg is usually caused by a lower motor neuron lesion and in rare cases, may contribute to a thoracic hemangioma. The following case is therefore thought to be worth reporting. A 55-year-old woman presented with weakness and numbness of the left leg during the previous 6 months. Neurologic examination showed left leg monoparesis (Grade 3/5) but with brisk reflexes. The findings of all other neurologic and general examinations were normal. After the symptoms progressively worsened during the following week, a magnetic resonance imaging (MRI) examination was performed. The MRI revealed an epidural tumor at the left T10 pedicle (Fig. 1). The patient underwent a T10 laminectomy, which revealed an extra-dural mass compressing the posterolateral spinal cord. Tumoral tissue was removed with, the dura remaining intact. Hemangioma was confirmed by pathological examination (Fig. 2). The postoperative course was uneventful, and the symptoms progressively improved. She was discharged 1 week after surgery, and 6 month follow up revealed no neurologic sequelae. Isolated leg proximal leg paresis can result from lesions in the primary motor cortex, the posterior limb of the internal capsule, the spinal cord or the peripheral nerves [1]. However, monoparesis limited to one lower extremity caused by a vertebral hemangioma is rare. Hemangioma is among the most common benign tumors of the spine with a reported prevalence of 10–12% in the general population [2]. The vast majority of patients with vertebral hemangioma are asymptomatic; only 0.9–1.2% are symptomatic [3]. A clinical presentation of spinal cord compression caused by vertebral hemangioma is extremely insidious. Patients typically experience back pain followed by gradually worsening neurologic symptoms over a course of several weeks to months [3]. The most common site of vertebral hemangiomas is the thoracic spine followed by the lumbar spine [4]. Vertebral hemangiomas are often discovered incidentally when screening radiographs or computed tomography (CT) scans. Histologically, hemangiomas can be classified as cavernous, capillary or mixed. In each type, blood vessels are well differentiated but vary in size [5]. Treatments for symptomatic vertebral hemangiomas, including surgery, transarterial embolization, direct ethanol injection and vertebroplasty, have varying success rates [2]. Although primary treatment with radiotherapy and ethanol injection remains controversial, radiotherapy is effective for pain control [2]. Indications for surgery include significant or progressive neurological deficit, long tract signs, neuroimaging evidence of cord compression, rapid disease progression, ineffective radiotherapy, and uncertain diagnosis [2]. In rare cases, S.-L. Hwang C.-H. Wu (&) T.-H. Tsai C.-W. Chu K.-S. Lee Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, No. 100, Tzyou 1st Road, Kaohsiung 807, Taiwan e-mail: myosinpp@yahoo.com.tw

Composite diffuse large B‐cell lymphoma and CD20‐positive peripheral T‐cell lymphoma

Composite lymphoma is defined as two or more distinct types of lymphoma in a single anatomical site. Among various combinations, composite B-cell and T-cell non-Hodgkin's lymphomas (CBTL) are very infrequent. Herein we describe a 66-year-old female with CBTL presenting with lymphadenopathy, multiple bone lesions and an epidural tumor. Light microscopic examination of a biopsied cervical node revealed a dual population of lymphoid cells: sheets of large cells admixed with medium-sized cells. The large cells expressed B-cell markers and showed immunoglobulin light chain restriction, consistent with diffuse large B-cell lymphoma (DLBCL). The medium-sized cells were positive for CD20 as well as T-cell markers. Because polymerase chain reaction amplification showed monoclonal rearrangement of the T-cell receptor β chain gene, this population was compatible with peripheral T-cell lymphoma not otherwise specified (PTCL-NOS). We therefore made a diagnosis of composite DLBCL and CD20-positive PTCL-NOS. Complete remission was achieved after six cycles of R-CHOP regimen (rituximab, doxorubicin, vincristine, cyclophosphamide and prednisolone). This is the first report of CD20-positive PTCL-NOS associated with composite lymphoma. Moreover, a literature review of composite DLBCL and PTCL-NOS indicates that this rare clinical entity may be featured by efficacy of systemic chemotherapy in spite of prevalent extranodal lesions.

Chordoma of the thoracic spine in an 89-year-old

Case report and literature review. Report the highly unusual presentation of thoracic spine chordoma in an 89-year-old and review existing literature as it impacts treatment in the elderly. Chordomas are infrequent tumors of the spine that commonly present during mid-adulthood at the spheno-occipital or sacrococcygeal junctions. The mobile spine is affected in 10-15% of cases but chordomas are extremely rare in the thoracic spine. Chordoma rarely enters the differential diagnosis of spinal tumors in elderly patients, for whom metastases and multiple myeloma are by far the most common. A case report is detailed of an 89-year-old male presenting with incapacitating pain and early signs of thoracic myelopathy. A lytic, expanding lesion of the T10 vertebral body with epidural spinal cord compression was identified. In the absence of evidence of other primary tumor, a CT-guided needle biopsy revealed chordoma. A literature review of reported thoracic spine chordomas was also performed. An intralesional posterolateral resection and reconstruction was performed with good results and no recurrence at 13 months' follow-up. 30 reports of thoracic spine chordomas were identified in the literature since 1902. Mean age of presentation at 35.7 years is earlier than for most chordomas. The oldest previously reported patient was 68-year-old. Neurological impairment at presentation is rare with the usual presenting symptom being pain. Response to radiation and chemotherapy is limited. 5-year survival rates range from 50 to 60%. Chordoma is a highly uncommon epidural neoplasm of the thoracic spine and is vanishingly rare in elderly patients. This report documents the oldest reported patient with thoracic spine chordoma at 89-year-old. Their locally aggressive behavior typically prompts consideration of aggressive surgical resection. When tailored to the individual patient, such procedures are feasible without excessive morbidity even in elderly patients.

Minimally invasive lateral extracavitary resection of foraminal neurofibromas

Nerve sheath tumors are the most common spinal tumors but extradural foraminal nerve sheath tumors are much rarer. Traditionally, these nerve sheath tumors have been resected via an open posterior approach. We describe an alternative minimally invasive (MIS) lateral extracavitary approach for resection of symptomatic extradural foraminal spinal neurofibromas. We describe three consecutive male patients (mean age, 37 years) who underwent a successful MIS lateral extracavitary approach for surgical resection of symptomatic extradural spinal neurofibromas. All patients presented with pain and two of the three presented with neurological deficit. Follow-up data, including functional and radiographic outcomes, were collected for all patients. The mean operative time, blood loss, and length of stay were 85 minutes (min) (range, 60–120 min), 150 mL (range, 100–200 mL), and two days (range, 1–3 day), respectively. There were no complications. All patients had complete resolution of their pain and motor deficits. Thus, the MIS lateral extracavitary approach is a safe and feasible alternative for resection of spinal extradural foraminal neurofibromas.

Concurrent spinal nerve root schwannoma and meningioma mimicking single‐component schwannoma

We present a first case of concurrent tumors consisting of schwannoma and meningioma arising at the same spinal level in a patient without neurofibromatosis. A 49-year-old man without clinical evidence of neurofibromatosis presented with a 5-month history of right neck pain. MRI demonstrated an extradural tumor involving the right-sided C2 nerve root with a small intradural component. T1- and T2-weighted and contrast-enhanced MRI could not differentiate the intradural tumor as different from the extradural tumor. Total removal of the tumors was performed. No contiguity of the extradural tumor with the intradural tumor was seen. The intradural tumor attached strongly to the dura mater around the C2 nerve root exits. Intraoperative pathological diagnosis confirmed the extradural tumor as schwannoma and the intradural tumor as meningioma. We therefore thoroughly coagulated the dura mater adjacent to the intradural tumor and resected the dura mater around the nerve root exits together with the tumor. Pathological examination revealed that the resection edge of the extradural component consisted of a spinal nerve with thickened epineurium and was free of neoplastic cells. No schwannoma component was evident in the intradural tumor. No obvious transition thus existed between the extra- and intradural tumors. Distinguishing these tumors prior to surgery is critical for determining an optimal surgical plan, as schwannoma and meningioma require different surgical procedures. We therefore recommend a careful review of preoperative imaging with the possibility of concurrent tumors in mind.

Epidural spinal tumor and periaortitis as rare complications of Wegener’s granulomatosis

This case report describes findings in a 61-year-old woman who manifested scleritis, small pulmonary nodules, otitis media, periaortitis, and progressive epidural spinal tumor, associated with elevated serum myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) levels. She was clinically diagnosed with Wegener's granulomatosis, although vasculitis was not diagnosed due to the lack of typical histological findings. We discuss the differential diagnosis in this patient, and the association of MPO-ANCA with periaortitis or epidural spinal tumor.

Pediatric Epidural Tumors of the Spine – Experience of a Decade from the Kashmir Valley

We present our experience after analyzing retrospectively the clinicopathological characteristics, surgical approaches, immediate and long-term postoperative complications and survival outcome of pediatric spinal epidural tumors treated over a period of 10 years from 2000 to 2009 in a tertiary-care hospital. Our study included benign and malignant tumors. The majority of our patients were boys (14:8). The duration of symptoms was longer in benign lesions. Non-Hodgkin’s lymphoma was the commonest malignant tumor and aneurysmal bone cyst was the commonest benign tumor. The mean duration of follow-up was 19 months (range 3–48 months). Most of the patients improved in their neurological grade after surgery; however, the degree of excision had no bearing on the length of survival for malignant lesions.

Use of a side-cutting aspiration device for resection of tumors during endoscopic endonasal approaches

Accessing intra- and extradural tumors via an endonasal approach requires working safely in a relatively narrow area with unobstructed visibility. The authors describe their experience to highlight the utility of a side-cutting aspiration device for endoscopic endonasal resection of skull base tumors. The authors used this device in 13 nonconsecutive endoscopic endonasal procedures for different skull base tumors (8 pituitary macroadenomas, 2 craniopharyngiomas, 1 chordoma, 1 recurrent ependymoma, and 1 lymphoma). Illustrative cases and video are presented to demonstrate its use. The instrument was easy to use and effective in the removal of the lesions presented in this series. In 10 patients (77%), gross-total resection was possible; in the other 3 patients (23%), more than 80% of the tumor was resected. No collateral tissue damage or any other complication resulted from device-related debulking or aspiration. The side-cutting tissue resector is a safe, easy to use, and effective tool for internal debulking and extracapsular dissection of nonvascularized tumors that are too firm for bimanual suction or blunt ring curette dissection. It is particularly useful when working through a deep and narrow corridor such as is encountered in endoscopic endonasal skull base surgery.

A Rare Case of Spinal Dumbbell Tanycytic Ependymoma

Case report. To report an extremely rare case of spinal dumbbell-type tanycyticependymoma. Only two previous cases of a dumbbell-type tanycyticependymoma in the spinal cordhave been reported. A 40-year-old female presented with low back pain and numbness of the left leg. Magnetic resonance imaging revealed a dumbbell tumor at the Th10-11 level that compressed the spinal cord extensively. The diagnosis of extradural dumbell spinal tumor was made, and a total tumor excision was performed with a thoracic 10-11 laminectomy. After surgery, the patient's low back pain and numbness disappeared. Detailed immunohistological examinations confirmed the diagnosis of tanycyticependymoma. At 16 months, there was no evidence of tumor recurrence and no further treatment was needed. A rare case of spinal dumbbell-type tanycyticependy-moma was presented. Detailed histologic examinations are essential to differentiate tanycyticependymoma from other tumors such as schwannoma and pilocyticastrocytoma.