Epidural Tumor Research Articles

Two cases in which 3D MRI was used to differentiate between a disc mass that mimics a tumor and neurinoma

BackgroundSince disc sequestration that mimics a tumor is rare and sometimes presents with an atypical appearance upon magnetic resonance imaging (MRI), it is often confused with other more common epidural and intradural neoplasms, particularly neurinoma. Open surgery is necessary due to the difficult of achieving a definitive diagnosis using computed tomography, MRI, and gadolinium- enhanced MRI prior to operation. Herein, we describe the use of coronal MR images of 3D fast-field echo with water selective excitation in the diagnosis of disc sequestration mimicking a tumor.Case presentationTwo patients were admitted to our hospital with back pain, radiating pain, and hypoesthesia in the right lower limb. MRI revealed tumor-like masses in the lateral recess of L3 and posterior to the body of L4. The initial diagnosis indicated disc sequestration mimicking a tumor and neurinoma. The coronal MR images of 3D fast-field echo with water selective excitation showed a clear boundary between the tumor-like mass and the nerve root. Moreover, the mass was also completely separated from the dura. Therefore, neurinoma was excluded as a possible diagnosis prior to operation. Surgical excision to perform removal of the gross mass was performed in one patient. The histopathological diagnosis was consistent with the 3D fast-field echo with water-selective excitation MRI. Another patient was successfully treated by minimally invasive endoscopic surgery.ConclusionsDisc sequestration that mimics a tumor is difficult to diagnose preoperatively. As a non–invasive strategy, coronal MR images of 3D fast-field echo with water selective excitation is a helpful imaging tool for differentiating between diagnosis of disc sequestration that mimics a tumor and neurinoma prior to operation. If the disc fragment of mimicking tumor can be identified prior to operation, open surgery may not be necessary for all patients. Minimally invasive endoscopic surgery also is an alternative strategy.

Neoplastic Myelopathies.

This article discusses the diagnosis and management of neoplasms that affect the spinal cord as well as spinal cord disorders that can occur due to cancer treatments. Neoplastic myelopathies are uncommon neurologic disorders but cause significant morbidity when they occur. Primary spinal cord tumors can be classified into intramedullary, intradural extramedullary, or extradural tumors. Diffuse gliomas and ependymal tumors are the most common intramedullary tumors. Diffuse gliomas include the World Health Organization (WHO) grade II and grade III astrocytomas, the grade II and grade III oligodendrogliomas, the grade IV glioblastomas, and newly recognized pediatric diffuse midline gliomas with H3 K27M mutation. The majority of diffuse and anaplastic astrocytomas are IDH-mutant tumors, whereas only 10% of glioblastomas are IDH-mutant. Oligodendrogliomas are typically IDH-mutant and are characterized by the molecular signature of 1p/19q codeletion. Nine distinct molecular subgroups of ependymomas have been identified based on their genetic features and location. NF2 mutations are frequently found in spinal cord ependymomas. Metastatic tumors are the most common tumors of the spine and can be extradural, leptomeningeal, or, rarely, intramedullary. Extradural metastatic spinal cord compression is a neurologic emergency and should be promptly diagnosed as pretreatment neurologic status dictates the posttreatment outcome. Neoplastic myelopathies encompass many diagnoses ranging from benign and malignant spinal tumors to paraneoplastic syndromes heralding cancers. The knowledge of the clinical features and management of neoplastic myelopathies is essential to practicing neurologists as early diagnosis and treatment can prevent devastating neurologic sequelae.

Risk Factors for Thirty-Day Morbidity and Mortality in Extradural Lumbar Spine Tumor Resection.

Epidural tumors in the lumbar spine represent a unique cohort of lesions with individual risks and challenges to resection. Knowledge of modifiable risk factors are important in minimizing postoperative complications. To determine the risk factors for 30-day morbidity and mortality in patients undergoing extradural lumbar tumor resection. A retrospective study of prospectively collected data using the American College of Surgeons National Quality Improvement Program database was performed. Adults who underwent laminectomy for excision of lumbar spine tumors between 2011 and 2014 were included in the study. Demographics and medical comorbidities were collected, along with morbidities and mortalities within 30 postoperative days. A multivariate binary logistic analysis of these clinical variables was performed to determine covariates of morbidity and mortality. The database search yielded 300 patients, of whom 118 (39.3%) were female. Overall, complications within 30 days of surgery occurred in 102 (34%) patients. Significant risk factors for morbidity included preoperative anemia (P < 0.0001), the need for preoperative blood transfusion (P= 0.034), preoperative hypoalbuminemia (P=0.002), American Society of Anesthesiologists score 3 or 4 (P= 0.0002), and operative time >4 hours (P < 0.0001). Thirty-day mortality occurred in 15 (5%) patients and was independently associated with preoperative anemia (odds ratio 3.4, 95% confidence interval 1.8-6.5) and operative time >4 hours (odds ratio 2.6, 95% confidence interval 1.1-6.0). Excision of epidural lumbar spinal tumors carries a relatively high complication rate. This series reveals distinct risk factors that contribute to 30-day morbidity and mortality, which may be optimized preoperatively to improve surgical safety.

Population description and clinical response assessment for spinal metastases: part 2 of the SPIne response assessment in Neuro-Oncology (SPINO) group report.

Approximately 40% of metastatic cancer patients will develop spinal metastases. The current report provides recommendations for standardization of metrics used for spinal oncology patient population description and outcome assessment beyond local control endpoints on behalf of the SPIne response assessment in Neuro-Oncology (SPINO) group. The SPINO group survey was conducted in order to determine the preferences for utilization of clinician-based and patient-reported outcome measures for description of patients with spinal metastases. Subsequently, ClinicalTrials.gov registry was searched for spinal oncology clinical trials, and measures for patient description and outcome reporting were identified for each trial. These two searches were used to identify currently used descriptors and instruments. A literature search was performed focusing on the measures identified in the survey and clinical trial search in order to assess their validity in the metastatic spinal tumor patient population. References for this manuscript were identified through PubMed and Medline searches. Published literature, expert survey, and ongoing clinical trials were used to synthesize recommendations for instruments for reporting of spinal stability, epidural tumor extension, neurological and functional status, and symptom severity. Accurate description of patient population and therapy effects requires a combination of clinician-based and patient-reported outcome measures. The current report provides international consensus recommendations for the systematic reporting of patient- and clinician-reported measures required to develop trials applicable to surgery for spinal metastases and postoperative spine stereotactic body radiotherapy (SBRT).

Abstract No. 491 Simultaneous bipedicular radiofrequency ablation for local tumor control of vertebral metastases

To evaluate the safety and effectiveness of simultaneous bipedicular radiofrequency ablation (RFA) for local tumor control of vertebral metastases. Thirty-five spinal lesions in 29 patients were treated, of which 31/35 (89%) and 19/35 (54%) involved the posterior vertebral body and pedicle, respectively. Sixty percent of the lesions involved 75% or more of the vertebral body. Lesions were treated with two articulating, navigational bipolar RFA probes (STAR, Merit) simultaneously to allow more confluent overlapping ablation zone to encompass as much vertebral body volume as possible while minimizing risk of thermal injury and impedance by using variable wattage (3, 5, 7.5, or 10 watts). Mean total ablation times per probe were 18.3 minutes (range, 9.9–29.3) with overlapping ablations zones performed anteriorly, posteriorly, and within the pedicle. Postablation cementoplasty was performed in all cases via the same introducer cannula. Complications were assessed based on the Society of Interventional Radiology classification. Postprocedure local tumor control was defined as the absence of residual enhancement on contrast-enhanced MRI, radiotracer activity on PET, or stability of osteolysis on CT. All lesions were successfully ablated without any complications or thermal injury. Of the 28 lesions with postprocedure imaging, local tumor control was observed in 96% (27/28) of cases at a mean follow-up of 12.7 weeks (range, 1–48). Retraction of epidural tumor was seen in 3 cases. Simultaneous bipedicular RFA is safe and effective in the treatment of vertebral metastases, including those involving the posterior vertebral body and pedicle. This novel technique supports the stereotactic spine radiation surgery paradigm to treat the entire vertebral body and pedicles (i.e. clinical target volume) to account for microscopic disease and marginal failures for better local tumor control rates and more durable pain relief.

Sudden paraplegia due to spontaneous bleeding in a thoracic epidural angiolipoma and literature review

BackgroundSpinal angiolipomas are rare epidural tumours that are usually revealed by chronic symptoms of medullar irritation. We report a case of acute paraplegia caused by spontaneous bleeding revealing a thoracic angiolipoma. Case descriptionA 17-year-old male patient with no previous medical history was admitted for acute onset of paraplegia with bladder retention and loss of sensation in the lower limbs, preceded by dorsal pain during the three previous days. MRI showed an enhanced T1-weighted image of a T7–T12 epidural lesion. The T1-weighted isosignal and the T2-weighted hyposignal suggested haemorrhagic complications. Due to a mass effect on the spinal cord, an emergency laminectomy was performed. Histopathological examination of the lesion revealed an angiolipoma with spontaneous bleeding. Clinical outcome was favourable after two months. ConclusionThis case is one of the first to be reported, although the clinical presentation is similar to that of other rare reported cases of paraplegia due to spinal compression by tumoural bleeding.

Age Stratification of 30-Day Postoperative Outcomes Following Excisional Laminectomy for Extradural Cervical and Thoracic Tumors.

Study Design:Retrospective cohort study.Objectives:To evaluate age as an independent predictive factor for perioperative morbidity and mortality in patients undergoing surgical decompression for metastatic cervical and thoracic spinal tumors using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011 to 2014.Methods:We identified 1673 adult patients undergoing excisional laminectomy of cervical and thoracic extradural tumors. Patients were stratified into quartiles based on age, with Q1 including patients aged 18 to 49 years, Q2 including patients aged 50 to 60 years, Q3 including patients aged 61 to 69 years, and Q4 including patients ≥70 years. Univariate and multivariate regression analyses were performed to examine the association between age and 30-day perioperative morbidity and mortality.Results:Age was an independent risk factor for 30-day venous thromboembolism (VTE) and reoperation. Patients in Q3 for age had nearly a 4 times increased risk of VTE than patients in Q1 (odds ratio [OR] 3.97; 95% CI 1.91-8.25; P < .001). However, there was no significant difference in VTE between patients in Q4 and Q1 (P = .069). Patients in Q2 (OR 1.99; 95% CI 1.06-3.74; P = .032) and Q4 (OR 2.18; 95% CI 1.06-4.52; P = .036) for age had a 2 times increased risk of reoperation compared with patients in Q1.Conclusions:Age was an independent predictive factor for perioperative VTE and reoperation, but there was no clear age-dependent relationship between increasing age and the risk of these perioperative complications.

Acute epidural hematoma due to spinal venous angioma: A case report

Abstract Background Spinal epidural cavernous angioma was reported about 4% of all spinal epidural tumors, mostly generating as a primary lesion in the vertebral bone. Spinal epidural hematoma (SEDH) due to angioma without primary origin was very rare, which reported in the English literatures was only 10 cases including our case. The main symptoms were numbness and pains and motor weakness owing to the acute compression signs of cord and roots. Emergency surgical treatment was required for the good surgical results. We present a rare case of cervical acute epidural hematoma due to ruptured venous angioma. Case presentation A 78-year-old man, who suffered from sudden severe right suboccipitalgia., and sent to our hospital. He also noticed progressive numbness and motor weakness over his bilateral upper and lower extremities after the onset. Cervical CT and MRI showed acute intracanal hematoma over the right side of the cervical spine at C2 to C6. Emergency operation was performed 13 h after the onset. His sensory and motor symptoms were disappeared quickly after the operation. Pathological examination revealed spinal epidural hematoma due to venous angioma. Conclusion This case presented with acute progressive deterioration of paresis and sensory disturbance, and required emergency operation. Early diagnosis and emergency surgical treatment are essential for the therapy of acute spinal epidural hematoma due to venous angioma.

Spinal Metastasis of Unknown Primary Accompanied by Neurologic Deficit or Vertebral Instability.

Spinal bone metastases are common. They are mostly localized to the lumbar, thoracic, and cervical spine. The most common primaries to result in spinal metastases include lung, breast, and prostate carcinomas in adults as opposed to leukemia, Ewing sarcoma, rhabdomyosarcoma, and neuroblastoma in children. In patients diagnosed with cancer, bone metastases are found in 40% and spinal metastases in 10%. In this study, we reviewed 25 patients diagnosed with a spinal metastasis of unknown primary who presented with low back pain or acute-onset neurologic deficits and underwent operative treatment. The retrospective study included 25 patients with a spinal metastasis of unknown primary who presented to our clinic with acute-onset vertebral fracture or neurologic deficit. Statistical descriptions were obtained for each patient. Survival analysis was performed using the Kaplan-Meier method. The 25 patients included 17 men (68%) and 8 women (32%), with a mean age of 55 years (range, 14-81 years). Eleven patients (44%) presented with varying degrees of motor deficits ranging from flaccid paralysis to paraplegia. Motor deficits were completely reversed in 4 patients postoperatively. The tumors were localized to the upper thoracic spine (T1-4) in 2 patients, in the midthoracic spine (T5-8) in 2 patients, in the lower thoracic spine (T9-12) in 8 patients, in the cervical 7 in 1 patient, and in the lumbar spine in 12 patients. In 10 patients, the tumor affected multiple spinal regions. Nonosseous tumors were not present in 10 patients. Ten patients had an extradural tumor. Costal involvement was detected in 2 patients. The tumors were pathologically identified as lung cancer (n= 3), lymphoma (n= 5), breast cancer (n= 3), gastric cancer (n= 2), liver cancer (n= 2), prostate cancer (n= 2), renal cell carcinoma (n= 2), malignant melanoma (n= 1), plasmacytoma (n= 1), bladder cancer (n= 1), paraganglioma (n= 1), Ewing sarcoma (n= 1), and yolk sac carcinoma (n= 1). Posterior instrumentation was performed in patients with instability. In addition, decompression was performed in patients with neurologic deficit. Considering that 10% of patients with cancer are diagnosed by vertebral metastasis, presence of malignancy should be suspected and a detailed examination should be performed in patients presenting with vertebral fractures caused by no or minor trauma. Moreover, in patients presenting with neurologic deficit, soft tissue metastases leading to spinal cord compression should be kept in mind and further examinations should be promptly administered.

APPLICATION OF THE APPARENT DIFFUSION COEFFICIENT IN PREOPERATIVE ASSESSMENT OF THE PROLIFERATIVE POTENTIAL OF SPINAL TUMORS

Objective. To analyze and compare the measured values of apparent diffusion coefficient (ADC) in tumors of the spinal canal with cell density and Ki-67 index of proliferative activity. Material and Methods . The study included diffusion-weighted MR images of 36 patients with different types of tumors of the spinal canal. In the morphological study of tumors, the degree of malignancy according to the WHO classification, the value of the Ki-67 index, and cell density were assessed. Results . The average ADC of the extradural tumors G = I–II and G = III–IV was 1390.0 ± 94.8 mm2/s and 821.3 ± 111.1 mm2/sec, respectively. For intradural extramedullary neoplasms G = I–II, the ADC was 1328.7 ± 172.1 mm2/sec, for G = III – 957.6 ± 50.7 mm2/sec. Intramedullary tumors G = I–II had an average ADC value of 1604.6 ± 28.7 mm2/sec, and tumors G = III – 1066.5 ± 74.2 mm2/sec. For extradural tumors G = I–II, the Ki-67 index varied from 2 to 4 %, and for tumors G = III–IV – from 12 to 27 %; in the group of intradural extramedullary tumors G = I–II – from 1 to 5 %, for tumors G = III – from 7 to 11 %; for intramedullary tumors G = I–II – from 2 to 6 %, and for G = III tumors – from 7 to 19 %. Conclusion . The diffusion-weighted MRI with ADC counting can be used as an additional non-invasive method for preoperative evaluation of the proliferative potential of a number of spinal canal tumors.

A rare case of metastatic extramammary Paget disease of the spine and review of the literature

Extramammary Paget disease is an intraepithelial neoplasm affecting cells rich in apocrine glands-often located in the vulvar, scrotal, or perianal region. It typically affects older patients, between the ages of 50 and 80years old, and is most often limited to the epidermis. A 47-year-old Asian male first presented with enlargement of the right inguinal lymph node. A subsequent biopsy revealed extrammamary Paget disease of the scrotum. The patient eventually developed significant worsening back pain with bilateral lower extremity numbness and weakness three months later. Imaging demonstrated a pathologic compression fracture of the L4 vertebral body with metastatic epidural spinal cord compression. The patient underwent surgical decompression of the spine with bilateral L4 laminectomy, resection of epidural tumor, and pedicle screw fixation from L2 to S1. Surgical pathology demonstrated metastatic adenocarcinoma consistent with extramammary Paget disease. Although two other case reports have described spinal metastases from extramammary Paget disease, to the author’s knowledge, this represents the first report of surgical decompression and fusion for extramammary Paget disease of the spine.

Transorbital endoscopic approach for exposure of the sylvian fissure, middle cerebral artery and crural cistern: an anatomical study.

The availability of minimal access instrumentation and endoscopic visualization has revolutionized the field of minimally invasive skull base surgery. The transorbital endoscopic approach using an eyelid incision has been proposed as a new minimally invasive technique for the treatment of skull base pathology, mostly extradural tumors. Our study aims to evaluate the anatomical aspects and potential role of the transorbital endoscopic approach for exposure of the sylvian fissure, middle cerebral artery and crural cistern. An anatomical dissection was performed in four freshly injected cadaver heads (8 orbits) using 0- and 30-degree endoscopes. First, an endoscopic endonasal medial orbital decompression was done to facilitate medial retraction of the orbit. An endoscopic transorbital approach through an eyelid incision, with drilling of the posterior wall of the orbit and lesser sphenoidal wing, was then performed to expose the sylvian fissure and crural cisterns. A stepwise anatomical description of the approach and visualized anatomy is detailed. A superior eyelid incision followed by orbital retraction provided a surgical window of approximately 1.2cm (range 1.0-1.5cm) for endoscopic transorbital dissection. The superior (SOF) and inferior (IOF) orbital fissures represent the medial limits of the approach and are identified in the initial part of the procedure. Drilling of the orbital roof (lateral and superior to the SOF), greater sphenoidal wing (lateral to the SOF and IOF) and lesser sphenoidal wing exposed the anterior and middle fossa dura. A square-shaped dural opening provided visualization of the posterior orbital gyri, sylvian fissure and temporal pole. Intradural dissection allowed exposure of the sphenoidal portion of the sylvian fissure, M1, MCA bifurcation and M2 branches and lenticulostriate perforators. Dissection of the medial aspect of the sylvian and carotid cisterns with a 30-degree endoscope allowed exposure of the mesial temporal lobe and crural cistern. The transorbital endoscopic approach allows successful exposure of the sphenoidal portion of the sylvian fissure and M1 and M2 segments of the middle cerebral artery. Angled endoscopes may provide visualization of the mesial temporal lobe and crural cistern. Although our anatomical study demonstrates the feasibility of intradural dissection and closure via an endoscopic transorbital approach, further studies are necessary to evaluate its role in the clinical scenario.

Incidental durotomy during total en bloc spondylectomy

Background ContextThe incidence of incidental durotomy (ID) during total en bloc spondylectomy (TES) tends to be higher than that during other spinal surgeries because of the peculiarities of TES, including its highly invasive nature, epidural tumor extension, and use in patients who often have complicated medical backgrounds. However, there have been no detailed reports on ID associated with TES. PurposeThe study aimed to investigate ID during TES in detail. Study DesignThis is a retrospective review of prospectively collected data. Patient SampleThe study included 105 consecutive patients with spinal tumor who underwent TES between May 2010 and February 2015 (59 men, 46 women; mean age, 54.0 years [range, 14–75 years] at the time of surgery). Outcome MeasuresOutcome measures included the incidence, risk factors, anatomical location, intraoperative maneuvers, and postoperative course of ID associated with TES. Materials and MethodsMedical and operative records and imaging findings were reviewed. Univariate analysis and multivariable stepwise logistic regression models were used to identify independent risk factors for ID. ResultsIncidental durotomy occurred in 18 (17.1%) of the 105 patients. The univariate and multivariate analyses demonstrated that older age (adjusted odds ratio [aOR], 6.09; 95% confidence interval [CI], 1.17–31.76; p=.03), radiotherapy (RT) history (aOR, 5.31; 95% CI, 1.46–19.49; p=.01), and revision surgery (aOR, 19.42; 95% CI, 3.46–109.14; p<.01) were independent risk factors for ID. Incidental durotomy was more likely to occur during dissection of tumor tissues in proximity to the nerve root. Although all of the ID cases were primarily sutured and covered with polyglycolic acid mesh and fibrin glue spray, eight cases required additional intervention because of intractable postoperative cerebrospinal fluid leakage. Six of these eight had a history of RT. ConclusionsOur results may help better identify high-risk patients for ID during TES, which may aid surgeons with optimal surgical decision making and in counseling patients on perioperative complications.

Extradural spinal schwannoma in a 5 year old non NF child: A rare entity

Abstract Pediatric spinal schwannomas constitute 2.5-4% of all pediatric spinal tumors. They often occur in the setting of neurofibromatosis type 2 (NF-2) and are almost always intradural (with/without dumbbell extension). Rarely are they confined to extradural space alone. Till date only one case of totally extradural lumbosacral schwannoma in a non NF child has been reported. We here report the second case of totally extradural spinal schwannoma in a non NF child. A five year old female child presented with progressively increasing paraperesis and bladder symptoms, with no clinical features of Neurofibromatosis type I or II. Imaging revealed a dorsolumbar extradural lesion from DV11 to LV1. Patient underwent laminoplasty with total excision of tumour. Intraoperatively, the tumor was confined to extradural space alone. Histopathology confirmed Schwannoma. This case highlights that possibility of schwannomas should be considered as a differential diagnosis for intraspinal extradural tumors even in children without NF.

Monitoring rate and predictability of intraoperative monitoring in patients with intradural extramedullary and epidural metastatic spinal tumors.

Single-center retrospective study. To evaluate the monitoring rate, sensitivity and specificity of intraoperative monitoring (IOM) during removal of intradural extramedullary (IDEM) or epidural metastatic spinal tumors. Also, to assess the efficacy of monitoring somatosensory-evoked potentials (SSEP) when motor-evoked potentials (MEP) are not measurable. The Neuro-Oncology Clinic, National Cancer Center, Korea. Patients (n=101) with IDEM or epidural metastatic spinal tumors at the cord level underwent surgeries monitored with SSEP and/or MEP. The monitoring rate was defined as negative when MEP or SSEP could not be measured after reversal of the neuromuscular block under general anesthesia. Positive IOM changes included more than a 50% change in the MEP or SSEP amplitude and more than a 10% delay in SSEP latency. MEP was measurable in 73% of patients. The MEP monitoring rate in patients with motor power grades of 3 or less was 39%, which was lower than that of SSEP (83%). The sensitivity, specificity and predictability of MEP for motor changes were 93, 90 and 91%, respectively. Conversely, the sensitivity, specificity and predictability of SSEP were 62, 97 and 89%, respectively. In patients in whom MEP was not measurable (n=24), SSEP was monitored with a predictability of 83%. In cases of extramedullary spinal tumors, MEP shows a higher sensitivity than SSEP does. However, the monitoring rate of MEP in non-ambulatory patients was lower than that of SSEP. In those cases, SSEP can be useful to monitor for postoperative neurological deficits.

Curcumin alleviates lumbar radiculopathy by reducing neuroinflammation, oxidative stress and nociceptive factors.

Current non-surgical treatments for lumbar radiculopathy [e.g. epidural steroids and Tumour necrosis factor-α (TNF-α) antagonists] are neither effective nor safe. As a non-toxic natural product, curcumin possesses an exceptional anti-inflammatory profile. We hypothesised that curcumin alleviates lumbar radiculopathy by attenuating neuroinflammation, oxidative stress and nociceptive factors. In a dorsal root ganglion (DRG) culture, curcumin effectively inhibited TNF-α-induced neuroinflammation, in a dose-dependent manner, as shown by mRNA and protein expression of IL-6 and COX-2. Such effects might be mediated via protein kinase B (AKT) and extracellular signal regulated kinase (ERK) pathways. Also, a similar effect in combating TNF-α-induced neuroinflammation was observed in isolated primary neurons. In addition, curcumin protected neurons from TNF-α-triggered excessive reactive oxygen species (ROS) production and cellular apoptosis and, accordingly, promoted mRNA expression of the anti-oxidative enzymes haem oxygenase-1, catalase and superoxide dismutase-2. Intriguingly, electronic von Frey test suggested that intraperitoneal injection of curcumin significantly abolished ipsilateral hyperalgesia secondary to disc herniation in mice, for up to 2 weeks post-surgery. Such in vivo pain alleviation could be attributed to the suppression, observed in DRG explant culture, of TNF-α-elicited neuropeptides, such as substance P and calcitonin gene-related peptide. Surprisingly, micro-computed tomography (μCT) data suggested that curcumin treatment could promote disc height recovery following disc herniation. Alcian blue/picrosirius red staining confirmed that systemic curcumin administration promoted regeneration of extracellular matrix proteins, visualised by presence of abundant newly-formed collagen and proteoglycan content in herniated disc. Our study provided pre-clinical evidence for expediting this natural, non-toxic pleiotropic agent to become a new and safe clinical treatment of radiculopathy.

Giant cell tumor of the thoracic spine completely removed by total spondylectomy after neoadjuvant denosumab therapy

Denosumab, a novel monoclonal antibody that targets the receptor activator of nuclear factor-κB (RANK) ligand (RANKL), has recently been used to treat patients with giant cell tumor of bone (GCTB). However, few reports have described the clinical results of denosumab therapy for spinal GCTB and evaluated treatment efficacy with respect to the entirety of the resected vertebra after denosumab therapy. We present the case of a 51-year-old man with T12 GCTB that was completely removed by a total spondylectomy following 10 courses of neoadjuvant denosumab therapy. Post-therapy radiological findings indicated epidural tumor reduction in the spinal canal and sclerotic rim formation. However, the affected vertebra collapsed despite denosumab therapy and a massive bridging callus formation was present between the spinal GCTB and adjacent vertebra. These morphological changes made the tumor margins unclear and increased the difficulty of dissection of the segmental arteries from the vertebral body and en bloc corpectomy by a posterior-approach. Pathological findings indicated increased woven bone at the peripheral lesion of the resected vertebra and RANKL-positive stromal cells remained around the woven bone. These findings support that GCTB stromal cells survived around the newly formed woven bone after long-term denosumab treatment and total surgical resection of such primary spinal lesions as the gold-standard treatment, even following administration of denosumab. Surgeons should note that prolonged adjuvant denosumab therapy may increase the difficulty of performing a posterior-approach total en bloc spondylectomy.

İhmal edilmiş bir dev servikal intradural extramedüller tümör

Primary spinal tumors are rarely seen, and representing 4-8% of all central nervous system tumors. Extradural tumors constitute approximately 40% of intraspinal tumors whereas intradural-extramedullary tumors make up the remaining approximately 60%. These tumors are classified as extradural, intradural, extramedullary, and intramedullary depending on their origin and anatomic location. Intradural extramedullary spinal tumors form schwannomas and meningiomas. Spinal meningiomas are usually intradural extramedullary tumors. Meningiomas can be seen in epidural localization, extradural extension only, with nerve rostral invasion as, vertebral meningioma, or as multiple spinal meningioma. Spinal meningiomas are the most common intradural-extramedullary tumors and are generally slow-growing. Spinal meningiomas may have different clinical manifestations depending on their location and size. Surgical treatment should be planned according to the size of the tumor in the clinical situation after diagnosis. This study reports the case of a 57-year-old female patient presenting with a one-month history of increasing weakness in the lower extremities and numbness in the upper extremities. In addition, the report includes a literature review.

Clinical outcomes of posterior spinal stabilization with rigid vertical strut and spinal process wires (the Adeolu's technique) in a developing country.

IntroductionConventional instrumentation for spinal stabilization is beyond the reach of many patients in developing countries. A low-cost and easily-available method of spinal stabilization using vertical struts and spinal process wires (Adeolu's technique) was recently introduced in Nigeria. We describe the clinical outcomes of a prospective series of patients managed using the technique.MethodsFrom 2011 to 2012, we performed posterior spinal stabilization in eighteen patients using the technique. Primary outcomes were radiological evidence of rigid stabilization and mobilization without restrictions referable to the procedure in the immediate post-operative period. Implant rotation, migration, back-out, fracture, wound infection, worsening neurological status and need for implant removal were secondary measures. Overall patient satisfaction was assessed using a five-point Likert scale. The average follow-up period was 11.6 months.ResultsThe average age of the patients was 45.8 years. Trauma with unstable spinal fractures (11), spondylosis (5), and thoracic extra-dural tumour (2) were the indications for surgery. The average number of spinal levels stabilized was 6. All patients had satisfactory primary outcomes. Implant rotation occurred in 3 patients (16.7%). There was no case of implant migration, back-out or fracture. Superficial surgical site infection occurred in one patient. There was no need to remove the implant in any subject and none had post-operative worsening of neurological status. The overall patient satisfaction was good with 17 patients (94.4%) reporting “highly satisfied” or “satisfied” with the surgical procedure.ConclusionThe technique offers utility in a wide range of spinal pathologies and short-term clinical outcomes are good.

Primary Spinal Epidural B-Lymphoblastic Lymphoma

Extranodal lymphomas constitute 20% to 30% of all non-Hodgkin's lymphomas. The common sites involved are skin, stomach, brain, and small intestine. Epidural localization is a rare site for lymphomas, accounting for 10% of spinal epidural tumors. Lymphomas occurring primarily in the epidural space without other previously detected lymphomatous foci (i.e., primary spinal epidural lymphomas) represent an even rarer entity. We report a case of primary spinal epidural B-lymphoblastic lymphoma. The patient presented with paraparesis, and a spinal epidural lesion was diagnosed. Considering the rapidity of symptom onset, the possibility of epidural abscess was considered, and he underwent partial laminectomy with decompression of the lesion. Histopathology and immunohistochemistry were diagnostic of B-lymphoblastic lymphoma. The present case is the first report in the literature of B-lymphoblastic lymphoma presenting as a spinal epidural lesion.