Extradural Component Research Articles

Results of surgical treatment of posterior cranial fossa meningiomas

Surgery of meningiomas of the posterior cranial fossa, due to its small volume and close anatomical relationship of neoplasms with the brain stem, cranial nerves, main arteries and venous collectors, remains one of the urgent problems of neurooncology. Despite the improvement of microsurgical techniques and neurophysiological control, maintaining a high level of quality of life after radical removal of meningiomas is still far from desired. Purpose of the study. Retrospective analysis and generalization of clinical results of surgical treatment of patients with meningiomas of the posterior cranial fossa. Material and methods. The paper analyzes the results of surgical treatment of 101 patient with meningiomas of the posterior cranial fossa of various localization (80 women (79.2 %) and 21 men (20.7 %), age 58.26 ± 1.00 years). According to the localization of meningiomas, they were distributed as follows: convexital – 49 (48.5 %), cerebellopontine angle – 22 (21.8 %), jugular foramen – 4 (4 %), petroclival – 16 (15.8 %), foramen magnum – 10 (9.9 %). Results. All patients underwent surgical removal of the formation. In 99 (98 %) one-stage and in 2 (1.9 %) cases of additional surgical intervention, in the form of external drainage according to Arendt and ventriculoperitoneal shunting, due to frolicking liquorodynamic disorders. Radical removal of meningioma (grade I according to Simpson scale) was achieved in 72 (71.3 %) of cases, tumor resection with coagulation of the tumor matrix zone (Simpson II) – in 21 (20.8 %), removal without resection and coagulation of the matrix, or leaving the extradural component of meningiomas (Simpson III) – in 8 (7.9 %). Conclusions. The results obtained on the basis of the complex use of modern neuroimaging diagnostic tools, microneurosurgery, optimal surgical approaches in combination with the mandatory intraoperative physiological control of the function of the brain stem and cranial nerves in the early postoperative period indicate an improvement in the functional state, and sometimes complete regression of the neurological symptoms in 58 (57.4 %) of operated patients. Complete regression of symptoms and restoration of the functional state was achieved in 30 (29.7 %) of cases, deterioration was noted in 17 (16.8 %) of the operated patients, mortality was 4.95 % (n = 5).

Minimally Destabilizing Corridor for Resection of Dumbbell Nerve Sheath Tumors: A Novel Surgical Technique.

Current surgical strategies for dumbbell nerve sheath tumors (DNSTs) with cord compression have primarily involved wide spinal exposures with total laminectomy and unilateral facetectomy, often leading to spinal destabilization and requiring fusion, or staged procedures separately addressing the intraspinal and extraforaminal tumor components. This study highlights technical nuances of a novel approach for DNST resection to minimize spinal destabilization and avoid fusion while facilitating safe, single-stage complete resection. A retrospective chart review was conducted on patients undergoing DNST resection. Using unilateral subperiosteal dissection, hemilaminotomy and medial facetectomy procedures are performed. The extradural tumor component is resected, followed by internal decompression of the intradural tumor. A small horizontal incision at the origin of the nerve root sleeve releases the underlying dural stricture, facilitating delivery of the remaining intradural tumor and allowing section of the nerve root of origin. Ultrasonography confirms complete tumor resection and return of cord pulsation, and excludes intradural hemorrhagic complications. The dura is reconstructed using a dural substitute bolstered with fat graft and sealant. Twelve consecutive patients undergoing this approach from 2014 to 2021 were included. Mean patient age was 53.5 years, and 58.3% were male. Nine tumors were cervical and 3 were lumbar. Five patients presented with myelopathy, 4 with radiculopathy, and 4 with axial pain. Two cases had transient intraoperative neuromonitoring signal changes. Eleven tumors were diagnosed as schwannomas and 1 as neurofibroma. All patients had complete resection of the intraspinal component; 2 had far distal extraforaminal residual. No patient has had recurrence, progression of residual, or signs of spinal instability during follow-up (median 28.5 months, range 6-66 months). This study highlights technical considerations for DNST resection, focusing the approach at the center of the tumor, with minimal bone removal and ligamentous disruption. Intraoperative ultrasound is instrumental in the safety of this approach.

C2 Nerve Sheath Tumors: An Analysis of Radiological – Intraoperative Concordance for Intradural Extension and Systematic Review

Background: Nerve sheath tumors (NSTs) of C2 nerve-root are clinically and radiologically distinct from NSTs of rest of the spine. On imaging, they appear to have a major intradural component in addition to the large extradural part. Thus, they may require durotomy with its possible added complications. Objective: The aim of this study is to evaluate the radiological – intra-operative discordance for intradural component and need for tailored durotomy for complete resection of C2 NSTs. Material and Methods: We retrospectively analyzed 14 consecutively operated patients of C2 NSTs over the past 10 years (2013-2023). Dura was opened in patients where there was a radiological or intra-operative suspicion of intradural extension. Results: Mean(±SD) age at presentation was 37.5(±13) years, with no gender predominance (Male:Female-1.3:1). Dura was opened in 7(50%) patients. On preoperative radiological study, all the patients had a dominant extradural tumor, while 7(50%) patients appeared to have an intradural tumor extension also. Intra-operatively, 5(35.7%) of these 7 patients had only extradural component, while 2(14.3%) patients had an intradural extension. 7(50%) patients had extradural tumor radiologically, while only one patient was found to have a small intradural extension intraoperatively. Thus, only 21.4% of the patients (n=3) were found to have an intradural extension as against 50%(n=7) predicted on imaging. Post-operatively there was clinical improvement in all 14 patients (100%). Conclusions: Due to radiological and intra-operative discordance in intradural tumor extension, decision for midline durotomy should be taken following excision of extradural component. Thus, limiting the number of unnecessary midline-durotomies.

ROLE OF MAGNETIC RESONANCE IMAGING IN THE EVALUATION OF SPINAL CORD LESIONS IN A TERTIARY CARE HOSPITAL, HYDERABAD

Background: Using other imaging modalities, subtle bone marrow, soft tissue, and spinal cord abnormalities, which may not be apparent, can be readily detected on magnetic resonance imaging (MRI). Prompt and accurate diagnosis, expeditious management, and avoidance of unnecessary procedures are achieved by early detection. Aim: The aim is to study the role of MRI in diagnosing spinal cord lesions. Methods: This study was conducted during the period from November 2018 to November 2020 and it is a prospective descriptive study of 50 patients who were referred to the Department of Radiodiagnosis Osmania General Hospital and MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana. Results: In the present study of 50 cases, different spinal cord lesions were found. The most common spinal cord lesions were neoplastic (38%) followed by spinal cord trauma (28%), and congenital lesions (16%). The most common spinal lesions were found in the 20–29 age group (40%), with more male predilection of 72% in comparison to 28% female in the present study. Out of 19 neoplastic lesions, the most common type of intramedullary spinal cord tumor (IMSC) is ependymoma (31.5%). The second most common IMSC tumor is astrocytoma 15.7% of all neoplastic lesions in the present study and the most common tumor among children. The most common location of the lesion is the thoracic cord. Hemangioblastomas constitute 10.5% of all spinal cord tumors in the present study. Meningiomas which are intradural extramedullary lesions constituted 10.5%. Neurofibroma constituted 5.2% which are intradural extramedullary with extradural component noted in NF1. Spinal cord metastasis constituted 26.3%. Intradural intramedullary lesions constituted 48% followed by extradural lesions 40% followed by intradural extramedullary lesions 12%. Conclusion: MRI by virtue of non-invasiveness, lack of radiation hazard, and the ability to demonstrate structural changes is an investigation of choice for spinal cord pathologies. The ability to image the cord directly rather than indirectly as in myelography, the absence of bone artifacts as in computed tomography, and the multiplanar capabilities indicate that MRI is the procedure of choice in the examination of the spinal cord.

Diagnosis and Management of Tethered Cord Syndrome.

Tethered cord syndrome is a condition in which the spinal cord is tethered by pathological structures such as a tight filum terminale, intradural lipomas with or without a connecting extradural component, intradural fibrous adhesions, diastematomyelia, and neural placode adhesions following closure of a myelomeningocele.It usually occurs in childhood and adolescence as the spine grows in length, but it can also develop in adulthood. Symptoms of tethered cord syndrome are slowly progressive and varied. Incorrect diagnosis and inappropriate treatment may be provided if the physician lacks knowledge and understanding of this disease.This chapter aims to describe the pathophysiology, syndromes, diagnostic imaging, surgical treatment, and prognosis of tethered cord syndrome to enhance the understanding of this condition.

Beklenmedik bir lokalizasyonda ortaya çıkan primer mediastinal büyük B hücreli lenfoma

Primary mediastinal large B-cell lymphoma (PMLBCL) is a mature aggressive large B-cell lymphoma of putative thymic B-cell origin arising in the mediastinum, with distinctive clinical, immunophenotypic, genotypic, and molecular features. Cases that arise outside the mediastinum are very uncommon. A 27-year-old woman presented with mass which had an extramedullary, extradural component at the right T5-6 foramina indenting to the spinal canal, extending craniocaudally from the middle mediastinum to the level of the aortic hiatus. Pathological examination of the mass revealed atypical lymphoid cells with medium-large size, eosinophilic and clear cytoplasm In our case CD23 and MAL expression with morphological findings supported PMLBCL. PMLBCL may be seen with abnormal localization and clinical presentation. Immunohistochemical profile including MAL is helpful to detect these cases.

Operative Technique for Resection of a Ventral Transdural Retro-Odontoid Pannus: A 2-Dimensional Operative Video

Retro-odontoid pseudotumors are rare inflammatory complications of atlantoaxial instability often associated with cervical degenerative disease and rheumatoid arthritis. While propagation of these lesions has been shown to cause spinal cord compression and cervical myelopathy, intradural extension has rarely been reported. In this manuscript and 2-dimensional illustrative intraoperative video, we demonstrate cervical decompression, removal of the intradural component, and stabilization with C1-2 instrumentation using a posterior approach. A 71-year-old patient presented with progressive cervical myelopathy. Preoperative imaging demonstrated a large retro-odontoid pannus causing severe spinal cord compression and an associated contrast-enhancing intradural lesion, in the absence of obvious C1-2 instability or fractures on computed tomography scan. C1-2 posterior decompression and fusion were performed with maximally safe intradural pannus resection and ventral dural reconstruction. Postoperatively, the patient experienced significant improvement in myelopathic symptoms. Imaging demonstrated good spinal cord decompression with complete intradural pannus resection and debulking of the extradural component. Our outcome in this rare complication suggests a posterior approach may be effective in treating similar patients.

Giant Cell tumor of the Zygomatic Arch in a Pediatric Patient: Rare Case Report

Introduction: A giant cell tumor (GCT) is a rare tumor, usually benign, which can be locally aggressive, with an almost unknown incidence in the skull. Case report: Case report of a pediatric patient diagnosed with Ewing’s sarcoma (ES) and later GCT when sought medical care for an increased volume in the zygomatic arch and the right preauricular region. Imaging exams showed an expansive lesion in the zygomatic and squamous portion of the right temporal bone, with an extradural intracranial component in the middle fossa, with no evidence of infiltration. From the anatomopathological view, fusocelullar neoplasia was seen. The CD68 marker was positive and the S100 marker was negative. Tumor resection by microsurgery was performed. The patient remains in follow-up, with imaging exams at neurosurgery and orthopedics, the latest magnetic resonances of the skull showing a reduction in the size of the lesion. In addition, the patient did not submit to adjuvant therapy and is currently without complaints. Conclusion: This is an important case due to its rarity and clinical data that contributes for the understanding of the pathologies presented, allowing that, in the future, new studies are able to optimize the treatment, and the prognosis for these patients.

Intradural disc herniation: A case report and literature review

Background: Intradural disc herniation (IDH) is rare and is thought to be caused by posterior longitudinal ligament and posterior adhesions. MRI findings are inadequate for definitive diagnosis. We reported a patient with an L4-5 IDH and reviewed the literature.
 Case Description: A 71-year-old male patient presented with acute exacerbation of right lower extremity radiculopathy. MRI with/without contrast suggested IDH and spinal cord compression at the L4-5 spine level. While elective surgery was planned for the patient who did not have motor deficits at the time of admission, he underwent emergency surgery due to sudden urinary incontinence. At surgery, the disc herniation was appropriately resected, the dura was closed.
 Conclusion: Although MRI is helpful in the diagnosis of IDH, the definitive diagnosis is made intraoperatively. In surgery, both the extradural and intradural disc components should be removed and as small laminectomy and dura incision as possible.

Surgical Treatment of Spinal Arachnoid Cysts: Cyst Excision or Fenestration?

Arachnoid cysts in the spinal canal account for 1%-3% of all spinal canal lesions. There is no consensus on surgical treatment yet. Dural defect repair is crucial in surgical treatment patients with an extradural component. Fenestration or total resection of the spinal arachnoid cyst is among the preferred methods. This study aimed to examine a series of surgically treated spinal arachnoid cysts in light of the literature. This was a retrospective study of patients treated in the Istanbul Umraniye Training and Research Hospital Neurosurgery Clinic. A total of 18 patients with spinal arachnoid cysts underwent surgical treatment between 2012 and 2021. All patients were assessed before and after surgery for muscle strength, pain, sensory changes, and bowel-bladder symptoms. All patients underwent magnetic resonance imaging and computed tomography for diagnosis and treatment. Among the 18 patients, 8 were men and 10 were women, with a mean age of 43.7 (25-66) years. Congenital conditions were discovered in 15 of the patients, 2 after lumbar drainage and 1 after spinal anesthesia. Intradural extramedullary and intra-extradural cysts were found in 17 patients and 1 patient, respectively. The cyst was smaller than level 3 in 14 patients and greater than level 3 in 4 patients. Cyst excision and cyst fenestration were performed in 11 and 7 patients, respectively. Cyst excision was performed in four of the patients who underwent cyst fenestration because their complaints did not improve. Surgery should be considered in patients with symptomatic spinal arachnoid cysts. Fenestration may be a suitable alternative, especially if magnetic resonance imaging reveals no intracystic adhesion or trabeculation. Residual and recurrence rates are high in patients with a history of intradural intervention, adhesions, or trabeculation. When there is trabeculation, the best option is cyst removal.

Compressive vertebral hemangiomas with neurological deficits: diagnosis, surgical strategies and long term outcome

Purpose Compressive vertebral hemangiomas with neurological deficits (CVHND) form a rare, unique subset of lesions comprising of differing clinico-imaging findings, pathologic behavior and treatment, when compared to the commoner and usually incidental intra-osseus vertebral hemangiomas (VH). Though various surgical strategies and a broad array of adjuncts have evolved and changed over the years, there is paucity of comprehensive data from sizeable series of such patients treated surgically with long term follow up. The purpose of this study is to device an optimum management strategy in CVHND based on our surgical experience. Materials and methods The data from electronic medical records of 26 consecutive patients operated in our department from 2009 to 2019 were retrospectively analyzed. Results There were 11 males and 15 females with a mean age of 34.7 years. Neurological examination revealed paraparesis or paraplegia with myelopathy in all patients with Frankel score of B, C and D in 1 (3.9%), 11 (42.3%) and 14 (53.8%) patients respectively. Sixteen patients (61%) underwent laminectomy and gross total excision of extradural soft tissue component, 7 (27%) laminectomy with posterolateral fusion, three (12%) underwent additional anterior interbody support. The mean follow up was 72.4 months and at last follow-up 24 patients (92%) were Frankel E. Symptomatic recurrence was seen in two patients operated early in the series, they underwent re-surgery, gross total excision with posterolateral fusion, remaining neurologically intact at last follow up. Conclusions Pre-operative embolization, surgical excision of extradural component and intra-operative vertebroplasty form the mainstay of treatment for CVHND. Instrumented posterolateral fusion with optional anterior interbody support accomplished through the same approach is required only in a minority of cases. The long-term outcome following timely and appropriate treatment is excellent. Anterior or anterolateral approaches for intervertebral support and radical procedures like total en-bloc spondylectomy (TES) are not usually required.

Unusual presentation of a common tumor

Hepatocellular carcinoma(HCC) is the most common primary malignant tumour of liver. It is 5th most common malignancy in males and 8th most common tumour in females. The patients of HCC may remain clinically asymptomatic or may present with abdominal pain, weight loss, malaise, fever, jaundice or ascitis. HCC is a highly malignant tumor with frequent extrahepatic metastasis. The most frequent site of metastasis is lungs (47%), followed by lymph nodes (45%), bones (37%), and adrenal glands (12%). We present a case of 67 year old male, who presented with progressively increasing swelling in the left occipital region for 2 months. MRI brain showed large lobulated moderately enhancing T2 isointense to hyperintense and T1 hypointense mass lesion in occipital region, causing destruction of occipital bone with large intracranial extradural soft tissue component. Possibilities suggested were Meningioma or metastatic lesion. The scalp mass was excised. The histopathological examination of the excised tissue followed by elaborate immunohistochemistry suggested metastatic hepatocellular carcinoma, which was later confirmed by S.AFP and multiphase CT thorax, abdomen, pelvis which showed multiple liver lesions. Initial presentation of HCC as a subcutaneous lesion is very rare and only very few cases of HCC presenting with primary soft tissue swelling have been reported.

Spinal Primitive Neuroectodermal Tumor (PNET) in a 64-year-old Male Treated with Surgery, Radiotherapy, and Chemotherapy: A Case Report

Primitive neuroectodermal tumors (PNETs) are a heterogeneous group of malignant neoplasms found primarily in childhood and early adulthood. In this paper, we described the case of a 64-year-old male with primary spinal PNET, successfully treated with surgery, craniospinal radiotherapy, and concurrent chemotherapy. This is the case of a 64-year-old male who presented with a 2-month history of bilateral lower extremity weakness and numbness associated with urinary and bowel incontinence. Work-up was done, and the spine's plain magnetic resonance imaging (MRI) revealed a heterogeneously enhancing intradural lesion with an extradural component at the right T9/T10 level, causing mild to moderate cord compression. The patient underwent laminectomy and gross total resection of the said tumor. Histology and immunohistochemistry were consistent with a primitive neuroectodermal tumor of the spine. The tumor recurred three months after the surgery, and the patient was then referred for radiation therapy with concurrent chemotherapy. Repeat spinal MRIs with three- to six-month intervals after treatment showed no tumor recurrence as of August 2021. Primary spinal PNETs are rarely found in adults, especially in the elderly. These tumors currently have no recommendations or guidelines regarding their management. Thus, most cases are presently being managed based on studies on children and central nervous system (CNS) PNETs. This paper presented a case of a successfully treated primary spinal PNET in the elderly. The management was primarily based on studies done on that of the pediatric population and CNS PNETs.

Morphometric study of the meningeal sheath of the oculo motor nerve in the latero-sellar lodge: Neuro surgical interest

The meningeal sheath of the oculomotor nerve is also known that the latero-sellar lodge. It has both dural and extra-dural components. This sheath contains vascular elements including the carotid and nervous siphon, the motor nerves of the eye to which are added the division branches V1 and V2 of the trigeminal nerve. The oculomotor nerve runs through this lodge wrapped in its meningeal sheath. The purpose of this study was to document the dimensions of the different segments of the nerve as it crosses the lodge. Eight pairs of lodges were the subject of this study. Dead bodies fixed with 10% formalin for two to three weeks underwent a craniotomy. After removal of the brain, nerve III and its meningeal envelope were dissected and exposed. The different segments of the nerve were measured in both sides. The entrance orifice of the porus of the oculomotor nerve III was located behind the anterior clinoid process to 7.2 mm (extreme from 3 to 13mm) on the right and to 7.40mm (extreme from 4 to 12) on the left. The meningeal cul-de-sac represented the intra-conical segment and was either 5.2mm long (extreme from 4 to 6.5mm) or short 3.25mm (extreme from 2 to 3.5mm). The supra-cavernous segment measured on the right 5.2 mm (extreme from 2 to 8 mm) and on the left 4.6 mm (extreme from 3 to 7 mm). The latero-sellar lodge, a complex and narrowed region is crossed by nervous elements each in its meningeal sheath. This deserves an approach by surgical microdissection.
 Key words: Oculomotor nerves - meningeal cone - measurement – cadaver – latero-sellar lodge.

Pediatric primary spinal atypical teratoid rhabdoid tumor: a case series and review of the literature.

Atypical teratoid rhabdoid tumors (ATRTs) are rare malignant central nervous system tumors, commonly occurring before 3 years of age. Median overall survival (OS) of patients with these tumors is about 1 year, despite aggressive multimodal therapy. Pediatric primary spinal ATRTs are even more rare, with fewer than 50 cases reported. The authors present a series of four patients who were treated at Ann and Robert H. Lurie Children's Hospital of Chicago in the period from 1996 to 2017.These patients, with ages 2-11 years, presented with pain and a decline in motor functions. They were found to have lesions in the lumbar, thoracic, and/or cervical spine. One patient's tumor was intramedullary with exophytic components, while another patient's tumor had both intra- and extradural components. All patients underwent resection followed by chemotherapy (systemic and intrathecal). Two patients had fractionated radiation therapy and one had an autologous stem cell transplant. Three patients are known to be deceased (OS 8.5-45 months). The fourth patient was in remission 19 years after her initial diagnosis. To the authors' knowledge, this is the largest series of pediatric primary spinal ATRTs documented at a single institution. These cases illustrate a variety of presentations of spinal ATRT and add to the body of literature on this aggressive pathology.A systematic MEDLINE search was also conducted using the keywords "atypical teratoid rhabdoid tumor," "pediatric spinal rhabdoid tumor," and "malignant rhabdoid tumor spine." Reports were included for patients younger than 21 years, without evidence of intracranial or systemic disease at the time of diagnosis. Clinical characteristics and outcomes of the four institutional cases were compared to those in the literature. This review yielded an additional 48 cases of primary pediatric spinal ATRTs reported in the English-language literature. Patients (ages 2 months to 19 years) presented with symptoms of pain, regression of motor function, and spinal cord compression. The majority of tumors were intradural (14 extramedullary, 8 intramedullary, 1 both). Eleven cases in the literature described tumors limited to extradural structures, while 10 tumors involved the intra- and extradural spine. Four reports did not specify tumor location. Although rare, spinal ATRT should be considered in the differential diagnosis of pediatric patients presenting with a new spinal mass.

Radical Intracapsular Dissection Technique for Dumbbell-Shaped Spinal Schwannoma with Intradural and Extradural Components

Dumbbell-shaped spinal schwannomas with intradural and extradural components are associated with higher complication rates. This may be in part due to epineurial dissection of the extradural component, which inevitably damages the functioning nerve fibers beneath the epineurium and may lead to dural defects that are often difficult to repair. The objective was to describe a radical intracapsular dissection technique that provides a simpler operative field with no need for dural repair and a better chance of preserving functioning nerve fibers. The technique comprised the following: 1) exposure of the tumor while preserving spinal stability; 2) a single incision encompassing the dura and epineurium; 3) microsurgical dissection of the tumor just beneath the epineurium, preserving the viable nerve fibers; and 4) primary closure of the duroepineurial incision. We describe a case series of 7 patients in whom this type of tumor was excised using this technique. Gross total excision was achieved in 5 patients. In 1 patient with a large paravertebral component, the remaining tumor was removed with an additional anterior approach. No cerebrospinal fluid leak was noted, and no recurrence was observed in the median follow-up period of 36 months. The radical intracapsular dissection technique described herein represents an alternative technique for the removal of dumbbell-shaped spinal schwannomas with intradural and extradural components.

Conus Medullary Syndrome secondary to Spinal Schwannoma : A report of 3 cases

Spinal Schwannoma originates from the Schwann cells, hence it is called Schwannoma. The tumor localization is in various parts of the spinal cord, but prevails in cervical and thoracic. In the literature 70 to 80% of spinal schwannomas are reported to be intradural in location, and 15% with both intradural and extradural components. All 3 cases were female in their 4th-5th decade, presented with either low back pain, radiculopathy, weakness of both lower limbs associated with urinary incontinence. MRI revealed a well defined mass adjacent to conus medullary area located intradural, extramedullary. All three patients underwent microscopic assisted excision of the tumour. All patients had Good Early Outcome. Spinal schwannoma causing Conus Medullary Syndrome is rare. Back pain and radicular pain were most common early presenting symptoms while urinary symptoms occur later. Schwannomas typically arise from a single nerve root originating from the schwann cells. To obtain total resection, the affected nerve root is commonly sacrificed in order to prevent recurrence. Intradural Extramedullary Schwannoma, even presented at a later stage with significant neurological deficit, has a Good Outcome post operatively owing to its Benign nature, Extramedullary location, and a Meticulous Microscopic assisted Complete Surgical Excision.

Clinicoradiologic Profile of Involvement and Healing in Tuberculosis of the Spine.

Background:There is no much information about how tuberculous lesions of the spine progress/heal; what clinical and radiological features suggest progression/healing; what is the optimal duration of antitubercular treatment; and what clinical, laboratory, and radiological investigations and their frequency should be done to monitor the disease course.Aims:The present study aimed to evaluate what specific clinicoradiologic features suggest involvement and healing in tuberculosis of the spine.Subjects and Methods:Fifty spinal tuberculosis patients (30 males and 20 females) diagnosed clinicoradiologically were enrolled in the study. Patients were evaluated clinically, radiographically, and by magnetic resonance imaging (MRI) at regular intervals to monitor the disease course till 24 months of the initial presentation.Results:Wedge/collapse (23/50 cases), soft tissue mass (29/50 cases), disc narrowing (45/54 discs), and endplate erosions (89/107 endplates) were the plain radiological findings of tubercular spinal involvement. Earliest sign of healing on plain radiography was decrease in fuzziness of endplate, ultimately leading to either sclerosis of endplate or fusion of adjacent vertebrae. Initial MRI findings included bone marrow edema (50/50 cases), discitis (53/62 discs), endplate erosions (105/123 endplates), pre- and para-vertebral collections (45/50 cases), epidural involvement (26/50 cases), epidural spread (77/109 vertebrae), and subligamentous spread (42/50 cases). Earliest feature of healing on magnetic resonance (MR) examination was decrease in inflammatory soft-tissue masses and reduction in marrow edema.Conclusions:Salient features of spinal involvement in tuberculosis on plain radiograph were paradiscal involvement, endplate destruction, and soft tissue masses. Marrow edema, paravertebral collections, subligamentous spread, extradural component, endplate erosion, and discitis suggested tubercular involvement of the spine on MRI. A decrease in these was observed to have prognostic value both in monitoring disease course and response to chemotherapy. Based on the clinicoradiologic findings of the present study, we propose decision-making algorithm, follow-up algorithm, and MR examination protocol for spinal tuberculosis.Level of evidence:This was a Level II study.

Involvement of two consecutive vertebral bodies and intervertebral disc space in dorsal spinal hydatid disease

A 59-year-old man who had a history of hepatic hydatid cyst operation presented with progressive back pain and paraparesis. Thoracic spine magnetic resonance imaging revealed heterogeneous low and high signal in the T9, T10 vertebral bodies and intervertebral disc space on both T1and T2weighted magnetic resonance imaging caused by hydatid disease. The intraspinal extradural cystic components of the lesion demonstrated low T1 signal and high T2 signal with low-signal-intensity rims on images (Figs. 1 and 2). Postcontrast images did not reveal significant enhancement (Fig. 3). Plain computed tomography demonstrated destruction of the T9, T10 vertebral end plates and posterior portion of the T10 vertebral body with sclerotic areas (Fig. 4). Surgery was performed, and a pathologic examination confirmed the diagnosis of hydatid disease. Involvement of two consecutive vertebral bodies together with intervertebral disc space involvement in dorsal spinal hydatid disease is extremely rare and should be considered in the differential diagnosis of atypical spondylodiscitis.

Single stage transforaminal retrojugular tumor resection: The spinal keyhole for dumbbell tumors in the cervical spine.

Background:Dumbbell tumors are defined as having an intradural and extradural component with an intermediate component within an expanded neural foramen. Complete resection of these lesions in the subaxial cervical spine is a challenge, and it has been achieved through a combined posterior/anterior or anterolateral approach. This study describes a single stage transforaminal retrojugular (TFR) approach for dumbbell tumors resection in the cervical spine.Methods:This is a retrospective review of a series of 17 patients treated for cervical benign tumors, 4 of which were “true” cervical dumbbell tumors operated by a simplified retrojugular approach. The TFR approach allows a single stage gross total resection of both the extraspinal and intraspinal/intradural components of the tumor, taking advantage of the expanded neural foramen. All patients were followed clinically and radiologically with magnetic resonance imaging (MRI).Results:Gross total resection was confirmed in all four patients by postoperative MRI. Minimal to no bone resection was performed. No fusion procedure was performed and no delayed instability was seen. At follow up, one patient had a persistent mild hand weakness and Horners syndrome following resection of a hemangioblastoma of the C8 nerve root. The other three patients were neurologically normal.Conclusions:The TFR approach appears to be a feasible surgical option for single stage resection in selective cases of dumbbell tumors of the cervical spine.