Epidural Tumor Research Articles

Incidentally discovered intrathoracic extra-adrenal pheochromocytoma during preoperative screening

Introduction: We are reporting a case of an incidental mass later diagnosed as an extradural pheochromocytoma at t2-t4 level during a presurgical work up for a gynecological procedure. Only a few cases of extradural paravertebral tumors are described in literature. case report: this is a clinical case of an asymptomatic 26-year-old female with an incidental finding of thoracic mass in chest X-ray during preoperative screening for myomectomy. Work up for this mass showed elevated plasma and urinary metanephrine levels which was consistent to pheochromocytoma. computed tomography, magnetic resonance imaging and metaiodobenzylguanidine scans demonstrate a mass originating from thoracic spine with cord compression, no adrenal mass, multifocal disease or metastasis. Prior to surgery, the patient was treated with phenoxybenzamine and metoprolol to decrease hemodynamic instability during surgical procedure and also embolization to the arteries supplying the mass to decrease intraoperative bleeding. Patient

Triple primary origin tumor: a case report.

Generally, among the extradural spinal tumors, metastatic spinal tumor is much more common than primary spinal tumors. Thus, in the case of a spinal tumor patient with cancer history (such as lung cancer, breast cancer, etc.), we used to infer that the spinal lesion is the metastasis from, primary malignancy. We introduce an experience of a case of triple primary origin tumor in a 57-year-old man. When the spinal lesion was found on the abdominal computed tomography scan, he already had a history of colon cancer and liver cancer. Initially, it was thought that the lesion would probably be a metastatic tumor from the liver or colon cancers, and the operation was performed accordingly. In the pathologic final report, however, the mass was proven to plasmacytoma - the third primary lesion. The patient underwent chemotherapy after surgery. Globally, the triple primary origin tumor has been reported very rarely. With this report, we wish to emphasize the necessity of pathologic confirmation and adequate treatment even in a patient with known malignancies.

Lumbar Disc Herniation with End-Plate Fracture and Secondary Ossification Mimicking an Epidural Tumor: A Case Report

We report a unique case of lumbar disc herniation, in particular, with end-plate and surrounded by extensive ossification, mimicking a tumor with calcification. A 69-year-old female suffered from right buttock and leg pain. Computed tomography (CT) showed an intracanalar mass with calcification or ossification, which most likely originated from the vertebral body at the L1/2 level epidural space. On a T1-weighted gadolinium magnetic resonance image, the capsule of the mass was enhanced and not only the content of the mass but also that of the L2 vertebral body were partially and slightly enhanced. The final pathological diagnosis was disc herniation with end-plate fracture and secondary ossification. A combination of these pathological conditions as accompanied by both end-plate fractures and extensive secondary ossifications has not been previously reported. This rare pathological condition needs to be recognized as a differential diagnosis.

Eosinophilia and Bone Lesion as Clinical Manifestations of Aggressive Systemic Mastocytosis

We report a patient with aggressive systemic mastocytosis (SM), who exhibited eosinophilia and unusual destructive bone lesions. A 43-year-old female was referred to our hospital because of a vertebral compression fracture, multiple lytic bone lesions, and eosinophilia in February 2011. A diagnosis of aggressive SM was made on the basis of abnormal mast cells in the bone marrow, high serum tryptase levels, and multiple lytic bone lesions including vertebral compression fractures. Polymerase chain reaction and subsequent sequencing of its products to identify mutations of c-kit yielded negative results and imatinib mesylate failed to improve the SM of the patient. She was then treated with interferon-α, with considerable improvement of the disease, although severe myelosuppression prevented the continued administration of a sufficient dose of this agent. In August 2011, the patient suddenly developed paraplegia of the lower extremities. Magnetic resonance imaging demonstrated epidural mass lesions at the levels from Th9 to Th11, compressing the spinal cord. Emergent laminectomy and subsequent irradiation of the tumors were performed without improvement of the paraplegia. Histopathologic examination of the epidural tumors, from samples obtained intraoperatively, confirmed the diagnosis of SM. She was further treated with dasatinib and then cladribine without obvious improvement, although the latter reduced the eosinophilia to some extent ; however, she died of sepsis in September 2011.

Spinal Cord Compression Revealing an Intraosseous Schwannoma

A 68-year-old female presented with inflammatory lumbalgia and cruralgia. Physical examination revealed a lumbar stiffness without neurological deficit. Secondarily, paraplegia and urinary retention appeared. Magnetic resonance imaging showed a vertebral compaction of L3 vertebra with medullar compression. Emergent surgery revealed an epidural tumor involving largely the L3 vertebral body. Histology found schwannoma with positive protein S100 on the immunohistochemical study. Metastasis screening revealed bilateral nodular lesions of the lungs and a trochanter high scintigraphic signal. It was a malignant schwannoma. The patient underwent radiotherapy in addition to the total tumor resection.

A rare cause of Cauda equina syndrome: Epidural high grade primary non-Hodgkin lymphoma

Cauda equina syndrome (CES) may be caused by herniated disc, tumor, trauma, and spinal infections. However, CES due to epidural high-grade non-Hodgkin lymphoma (NHL) is very rare. Up to our knowledge, few cases have been reported in the literature. We report a case of epidural high-grade NHL presenting as CES. A 55-year-old man presented with CES caused by extradural compression by primary NHL. The patient underwent an L4-L5 laminectomy. The operative findings were suggestive of well-demarcated epidural tumor. The final histopathological diagnosis revealed epidural high-grade NHL. NHL causing CES is rare. This report highlights the importance of keeping afresh the various causes of CES for prompt diagnosis and management.

Isolated Metastatic Barrett’s Adenocarcinoma of the Thoracic Epidural Space Causing Paraplegia

Barrett’s adenocarcinoma is an esophageal cancer arising from Barrett’s esophagus. In this report, a metastatic epidural tumor from Barrett’s adenocarcinoma with paraplegia that required surgical treatment is documented. A 50-year-old man who had had a resection of the distal esophagus due to Barrett’s adenocarcinoma six month before presented with progressive weakness and numbness in lower limbs with urinary disturbance. Magnetic resonance imaging of the thoracic region revealed compression of the spinal cord at the T3-4 level by a dorsally located epidural mass. No signal changes were detected in vertebrae. Since the paraplegia and urinary disturbance were rapidly progressing, laminectomy and tumor resection was performed. Postoperatively, neurological function improved immediately and there was no recurrence of spinal region. This is the first report on an isolated metastatic Barrett’s adenocarcinoma of the thoracic epidural space.

Tumor or Hematoma?

Spinal epidural hematoma is a rare clinical entity. We present a case of atypical contrast enhancement pattern in a chronic epidural hematoma of the lumbar spine mimicking an extradural tumor. A 76-year-old man on treatment with oral anticoagulants presented with a 1-month history of lower back pain radiating into his right upper thigh accompanied by spinal claudication. Preoperative MRI showed a posterior epidural lesion compressing the cauda equina with almost homogeneous contrast enhancement. Surgery was performed under the presumptive diagnosis of spinal extradural neoplasm. Intraoperative and histological findings were consistent with a chronic spinal epidural hematoma. Postoperatively, the patient had instant relief of his symptoms. Chronic spinal epidural hematoma may resemble an extradural tumor, requiring surgery for histological confirmation and decompression.

The upper cervical spine tumor pathology C1-C2 - therapeutic attitude

Abstract Surgical treatment of upper cervical spine tumors, whether they are vertebral, epidural, subdural or intramedullary, raises technical and decisional difficulties regarding the approach of the region as well as in maintaining its stability. The authors performed a retrospective study on C1, C2 spinal tumor pathology, managed surgically in the Spinal Surgery Department of Bagdasar Arseni Clinical Hospital, between January 2007 and December 2011. We included in the study 44 patients, operated for C1, C2 cervical spine tumors, 23 men and 21 women with ages between 13 and 71 years. The pathology included 24 C1-C2 vertebral tumors, 11 subdural tumors, 2 epidural tumors and 7 intramedullary tumors. Presenting symptoms were cervical pain, occipital neuralgia, medullary compression syndrome, and/or cranio-spinal junction instability. The purpose of surgery was to establish a histopathologic diagnosis and to decompress the neural elements by attempting a total tumor removal as well as to stabilize the cranio - cervical junction in order to improve the patient's quality of life. The approach was chosen based on tumor location, prognosis and the need for fixation. For 6 patients an anterior approach was used, for 31 pacients we used a posterior approach and 7 patients required a combined anterior and posterior approach. Neurological improvement was observed in 17 patients, with a mean increase of 8 points on ASIA scale, 7 patients worsened immediately postoperatively with a mean decrease of 10 points on ASIA scale, (2 patients died), and 20 patients without neurological deficits preoperatively remained unchanged. In all cases where the craniospinal junction instability was the cause of occipito-cervical pain we noted the disappearence of pain after surgery. The development of new surgical techniques and fixation systems paved the way to a successful treatment for these difficult tumors, some of them considered inoperable in the past.

Dural repair after extensive tumour surgery

Surgery for spine tumours can be challenging, and due to the increased complexity of surgery, the dura may be transgressed either for purposeful resection of tumour margins or by inadvertent breach whilst removing extradural tumour. If leakage of CSF occurs, this may affect the patient’s quality of life, at a time when maintaining function and good outcome is paramount. Surgical planning should aim to minimise the risk of CSF leakage, but if dural breach does occur, the defect should be repaired by using sutures, dural patch techniques and application of tissue adhesives. We outline and illustrate the methods of dural closure that can be used to prevent leakage of CSF during surgery for spine tumours.

Mri and Neurological Findings in Patients with Spinal Metastases

Magnetic resonance imaging (MRI) is the recommended primary investigation method for metastatic spinal cord compression (MSCC). Initiating treatment before the development of motor deficits is essential to preserve neurological function. However, the relationship between MRI-assessed grades of spinal metastatic disease and neurological status has not been widely investigated. To analyze the association between neurological function and MRI-based assessment of the extent of spinal metastases using two different grading systems. A total of 284 patients admitted to our institution for initial radiotherapy or surgery for symptomatic spinal metastases were included in the study. Motor and sensory deficits were categorized according to the Frankel classification system. Pre-treatment MRI evaluations of the entire spine were scored for the extent of spinal metastases, presence and severity of spinal cord compression, and nerve root compression. Two MRI-based scales were used to evaluate the degree of cord compression and spinal canal narrowing and relate these findings to neurological function. Of the patients included in the study, 28 were non-ambulatory, 49 were ambulatory with minor motor deficits, and 207 had normal motor function. Spinal cord compression was present in all patients with Frankel scores of B or C, 23 of 35 patients with a Frankel score of D (66%), and 48 of 152 patients with a Frankel score of E (32%). The percentage of patients with severe spinal canal narrowing increased with increasing Frankel grades. The grading according to the scales showed a significant association with the symptoms according to the Frankel scale (P < 0.001). In patients with neurological dysfunction, the presence and severity of impairment was associated with the epidural tumor burden. A significant number of patients had radiological spinal cord compression and normal motor function (occult MSCC).

Pediatric Regional Anesthesia

Two articles in this month’s Anesthesia & Analgesia address safety of regional anesthesia and analgesia in pediatrics.1,2 At first glance, one is very reassuring, the other is frightening. In this Editorial, we will recommend a middle ground. Practitioners of pediatric regional anesthesia should be careful and vigilant but can be confident that many types of complications can be made extremely rare by adopting some recommended practice patterns. Over the past 30 years, pediatric applications of postoperative regional anesthesia and analgesia have expanded rapidly.3 There is now a substantial body of studies regarding techniques, pharmacokinetics, and clinical outcomes. Agerelated trends in local anesthetic pharmacokinetics have been characterized, and safe dosing guidelines have been established.4 Most regional anesthesia in adults is performed awake or with doses of sedatives and analgesics that maintain verbal responsiveness, permitting patient reporting of paresthesias, severe pain with needle movement or injection, immediate symptoms of systemic local anesthetic effect, and progression of sensory and motor blockade over the minutes after injections. Textbooks, review articles, and consensus documents often strongly criticize performing most types of major peripheral or neuraxial blocks in adults under deep sedation or general anesthesia.5 In contrast, most, but not all, regional anesthesia in children is performed under either deep sedation or general anesthesia. Advocates of pediatric regional anesthesia have cited a series of retrospective and prospective safety studies to support their contention that the widespread practice of performing regional anesthesia under general anesthesia is safe.6–8 Polaner et al. report on the first 3 years of prospective registry data from PRAN, the Pediatric Regional Anesthesia Network, a consortium of North American pediatric centers. This report has a number of strengths. The data collection and analysis plan was generally thoughtfully constructed. There is a good degree of detail and new information regarding how procedures are performed and regarding most adverse events. The methodology for data gathering is likely to be fairly complete for intraoperative serious adverse events and for events occurring during patients’ inpatient stay. There are several scenarios that could potentially lead to underreporting of peripheral nerve injuries, most notably partial nerve injuries in nonverbal or nonambulatory children that might evade detection by parents and physicians. For example, a thoracic nerve root or an intercostal nerve injury following thoracic epidural or thoracic paravertebral block might not be detected in a preverbal child. In addition, for a patient in a cast, a deficit might not be apparent until days to weeks postoperatively. The methodology for postoperative surveillance in this registry is likely to omit some cases with delayed detection. Despite these possible sources for underreporting, the PRAN investigators make a good case for the overall very good safety of pediatric neuraxial and peripheral blocks as performed by clinicians in these hospitals. In contrast to the conclusion of the PRAN investigators that “nothing really bad happened,” Meyer et al. showed admirable courage and forthrightness in reporting on 4 cases of neurologic injury following epidural anesthesia in children. All 4 cases involve care by experienced anesthesiologists with extensive experience in pediatric epidural analgesia and acute and chronic pain management. Based on the incomplete information available in this case report, we would tend to agree with the authors’ general contention that there was “absence of proof of medical negligence.” A more important question, which the authors have addressed in their discussion, might be phrased as follows: “Based on these cases and other available knowledge, do we have ways to modify our practice to prevent similar complications in the future?” We consider the 4 cases in this light, taking advantage of “20–20 hindsight.” Among the 4 cases, case 1 was perhaps the most frightening, because the patient was healthy and uncomplicated, the epidural catheter placement proceeded uneventfully at a lumbar level below the terminus of the spinal cord, the duration of general anesthesia was short, and there were no hemodynamic clues intraoperatively to raise concerns. The test dose was appropriate (0.1 mL/kg). E EDITORIAL

Paraspinal chordoma mimicking a neurofibroma: a rare but important radiological pitfall

We present an unusual case of a chordoma presenting as an extradural spinal tumour with extension through an expanded intervertebral foramen to form a large paraspinal mass. The magnetic resonance imaging appearances closely mimicked a neurofibroma; however, pre-operative biopsy confirmed the diagnosis of chordoma. This is, to our knowledge, the tenth reported case of chordoma presenting as a mass expanding the intervertebral foramen. Thus, while it is a rare form of chordoma, it can lead to a recognised radiological pitfall. Making the distinction from neurofibroma before surgery is essential, as radical dissection of chordoma is required to reduce the risk of local recurrence.

Extradural Subtemporal Transzygomatic Approach to the Clival and Paraclival Region With Endoscopic Assist

The authors describe the extradural subtemporal transzygomatic (ESTZ) approach and its variants to expose the clival and paraclival areas. A microanatomical study was conducted to quantify the clival and paraclival exposure and the maneuverability areas obtained by microscope and endoscope using the ESTZ approach. Section versus preservation of the third trigeminal branch (V3) and petrous apicectomy to obtain a wider clival exposure and a better internal carotid artery control are discussed. Eight cadaveric specimens were dissected to obtain morphometric measurements after performing the ESTZ approach and its variants. Anatomic areas exposed by the approaches were calculated using the ImageJ 1.37a software. The ESTZ approach performed with sectioning of V3 and petrous apicectomy allowed for a mean incremental exposed area of 1.8 cm2 (range, 1.24-2.43 cm2). The mean amount of additional anatomic areas visualized after the ESTZ approach with petrous apicectomy if compared with the ESTZ approach without petrous apicectomy was 24% (range, 14.4%-37.5%). The mean percentage increase of maneuverability area after petrous apicectomy was 69.9% (range, 43.8%-96.6%). The ESTZ approach is suitable when dealing with extradural tumors of the middle-upper clivus extending into the ipsilateral paraclival area. V3 section and petrous apicectomy increase the operability, the surgical exposure, and the maneuverability area and improve vascular control on the internal carotid artery. Application of endoscopy does not impact on the maneuverability area but enhances the visualization of blind corners; endoscopic surgical view without drilling the petrous apex is comparable to that obtained by the microscope after petrous apicectomy.

Considering Symptomatic Spinal Epidural Lipomatosis in the Differential Diagnosis

Spinal epidural lipomatosis (SEL) is the abnormal accumulation of normal fat within the spinal canal. It is more frequent in those patients receiving chronic glucocorticoid therapy or in cases of endogenous hypercortisolism states. We report a case of SEL in a patient with metastatic prostate cancer with history of steroid treatment as part of his chemotherapy regimen, presenting with clinical manifestations of partial cord compression. Magnetic resonance imaging images of the lumbar spine revealed the presence of epidural tumor suspicious for metastatic disease. Operative findings were consistent with epidural lipomatosis. Spinal epidural lipomatosis is a rare condition that needs to be included in the differential diagnosis of patients with risk factors, presenting with symptomatic cord compression.

Cervical Extradural “En-Plaque” Meningioma

Spinal meningiomas with concurrent extradural localization and "en-plaque" growth are exceptional, with only five reported cases in the literature. We report another case and discuss the peculiar diagnostic and surgical features of this very unusual pattern of growth. A 74-year-old woman was observed because of a rapidly progressive tetraparesis, more marked in the left arm. Magnetic resonance imaging depicted an inhomogeneously enhancing tumor of the cervical spine, extending from C4 to T1, with diffuse dural enhancement and extension into the left brachial plexus roots. At operation by laminotomy from C4 to C7 a firm posterior extradural tumor arising from the dura was resected; however, the diffusely infiltrated dura could not be removed. Histology was in favor of a transitional meningioma (WHO I). Postoperatively, irradiation to the operative field with 50 Gy was performed. At follow-up, 18 months after surgery, clinical improvement to moderate tetraparesis was evidenced. Spinal extradural "en-plaque" meningiomas have been mainly reported in women and at the cervical region, and show extension to many spinal levels as well as diffuse dural infiltration. Preoperatively, they may be differentiated from spinal metastases and lymphomas because of the presence of a "dural tail" sign and calcifications. The surgical resection is mainly limited to the posterior and lateral extradural tumor component, whereas the whole invaded dura is very difficult to resect, mainly in cases with circumferential infiltration. This results in a high rate of tumor recurrence.

Solitary Spinal Extradural Plasmacytoma: A Case Report and Literature Review

Solitary spinal extradural plasmacytoma (SSEP) is a rare but distinct form of plasma cell disorder. The clinical picture and treatment of SSEP are reviewed using the seven previously reported cases. The three male and four female patients were aged 40-85 years. The location was cervical spine in one patient, cervicothoracic in one, thoracic in two, thoracolumbar in one, lumbar in one, and extensive involvement in one. Progressive paraparesis and sensory disturbance were the predominant symptoms. Neuroimaging showed a compressive extradural mass lesion in the dorsal spinal canal without findings of local bone destructive changes in all cases. Four of five patients who underwent decompressive surgical maneuver and tumor resection showed neurological improvement. Immunoglobulin (IgG) kappa subtype was the most predominant histological type, followed by IgD lambda and IgA kappa subtypes. SSEP should be included in the differential diagnosis of an extradural tumor located in the dorsal spinal canal without associated bony changes. Surgery may be effective for symptomatic relief.

Primary spinal epidural rhabdomyosarcoma: a case report and review of the literature

Primary intraspinal sarcomas are very rare in children. Rhabdomyosarcoma (RMS) is a highly aggressive and rapidly growing sarcoma with skeletal origin that occasionally appears in the spinal epidural space. We report a 13-year-old girl who presented with back pain, progressive paraparesis, and urinary retention. She had muscular weakness in her lower extremities and absent deep tendon reflex. An epidural dumbbell-shape mass at T11-T12 level was observed on MRI. The patient underwent T12 hemilaminectomy, partial T11 hemilaminectomy, and right facetectomy. A large, firm, dark-red vascular epidural tumor was found compressing the cord. The tumor which extended to intracanal and foraminal parts was removed completely. Histopathological examination revealed undifferentiated small round and oval tumoral cells. Immunohistochemical staining was positive for vimentin, desmin, and myogenin. The final diagnosis was alveolar RMS. She received radiotherapy and chemotherapy by vincristine, actinomycin-D, doxorubicin, and ifosfamide. The patient was in good condition with no tumor recurrence or metastasis at the 1-year follow-up.

Low back pain and lumbar radiculopathy as harbingers of acute myeloid leukemia recurrence in a patient with myeloid sarcoma

Myeloid sarcoma (MS) is an extra-osseous, solid collection of myeloblasts. It is associated with myeloid leukemias, and rarely affects the spine. The most common clinical presentation of MS in spine patients is some form of pain related to compression of neural elements. Given that MS is rare, and its imaging characteristics are similar to other more common diagnoses, it is frequently missed on initial presentation. We present a 28-year-old female, in her fifth year of remission from AML, with low back pain and right lumbar radiculopathy. Initially, the leading diagnosis was schwannoma in preference to neurofibroma; however, intra-operative pathology and subsequent bone marrow biopsy revealed the tumor to be MS. This report highlights the difficulties of diagnosis of MS in patients in remission from acute myeloid leukemia. Thus, in patients with a history of leukemia, MS should be considered in the differential diagnosis of any epidural or nerve root tumor. Timely diagnosis and treatment are key to optimal outcomes.

Spinal Cord Disease in Patients With Cancer

Spinal cord disease is not uncommon in patients with systemic cancer. Most cases are due to epidural tumor metastases with resulting cord compression, although intramedullary spinal cord metastases, radiation myelopathy, and myelopathic complications of chemotherapy must be considered. Techniques for surgical decompression of the spinal cord in patients with epidural tumor have improved significantly over the past decade. Several studies have demonstrated improved neurologic outcome in a subset of patients with epidural spinal cord compression treated surgically. This article outlines the clinical features, radiographic findings, and differential diagnosis of spinal cord disease in patients with cancer and describes the therapeutic approach to these patients. Early identification and treatment of patients with epidural spinal cord compression is critical to maintaining neurologic function and preserving quality of life.