Epidural Tumor Research Articles

Anterior construct location following vertebral body metastasis reconstruction through a posterolateral transpedicular approach: does it matter?

The posterolateral transpedicular approach (PTA) is a widely used method for the surgical treatment of vertebral body metastases. It is crucial to understand the optimal location of the anterior graft in terms of sound and durable reconstruction following PTA. The purpose of this study was to investigate whether postoperative construct stability is related to the location of anterior grafts. The authors conducted a retrospective review of 45 cases of metastatic spine disease with epidural tumor extension in which patients underwent circumferential decompression and fusion by means of PTA. Mechanical (anterior construct stability), pain (visual analog scale score), and neurological (American Spinal Injury Association scale) outcomes were evaluated and correlated with the anterior graft location (lateral or central) and surgical approach (unilateral or bilateral), number of decompressed levels, types of anterior graft, screw density of posterior fixation (number of screws used divided by the number of pedicles spanned), and kyphotic angle change from the immediate postoperative period to the most recent follow-up. Seven of 45 constructs were judged unstable--5 with a lateral location of the anterior graft and 2 with a central location. The anterior graft was located laterally in 31 cases (69%), centrally in 11 (24%), and bilaterally in 3 (7%). A unilateral approach was used in 33 cases and a bilateral approach in 12. Neither the location of the anterior graft nor the approach had a significant effect on the stability of the reconstructed spine (p > 0.05). There was a significant difference in construct stability between the single-level decompression group (33 patients) and the multiple-level decompression group (12 patients) (p = 0.0001). The types of anterior graft, screw density, and kyphotic angle change were not correlated to the mechanical outcome. The anterior graft location showed no significant relationship to the final mechanical, pain, and neurological outcomes.

Marginal zone lymphomas involving meningeal dura: possible link to IgG4-related diseases

Dura-based marginal zone lymphomas represent an uncommon group of low-grade B-cell neoplasms, and literature regarding the clinical, histological and genetic profile of these tumors in the context of the newly described IgG4-related entities is lacking. We analyzed 32 dura-based marginal zone lymphomas identified in 27 females and 5 males ranging in age from 33–82 years (median 50). Morphologic examination, immunohistochemical studies and PCR for B-cell clonality were carried out in all cases. In addition, IgG4 immunohistochemistry and cytogenetic studies (either by FISH or RT-PCR) were carried out in 20 (18 primary dural; 2 with associated extradural disease) and 9 cases, respectively. Clinically, most cases presented radiologically as dura-based masses, mimicking meningioma. Histologically, the majority exhibited plasmacytoid differentiation, and were clonal either by PCR or immunohistochemical light chain analysis (28 out of 32). In the subset tested for IgG4, 6 of 18 primary dural marginal zone lymphoma (including one epidural tumor) showed numerous IgG4-positive plasma cells; all 6 were light chain restricted and clonal by PCR in 5 of 6 tested cases. Three IgG4-positive marginal zone lymphomas tested for cytogenetics did not show any cytogenetic aberrations. Across all cases, FISH and RT-PCR identified abnormalities in three out of nine cases (trisomies 3 and 18; trisomies 3 and 1; trisomy 18) without any extranodal marginal zone lymphoma specific translocations. Regardless of the treatment modality, 16 of 17 patients with follow-up are alive without evidence of disease over a period of 4–124 months (median 19.5). The expression of IgG4 in light-chain-restricted clonal plasma cells of a significant subset of dural marginal zone lymphomas, including one in an epidural location, is a novel finding and points to distinctive biology. Cytogenetic aberrations are present only in a minority of dural marginal zone lymphomas.

Vertebroplasty in multiple myeloma with osteolysis or fracture of the posterior vertebral wall. Usefulness of a delayed cement injection

The goal of this study was to specifically address the incidence of dorsal leakage when performing vertebroplasty in patients with posterior wall osteolysis or fracture, by using a delayed injection of cement with the aim of increasing its viscosity. We prospectively reviewed the records of 24 patients (13 women, 11 men; age range 42-67years; mean age 54.7) with diagnosis of multiple myeloma (MM) who underwent 34 vertebroplasties between January 2007 and January 2010 for painful osteolytic localization of MM with dorsal cortical osteolysis or fracture. All vertebroplasties were performed with an 8min delay, which was half of the allotted injecting time given for the chosen cement. In 11 cases there were fractures involving the posterior wall, in 1 case with dorsal fragment dislocation, and in 33 cases there was dorsal cortical osteolysis. All of the patients showed no response to standard treatments such as radiotherapy, chemotherapy, and analgesic treatments. Technical success was achieved in all cases. In 20 patients, we treated only one high-risk vertebral lesion, in six patients we treated two segments, and in one patient we treated three segments. All patients experienced improvement in symptoms after the procedure as demonstrated by improved visual analogue scores (VAS) and performance status (PS) and decreased doses of analgesic. There was a dorsal leakage in 2/34 (5.8%) treated vertebral bodies in which an epidural space tumor extension was also diagnosed, without increasing neurological symptoms after the intervention. From these results vertebroplasty with delayed injection of cement is safe and effective in the treatment of vertebral localization of myeloma with osteolysis or fracture of the posterior vertebral wall.

Endoscopic removal of herniated nucleus pulposus migrated dorsally to the dural sac

A herniated nucleus pulposus (HNP) migrated dorsally to the dural sac is a rare condition. Here, we present a case, in which the HNP was removed with minimally invasive spinal endoscopy. A 54-year-old man presented complaining of left leg pain and paresis. Neurologic findings and an MRI suggested an epidural tumor or a dorsally migrated HNP compressing the S1 nerve root and dural sac. With a spinal endoscope, careful laminotomy of caudal L5 and cranial S1 was made. En bloc flavectomy exposed a mass covered with a thin capsule. The mass was identified as a dorsally migrated HNP. After complete HNP fragment removal, the dural sac and S1 nerve root were decompressed. Immediately postoperative, the leg pain subsided and motor function normalized, although the patient complained of numbness at the S1 dermatome area. In summary, a large HNP that had migrated dorsally to the dural sac was successfully removed endoscopically.

Epidural Cavernous Hemangioma with Foraminal Extension

The increased use of magnetic resonance imaging (MRI) has increased the frequency of diagnosis of cavernous hemangioma, but its presentation of an epidural lesion with foraminal extension without intramedullary involvement is very rare. We describe a 31-year-old woman admitted to our department with pain in the left side of her neck and shoulder. Gadolinium enhanced cervical MRI revealed a brightly enhanced, extradural mass (1×1×2 cm sized) with widened neural foramen; after surgical excision, it was histologically confirmed as a cavernous hemangioma. Postoperatively, the patient has no neurological deficit or specific complication. Although this lesion mimicked an epidural- neurogenic tumor, its enhancement pattern indicated a cavernous hemangioma. Accurate preoperative diagnosis is necessary for treatment planning. Cavernous hemangioma must be included in the differential diagnosis of a brightly enhanced, extradural tumors.

A Dumbbell-Shaped Meningioma Mimicking a Schwannoma in the Thoracic Spine

A 50-year-old man presented bilateral hypesthesia on and below the T6 dermatome and paresthesia. Magnetic resonance imaging (MRI) showed an intraspinal extradural tumor, which located from the 6th thoracic vertebral body to the upper margin of the 7th vertebral body, continuing dumbbell-like through the intervertebral foramen into the right middle thorax suggesting a neurogenic tumor (neurofibroma or neurilemmoma). With the patient in a prone position, we exposed and excised the tumor via a one stage posterior approach through a hemi-laminictomy of T6. Histologic examination showed a grade 1 meningothelial meningioma, according to the World Health Organization classification. Initially, we assumed the mass was a schwannoma because of its location and dumbbell shape. However, the tumor was actually a meningioma. Postoperatively, hypesthesia resolved completely and motor power of the leg gradually full recovered. A postoperative MRI revealed no evidence of residual tumor.

Spinal Angiolipoma-Case Report-

A 69-year-old male presented with a rare spinal angiolipoma manifesting as history of back pain, and numbness in both lower limbs, which progressed over a period of 5 years. Total T10-T12 laminectomy was performed and the tumor was removed en bloc. The symptoms gradually improved postoperatively. Spinal angiolipoma is an uncommon benign extradural tumor of spine, which accounts for 0.14-1.2% of all spinal tumors and is a rare cause of spinal cord compression. Recognition of this entity is crucial as a benign and curable cause of paraplegia and back pain.

Hemilaminectomy for Removal of Extramedullary or Extradural Spinal Cord Tumors: Medium to Long-Term Clinical Outcomes

PurposeLaminectomy is generally the treatment of choice for removal of spinal tumors. However, it has been shown that laminectomy may cause instability due to damage of posterior elements of the spinal column, which may induce subsequent kyphosis in the future. Therefore, to reduce the risk of deformity and spinal instability after laminectomy, hemilaminectomy has been used. However, the medium to long-term effects of hemilaminectomy on spinal sagittal alignment is not well understood. The present study was performed to evaluate the clinical outcomes, including spinal sagittal alignment of patients, associated with spinal cord tumors treated by surgical excision using hemilaminectomy.Materials and MethodsTwenty hemilaminectomy operations at our institute for extramedullary or extradural spinal cord tumors in 19 patients were evaluated retrospectively with an average follow-up of 85 months (range, 40-131 months). Neurological condition was evaluated using the improvement ratio of the Japanese Orthopaedic Association Score (JOA score) for cervical, thoracic myelopathy, or back pain, and sagittal alignment by sagittal Cobb angle of the hemilaminectomied area.ResultsThe mean improvement ratio of neurological results was 56.7% in the cervical spine (p < 0.01, n = 10), 26.3% in the thoracic spine (not significant, n = 5), and 48.6% in the lumbar spine (NS, n = 5). The sagittal Cobb angle was 4.3 ± 18.0° in the preoperative period and 5.4 ± 17.6° at the latest follow-up, indicating no significant deterioration.ConclusionHemilaminectomy is useful for extramedullary or extradural spinal cord tumors in providing fair neurological status and restoration of spinal sagittal alignment in medium to long-term follow-up.

Reliability analysis of the epidural spinal cord compression scale

The evolution of imaging techniques, along with highly effective radiation options has changed the way metastatic epidural tumors are treated. While high-grade epidural spinal cord compression (ESCC) frequently serves as an indication for surgical decompression, no consensus exists in the literature about the precise definition of this term. The advancement of the treatment paradigms in patients with metastatic tumors for the spine requires a clear grading scheme of ESCC. The degree of ESCC often serves as a major determinant in the decision to operate or irradiate. The purpose of this study was to determine the reliability and validity of a 6-point, MR imaging-based grading system for ESCC. To determine the reliability of the grading scale, a survey was distributed to 7 spine surgeons who participate in the Spine Oncology Study Group. The MR images of 25 cervical or thoracic spinal tumors were distributed consisting of 1 sagittal image and 3 axial images at the identical level including T1-weighted, T2-weighted, and Gd-enhanced T1-weighted images. The survey was administered 3 times at 2-week intervals. The inter- and intrarater reliability was assessed. The inter- and intrarater reliability ranged from good to excellent when surgeons were asked to rate the degree of spinal cord compression using T2-weighted axial images. The T2-weighted images were superior indicators of ESCC compared with T1-weighted images with and without Gd. The ESCC scale provides a valid and reliable instrument that may be used to describe the degree of ESCC based on T2-weighted MR images. This scale accounts for recent advances in the treatment of spinal metastases and may be used to provide an ESCC classification scheme for multicenter clinical trial and outcome studies.

Ultrasound measurement of optic nerve sheath diameter in patients with a clinical suspicion of raised intracranial pressure

BackgroundTo assess if ultrasound measurement of the optic nerve sheath diameter (ONSD) can accurately predict the presence of raised intracranial pressure (ICP) and acute pathology in patients in the emergency...

Transoral Robotic Surgery of the Skull Base: A Cadaver and Feasibility Study

Objective: The goal of this study was to determine the potential role as well as the current limitations of the da Vinci Surgical System robot in transoral surgery of the skull base. Methods: The da Vinci robot was used to perform dissections of the skull base on 7 cadaver heads with their neck and clavicles intact. Neurosurgeons and otolaryngologists familiar with all facets of the open microscopic, minimally invasive, endoscopic and transoral robotic surgical procedure proceeded with the approach to and dissection of the human skull base. Results: The da Vinci robot provided superb illumination and 3-dimensional depth perception. The 30- degree endoscope improved cephalad visualization, and the ‘intuitive’ nature of the da Vinci surgical robot arms provided an advantage by their ability to suture the dura at the level of the clivus. An entirely transoral route provides access to the middle and lower clivus as well as the infratemporal fossa, but access to the sellar region and anterior cranial fossa is limited via a purely transoral route. Tremor-free dural closure was successfully performed. Conclusion: Our findings suggest that transoral robotic surgery utilizing the da Vinci robot system holds great potential for skull base surgical resection of extradural and intradural tumors of the middle and lower clivus and infratemporal fossa. A collaborative approach with neurosurgeon and otolaryngologist alternating at the master console and bedside is a successful strategy. Further instrument development is necessary, and continued investigation is warranted.

Relationship of motor deficits and imaging features in metastatic epidural spinal cord compression

To explore the relationship of motor deficits of the lower extremities with the imaging features of malignant spinal cord compression (MESCCs). From July 2006 through December 2008, 56 successive MESCC patients were treated at our department. All were evaluated by magnetic resonance imaging and computed tomography and were scored according to motor deficits Frankel grading on admission. Imaging assessment factors of main involved vertebrae were level of vertebral metastatic location, epidural space involvement, vertebral body involvement, lamina involvement, posterior protrusion of posterior wall, pedicle involvement, continuity of main involved vertebrae, fracture of anterior column, fracture of posterior wall, location in upper thoracic spine and/or cervicothoracic junction. Occurrence was the same between paralytic state of MESCCs and epidural space involvement of imaging features. Multiple regression equation showed that paralytic state had a linear regression relationship with imaging factors of lamina involvement (X1), posterior protrusion of posterior wall (X2), location in upper thoracic spine and/or cervicothoracic junction (X7) of main involved vertebrae. The optimal regression equation of paralytic state (Y) and imaging feature (X) was Y = -0.009 +0.639X, + 0.149X, +0.282X. Lamina involvement of main involved vertebrae has a greatest influence upon paralytic state of MESCC patients. Imaging factors of lamina involvement, posterior protrusion of posterior wall, location in upper thoracic spine and/or cervicothoracic junction of main involved vertebrae can predict the paralytic state of MESCC patients. MESCC with lamina involvement is more easily encroached on epidural space.

Extradural Myxopapillary Ependymoma arising in the lower lumbar region

Spinal extradural ependymoma is a rare tumor; we report an unusual case of extradural lumbar ependymoma and review the relevant literature. A 58 years old male presented with the history of low back pain of 4 months duration radiating to both the lower limbs (left more than the right), difficulty in gripping footwear and limping while walking of one moth duration. Investigations were suggestive of extradural spinal tumor. Near total excision of the lesion was performed and the histology of the lesion showed myxopapillary ependymoma. The prognosis for extradural ependymomas does not appear to be as favorable because of high potential of distant metastases. Key words: Myxopapillary ependymoma, extradural, spinal tumor

Grading system of metastatic epidural spinal cord compression (MESCC).

e12514 Background: Surgery of MESCC improves ambulatory function. We demonstrated a radiosurgical decompression of MESCC, with 75% epidural tumor reduction, and 81% neurological improvement or stable. To better select patients for treatments, we developed a grading system of MESCC. Methods: Spine radiosurgery was performed in 62 pts with 85 MESCC lesions in phase II study. MESCC was diagnosed by MRI. Radiosurgery was given to the involved spine segment with median dose16 Gy in single session. All patients had prospective clinical follow-up with median 11.5 months (1–48). The proposed grading system has radiographic and neurologic components. Radiologic grades (0- V): grade 0 is spine bone involvement only, grade I is epidural tumor within the epidural fat with no thecal sac compression, grade II is involvement of dura and arachnoid with mild compression of thecal sac, grade III is tumor impingement to the spinal cord, grade IV is spinal cord displacement with CSF still visible, and grade V is spinal cord compression with CSF not visible between the tumor and the spinal cord. Neurologic gtrades (a-e): Grade a is no symptoms. Grade b is focal minor symptom such as pain. Grade c is functional paresis with muscle strength 4/5. The involved muscle is functional and ambulatory. Grade d is nonfunctional paresis with muscle strength ≤ 3/5, with the involved muscle nonfunctional or nonambulatory. Grade e is plegic, urinary or rectal incontinence. Results: There was no correlation between the radiographic and neurological grades. Patients were evenly distributed. After radiosurgery, all radiographic grade 0-II showed complete tumor response, and grade III-V showed progression in 13% (4/30 pts). Patients with neurological grades a-c progressed in 18% (9/50 pts) on neuro exam, whereas patients with grades d-e improved or stable neurologically. Conclusions: Radiographic grade and neurologic grade are mutually independent. Imaging study cannot be used to predict neurologic status. The proposed system appears to be useful in patient evaluation and reporting. Although there are many factors to be considered, this system may be used for selection of different treatments for spinal cord compression. No significant financial relationships to disclose.

Total Excision of a Recurrent Chondrosarcoma of the Thoracic Spine

A case report is presented. To describe the surgical procedure for removal of the recurrent tumor. Marginal or wide en bloc excision for recurrent chondrosarcoma is extremely difficult because of the postsurgical adhesion with surrounding soft tissues such as the dural tube. This case report includes a chart review, an examination of the patient, and a literature search. RESULTS.: A 7-year-old boy had difficulty with ambulation because of a tumor recurrence 18 months after posterior curettage of the primary chondrosarcoma of the T6 and T7. The spinal cord was severely compressed by the epidural mass, which was located anterior and to the left side of the spinal canal. The epidural tumor including the tumor capsule on the left side of the dural tube was excised piecemeal fashion. En bloc corpectomy of T6 and T7 including the capsulated epidural tumor that was located ventrally to the spinal cord was performed. A fresh iliac crest strut allograft from the patient's father was grafted to the anterior defect, and in addition, H-shape allograft was placed over the posterior side. At 15-year follow-up, the patient is ambulating with the aid of a cane, and there is no sign of recurrence on computed tomography scan or magnetic resonance imaging. His spinal alignment was maintained. Total excision (en bloc corpectomy with partially piecemeal removal) including the tumor margin has given local control and survival for 15 years in this patient who had recurrent chondrosarcoma. Anteroposterior biologic spinal reconstruction has maintained spinal alignment.

Radiosurgical decompression of metastatic epidural compression

Surgical decompression of metastatic epidural compression (MEC) improved ambulatory function. Spine radiosurgery can accurately target the epidural tumor and deliver high radiation doses for tumor control. Therefore, a clinical trial was performed to quantitatively determine the degree of epidural decompression by radiosurgery of metastatic epidural compression. Sixty-two patients with a total of 85 lesions of metastatic epidural compression were treated. Epidural compression was diagnosed by magnetic resonance imaging (MRI) scans. Main criteria of inclusion were neurological status with muscle power 4 of 5 or better. Radiosurgery was performed to the involved spine segment, including the epidural mass with median dose of 16 Gy (range 12-20 Gy) in a single session. All patients had prospective clinical follow-up, ranging from 1-48 months (median 11.5 months), and 36 patients had pretreatment and post-treatment imaging, ranging from 2-33 months (median 9.3 months). Primary endpoints were epidural tumor control and thecal sac decompression. The mean epidural tumor volume reduction was 65 +/- 14% at 2 months after radiosurgery. The epidural tumor area at the level of the most severe spinal cord compression was 0.82 +/- 0.08 cm(2) before radiosurgery and 0.41 +/- 0.06 cm(2) after radiosurgery (P < .001). Thecal sac patency improved from 55 +/- 4% to 76 +/- 3% (P < .001). Overall, neurological function improved in 81%. This study demonstrated a radiosurgical decompression of epidural tumor. Although neurosurgical decompression and radiotherapy is the standard treatment in patients with good performance, radiosurgical decompression can be a viable noninvasive treatment option for malignant epidural compression.

Lateral Transcondylar Approach for Tumors at the Anterior Aspect of the Craniovertebral Junction

Tumors at the craniovertebral junction are difficult to remove because of their location and complex anatomic relations. The lateral transcondylar approach is a versatile approach to this area and allows access to a variety of intra- and extradural tumors. The lateral transcondylar approach has been used for a series of chordomas in this location. The nuances of this operation and its effectiveness in this group of patients are presented. There were 29 chordomas (1991-2007) in this region treated by one of the authors (CS) that were retrospectively reviewed. The imaging studies and medical records were evaluated. The location and extent of the tumor were defined, and the postoperative images were studied to determine the degree of resection. There were 11 male and 18 female patients; their age range was 7 to 67 years. Headache and neck pain were the predominant presenting symptoms, and hypoglossal nerve palsy was the most common cranial nerve palsy. Twelve patients had previous surgery and 9 had previous radiation. Anterior midline and lateral approaches were used independently or in combination to treat these patients. Dural invasion was found in 27 patients requiring resection of the dura. Surgery was performed in 1 stage in 19 patients, and the tumor resection in the remaining patients was done in 2 stages. The lateral transcondylar approach was used in 19 patients. The occipital condyle was involved in all these patients. Radical tumor resection was achieved in 17 patients. Patients who had complete removal of the occipital condyle required occipitocervical fusion (20 patients) in the immediate postoperative period. The lateral transcondylar approach is an effective approach to chordomas in this region. Most of the tumors were large and extended into multiple anatomic compartments. The approach allowed resection of all the involved tissues, intra- and extracranial, and afforded excellent neurovascular control.

Isolated extraosseous epidural myeloma presenting with thoracic compressive myelopathy

Background context Multiple myeloma is the commonest primary malignancy of the spine, but it rarely presents as an extraosseous epidural tumor with only five cases reported in literature so far. Purpose The purpose of this study was to heighten awareness and treatment options of a rare case of extraosseous epidural myeloma. Study design The study design comprises a case report and literature review. Methods We present a 60-year-old lady with progressive paraplegia (American Spinal Injury Association grade C) with sensory blunting below T8 level of 2 months’ duration. Magnetic resonance imaging showed an extradural tumor in the dorsal epidural space from T6 to T7 without local bony involvement. She underwent a T6 and T7 laminectomy, T5–T8 pedicle screw instrumentation, and gross total resection of tumor. Histopathological diagnosis was consistent with myeloma. After surgery, the patient underwent local irradiation and adjuvant chemotherapy. Results Neurological improvement of one grade (American Spinal Injury Association grade C to D) was observed at 3 weeks postoperatively. Conclusions Isolated extraosseous epidural myeloma without destruction or collapse of vertebral bodies should be included in the differential diagnosis of epidural mass lesions causing spinal cord compression. The overall prognosis in terms of survival is poor, but early decompression can prevent neurological deterioration and improve quality of life.

Spinal dermal sinus tract

neurological abnormalities were a common finding. The most common radiological finding was tethered cord, and most patients had abnormal findings in urological evaluation. The authors concluded that timely intervention and complete resection is of paramount importance for patient’s outcome. We have recently studied the DSTs that were treated in our institute over the last decade. We encountered one case of DST in the thoracic area and two cases in the lumbar area. All patients presented with meningitis. On radiological evaluation no addition abnormalities were revealed. In two cases, there was an extradural and intradural dermoid tumor along the sinus track (Figs. 1 and 2). Using a microsurgical technique, the DST was removed in all cases. Postoperative all patients were neurologically intact. Timely diagnosis and surgical intervention with intradural exploration is crucial in order to prevent DST’s complications.

Primary spinal angiosarcoma

Primary angiosarcoma of the spine is rare. To our knowledge, primary angiosarcoma in the posterior element of the spine has not been reported previously. A 39-year-old man suffered progressive numbness and paresis of the bilateral lower limbs. Neuroimaging showed a large dorsal extradural tumor compressing the spinal cord at the T11 level with bony destruction of the left foramen and posterior elements. Spinal angiography revealed a hypervascular tumor in the left T11 region. Successful preoperative endovascular embolization, laminectomy and removal of the tumor were performed.