Intradural Extramedullary Tumors Research Articles

Differentiating spinal intradural-extramedullary schwannoma from meningioma using MRI T2 weighted images.

Prior studies advocate the subjective visual differences between meningioma and schwannoma on T2 weighted images, however objective measurement of signal intensity differences may be useful in certain cases. The aim of this study was to investigate whether an objective evaluation of SIs on T2 weighted images would be useful to differentiate spinal schwannomas from meningiomas. The patients with spinal MRIs demonstrating path proven and subsequently treated intradural extramedullary spinal tumors were selected between April 2008 and May 2017. Regions of interest (ROIs) were measured in the tumor and subcutaneous fat on the same image, and we calculated the SI ratio between tumor and fat ROIs. Twenty patients each with meningioma and schwannoma were enrolled. The SI ratios of schwannomas were significantly higher than those of meningiomas (both researcher 1 and 2: p = 0.002). The areas under the curve by researchers 1 and 2 were 0.780. The cutoff value of SI ratio by both of researchers 1 and 2 to differentiate between schwannomas from meningiomas was 0.420 (sensitivity: 80.0%, specificity: 70.0-75.0%). The SI ratio, calculated from the SIs of the tumor and fat on T2 weighted images, is useful for differentiating spinal schwannomas from meningiomas to obtain an accurate diagnosis. Signal intensity ratio of the spinal tumor and fat on T2 weighted images is useful for differentiating schwannomas from meningiomas to obtain an accurate diagnosis.

In Reply: Guidelines for the Use of Electrophysiological Monitoring for Surgery of the Human Spinal Column and Spinal Cord.

In Reply: Guidelines for the Use of Electrophysiological Monitoring for Surgery of the Human Spinal Column and Spinal Cord.

Intraoperative Spinal Navigation for the Removal of Intradural Tumors: Technical Notes.

In recent years, spinal surgery has incorporated the many advantages of navigation techniques to facilitate the placement of pedicle screws during osteosynthesis, mainly for degenerative diseases. However, spinal intradural tumors are not clearly visible by intraoperative fluoroscopy or computed tomography scans, thereby making navigation necessary. To evaluate the use of spinal navigation for the removal of intradural and spinal cord tumors using spinal magnetic resonance imaging (MRI) merged with intraoperative 3-dimensional (3-D) fluoro images. After fixing the patient reference frame on the spinous process, the 3-D fluoro images were obtained in the surgical room. Using this image as the reference, the preoperative volumetric MRI images and intraoperative 3-D fluoro images were merged using automated software or manually. From January to July 2016, we performed 10 navigated procedures for intradural spinal tumors by merging MRI and 3-D fluoro images. Nine patients had an intradural extramedullary tumor, 6 had neurinomas, and 3 had meningiomas; 1 patient had an intramedullary spinal cord metastasis. The surgically demonstrated benefits of spinal navigation for the removal of intradural tumors include the decreased risk of surgery at the wrong spinal level, a minimal length of skin incision and muscle strip, and a reduction in bone removal extension. Furthermore, this technique offers the advantage of opening the dura as much as is necessary and, in the case of intrinsic spinal cord tumors, it allows the tumor to be centered. Otherwise, this would not be visible, thus enabling the precise level and the posterior midline sulcus to be determined when performing a mielotomy.

Rare intradural extramedullary spinal granular cell tumor in a young female

Rare intradural extramedullary spinal granular cell tumor in a young female

Spinal meningioma and factors predictive of post-operative deterioration.

Spinal meningiomas are slow-growing intradural-extramedullary tumors. They are usually associated with good outcomes. However, there are few descriptions of factors predictive of impaired evolution. Our objective was to identify predictive factors of post-operative deterioration as well as outcomes at follow-up. Between 2009 and 2016, 87 patients had surgery for spinal meningioma in our referral center. Clinical presentation, management and outcomes were reported during the post-operative period and at 3-month follow-up. Evaluation was based on post-operative neurological deterioration defined as an increase of at least one point in the McCormick score compared to the status at admission. During the study period, post-operative deterioration occurred in 17 patients (19.5%). Risk factors associated with this deterioration were the absence of pre-operative neurological signs (Relative Risk; RR = 2.38, p = 0.04), an anterior location of the meningioma and a grade 2 meningioma on WHO classification score (RR = 6, p ≤ 0.01). At 3-month follow-up, in patients who initially presented with a motor deficit, partial recovery was found in 75%, stability in 20% and a deterioration of their clinical status in 5%. After a mean follow-up of 92.4 ± 51.9 months, the recurrence rate was 8%. Spinal meningiomas are usually benign tumors whose treatment is based on complete surgical resection. Progress in surgical techniques has resulted in lower morbidity rates and improvement in post-operative recovery. In this study, we observed several factors associated with clinical deterioration. Before surgery, patients should be fully informed of these predictive factors of post-operative deterioration and their association with surgical morbidity.

MODIFIED LAMINOPLASTY AFTER EXCISION OF CERVICAL SCHWANNOMA WITH LARGE EXTRAVERTEBRAL EXTENSION

Tumour excision and laminoplasty are commonly performed as surgical treatment of extra vertebral extension of cervical schwannoma. It is worth knowing that the conventional technique of multilevel laminectomy may hinder younger patients in the long-term. This article reports a 30-year old man with an intradural-extramedullary tumour which extended from C4 to T1 that underwent modified laminoplasty. This modified technique is preferable in maintaining the anteroposterior diameter of spinal canal as well as reducing the displacement of guttered laminae

Surgical Complications in Intradural Extramedullary Spinal Cord Tumors - An ACS-NSQIP Analysis of Spinal Cord Level and Malignancy

Intradural extramedullary (IDEM) spinal cord tumors account for two-thirds of all intraspinal neoplasms. Surgery for IDEM tumors carries risks for many different complications, which to date have been poorly described and quantified. In this study, we better characterize risk factors and complications for IDEM tumors, stratifying patients by spinal cord level and malignancy. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to determine 30-day outcomes following surgery for IDEM tumors between 2005 and 2016. Patients with cervical, thoracic, and lumbar tumors were compared in terms of demographics, comorbidities, and postoperative complications. A similar analysis was performed comparing patients with benign and malignant tumors. A total of 991 patients with IDEM tumors were identified in the cohort. The majority of tumors were thoracic (44.3%), followed by lumbar (35.4%) and cervical (20.3%). Only 6.3% of patients were readmitted within 30 days, 4.2% returned to the operating room, and 1.0% died. Significant associations were noted between spinal cord level and patient sex, age, functional status, American Society of Anesthesiologists (ASA) classification, prevalence of diabetes and hypertension, and risk of developing pneumonia. Benign and malignant tumors differed by patient sex, baseline ASA class, risk of return to the operating room, mortality, and likelihood of transfusion. IDEM tumors are common and carry surgical risks, with different complication profiles for tumors at different spinal levels and degrees of malignancy. With definitive risk factors and outcomes, the ACS-NSQIP cohort provides a snapshot of national neurosurgery trends and outcomes in contemporary IDEM surgery.

Intradural extramedullary tumor in the stenotic cervical spine resected through open-door laminoplasty with hydroxyapatite spacers: report of two cases

BackgroundSafe excision of spinal cord tumors depends on sufficient visualization of the tumor and surrounding structures. In patients with spinal cord tumor adjacent to a stenotic spinal canal, extensive bony decompression proximal and distal to the tumor should be considered for safer excision of the tumor. Extensive wide laminectomy is one choice for such cases, but postoperative problems such as kyphotic deformity remain a concern.Case presentationA 76-year-old man and a 60-year-old woman presented with symptomatic intradural extramedullary spinal cord tumors in the cervical spine. Both patients showed a combination of spondylotic changes in the cervical spine and stenotic condition at the level of the tumor. Both tumors were successfully resected through open-door laminoplasty with hydroxyapatite (HA) spacers, with the tumor located on the side of the laminoplasty. Histological diagnosis was schwannoma for both tumors. HA spacers completely bonded to the host bone and did not interfere with postoperative magnetic resonance imaging (MRI) of the inside of the spinal canal. Cervical spine alignment was maintained at the final follow-up of 6 years in both cases.ConclusionLaminoplasty with HA spacers enabled successful tumor extirpation, reliable MRI follow-up after surgery, and maintenance of normal cervical spine alignment. Laminoplasty with HA spacers represents a good option for the treatment of cervical spinal cord tumor in patients combined with spinal stenosis.

Filum terminale paraganglioma with associated cyst: a case report

Abstract Background and importance: Paragangliomas are neuroendocrine tumors that occur most often within the adrenal glands. The most frequent extra-adrenal locations include the carotid body and the jugular bulb. Filum terminale paragangliomas are extremely rare, with just 33 cases reported to date. Imagistic appearance is similar with other types of intradural extramedullary tumors such as ependymomas and schwannomas. Histopathological examination is the only method of establishing a definitive diagnosis. They are classified as grade I WHO tumors with favorable prognosis in the case of total resection. Clinical presentation: A 46-year-old woman without any relevant medical history was admitted to our Neurosurgical Department, complaining of low back pain with bilateral sciatica. She presented no neurological deficits and routine blood tests, as well as heart rate and blood pressure, were within normal ranges. Lumbar spine MRI with gadolinium enhancement revealed an intradural tumor with irregular, well defined margins and intense homogeneous enhancement, located at the level of the L3 vertebra. It presented an unenhancing intradural cystic lesion that extended cranially up to the level of the L1 vertebra. The tumor and associated cyst were completely resected through L2-L4 laminectomy. The tumor-cyst complex was attached, yet nonadherent to the conus medullaris and nerve roots, which allowed safe total removal. Histopathological examination was suggestive for paraganglioma, a diagnosis confirmed by immunohistochemistry that classified it as moderately differentiated, non-secreting type. Serum metanephrines subsequently determined were within normal ranges. Also, additional imagistic tests consisting of cervical and abdominal ultrasound and contrast enhanced CT scans did not detect any additional tumors. Postoperatively, the patient was neurologically intact, with complete remission of presenting symptoms at 3 months follow-up. Conclusion: Filum terminale paraganglioma is a rare diagnosis which is frequently overlooked. However, gross total resection, a common goal for all spinal tumors, can be curative in these particular cases.

S122. Intraoperative electrical stimulation to identify the corticospinal tract and dorsal column during spinal cord tumor surgery

Introduction Anatomical identification of the corticospinal tract (CT) and the dorsal column (DC) of the exposed spinal cord is difficult when anatomical landmarks are distorted by tumour growth. Intraoperative neurophysiological identification is complicated by the fact that direct stimulation of the DC may result in muscle motor responses due to the centrally activated H-reflex. This study aimed to provide a technique for intraoperative neurophysiological differentiation between CT and DC in the surgical exposed spinal cord. Methods Recordings were obtained from 32 consecutive patients undergoing intramedullary or intradural-extramedullary spinal cord tumour surgery from 07/2015 to 03/2017. A double train stimulation paradigm with an intertrain interval of 60 ms was devised by a hand held probe with simultaneous recording of responses from limb muscles. Results In non spastic patients (55% of cohort) an identical second response was noted following the first response after CT stimulation, but the second response was absent after DC stimulation. In patients with preexisting spasticity (45%), CT stimulation again resulted in two identical responses, whereas DC stimulation generated a second response that differed substantially from the first one. The recovery times of interneurons in the spinal cord grey matter for the CT were much shorter than those for the DC. Therefore, when a second stimulus train was applied 60 ms after the first, the CT-fibre interneurons had already recovered ready to generate a second response, whereas the DC interneurons were still in the refractory period. Conclusion Intraoperative mapping of the surgical exposed spinal cord using double-train stimulation paradigm allows neurophysiological distinction of CT from DC pathways during spinal cord surgery in patients with and without preexisting spasticity.

LONG-TERM RESULTS OF SURGICAL TREATMENT IN PATIENTS WITH INTRADURAL SPINAL TUMORS

Background: Intradural spinal cord tumors include extramedullary and intramedullary tumors. The search for literature sources in the Pubmed, Medline, and E-Library databases detected a little number of researches on the long-term results of the surgical treatment of intradural spinal cord tumors. These clinical series include a small number of patients and do not consider the factors influencing clinical outcomes of surgical treatment.Aim: To evaluate the long-term results of surgical treatment in patients with intradural spinal cord tumors, to identify the main factors influencing the clinical and neurological outcomes of surgical interventions in this group of patients.Materials and methods: The study included 277 medical records of 244 patients with intradural extramedullary and 33 patients with intradural intramedullary tumors of the spinal cord. Clinical-neurological outcomes of surgical treatment in patients with intradural spinal cord tumors and factors influencing the outcomes were analyzed.Results: When comparing the degree of neurologic deficit in patients with intradural extramedullary tumors prior to surgery, no significant differences were found (p=0.241) both in the early postoperative period and 6 months after the surgery. Nevertheless, when comparing these indicators in a period of 12, 24, 36, 48, and 60 months after the surgery, statistically significant differences were revealed (p0.001). There was no statistically significant difference (p=0.437) between the scores in patients with intramedullary tumors on the modified McCormick Scale preoperatively, at the 6-month and one-year follow-up; however, comparison of the clinical and neurological indicators at 24, 26, 48, and 60 months revealed a significant difference (p0.001). The surgery outcomes in considered groups of patients were significantly influenced by the following indicators: the ASA risk level (odds ratio (OS) 2.138; 95% confidence interval (95% CI) 3.346–12.145) and intraoperative neurophysiological monitoring (OR 2.84; 95% CI 1.67–9.56).Conclusion: The study registered good and excellent long-term outcomes in most cases of intradural spinal cord tumors when the maximum possible tumor excision was performed. Analysis of the influence of various factors on the clinical and neurological outcomes in the study group of patients showed that the use of intraoperative neurophysiological monitoring and the degree of operational and anesthetic risk according to the ASA scale have a significant effect.

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.

Spinal Meningiomas

Objectives and Introduction: This study aims to present the cases and surgical outcomes of 14 cases of spinal meningiomas, along with an updated review of the medical literature of the disease. Spinal meningiomas are benign neoplasms that account for 25% to 50% of all intradural extramedullary tumors, and with a prevalence of up to 2:100,000/year, primarily affecting female adults. Treatment is primarily surgical. Patients and methods: We selected patients with diagnosis of spinal meningiomas, admitted in three different Brazilian hospital facilities from January 1995 to January 2014. Later, the cases were analyzed for age, clinical and neurological examination, neuroimaging studies, treatment, histopathological examination and prognosis. Results and Conclusion: Ten patients were female and four male with average age of 53 years. Pain was present in all patients; twelve patients (85%) had abnormal motor function in the lower limbs; paresthesia in eight (57%) and hypoesthesia in four (28%); sphincter changes in four (28%) and Brown-Sequard syndrome in one case (7%). Thirteen patients (92%) underwent laminectomy, and one patient (7%) was submitted to laminoplasty. During the follow-up sensory changes were present in six (42%), abnormal motor function in four (28%), urinary incontinence in two (14%) and neuropathic pain in one patient (7%). The extent of resection is considered the most important factor in determining the rate of recurrence. In this work, “en bloc” resection was possible in most of the cases. Recurrence risk in five years after total resection of the tumor was null, and in ten years was 13%. Spinal arachnoiditis is the most frequent complication in postoperative period, which has a poor prognosis.

Multifocal primary melanoma of the cervical spinal cord successfully treated by tumorectomy: a case report.

Multifocal primary melanoma of the spine is extremely rare. Here, we report a case of multifocal primary melanoma of the cervical spinal cord. A 39-year-old man presented with a 1-year history of numbness of the upper extremities and back. Magnetic resonance imaging of the cervical spine suggested multifocal intradural extramedullary tumors at levels C2 and C4-C5. A diagnostic biopsy revealed a pathological diagnosis of malignant melanoma. Tumorectomy was then performed. The numbness in the patient's upper extremities improved, and he was discharged. As of 2 years after surgery, no signs of local or systemic recurrence have been noted. Primary melanoma of the spinal cord usually carries a poor prognosis. However, in this case, the outcome following tumorectomy has been highly favorable. We speculate that this is because the MIB-1 labeling index of the tumors was less than 1%.

Arachnoid isolation sign: A predictive imaging feature of spinal meningioma on CT-myelogram

ObjectNumerous studies have demonstrated the imaging features to differentiate spinal meningioma and schwannoma. However, diagnosis can be controversial among clinicians. The purpose of our study was to evaluate the diagnostic value of a novel imaging finding of meningioma on CT-myelogram (CTM). Patients and MethodsImaging findings of patients who underwent surgeries for spinal cord tumors between April 2005 to May 2015 were retrospectively reviewed. Our inclusion criteria were as follows: 1) intradural extramedullary tumor, 2) both magnetic resonance imaging (MRI) and CTM were available. The exclusion criterion was a tumor that showed invasion to extradural space. ResultsThirty spinal meningiomas and schwannomas were identified (eight meningiomas and 22 schwannomas). Among these, two meningiomas showed a characteristic imaging phenomenon on CTM: they were diagnosed as intradural tumors on MR imaging while on CTM, they were isolated by the contrast agent in subarachnoidal space from the intact spinal cord. We named this imaging feature, the arachnoid isolation sign (AIS). None of the schwannomas showed this imaging feature. ConclusionWe identified a unique imaging feature of spinal meningioma on CTM. The sensitivity and specificity were 25% and 100%, respectively. In the current case, its diagnostic value was the same as the calcification on CT. Although the number is still small, the AIS may be useful to discern a spinal meningioma from schwannoma.

MENINGIOMA OF THE ANTERIOR PORTION OF THE CRANIOVERTEBRAL JUNCTION

The paper describes clinical features, diagnosis and treatment of spinal cord tumor localized in the anterior portion of the craniovertebral junction in a 43-years-old patient after a course of stereotactic radiotherapy with the CyberKnife linear accelerator. The surgical treatment included microsurgical total removal of intradural extramedullary tumor at the level of the craniovertebral junction through far lateral approach with neurophysiologic monitoring. Good clinical results achieved in the early postoperative period were presented by restoration of muscle force in the limbs (regression of tetraparesis) and headache relief.

Effectiveness of intraoperative monitoring of motor evoked potentials for predicting changes in the neurological status of patients with cervical spinal cord tumors in the early postoperative period

The study aim was to evaluate the effectiveness of intraoperative monitoring of motor evoked potentials (MEPs) for predicting changes in the neurological status of patients with cervical spinal cord tumors in the early postoperative period. The study included 74 patients with intradural cervical spinal cord tumors who were operated on using motor evoked potential monitoring in the period from 2013 to 2016. There were 29 (39%) males and 46 (61%) females. Group 1 included 26 (35%) patients with intramedullary tumors; group 2 included 48 (65%) patients with intradural extramedullary tumors. The neurological status was assessed by using a six-grade muscle power MRC scale; a modified McCormick scale was used to evaluate the functional status. Transcranial electrical stimulation of the precentral gyri was performed. Recording electrodes were located in the peripheral target muscles of the upper and lower limbs. Total intravenous anesthesia with propofol and fentanyl was used. In Group 1, MEPs decreased in 19 (73%) of 26 patients; MEPs remained unchanged in 7 (27%) patients. Among the patients with decreased MEPs, 14 (74%) patients had postoperative deterioration of the neurological status; 6 (32%) patients had a preoperative severe neurological deficit; 4 (21%) patients had no changes in the neurological status. The sensitivity and specificity of MEPs from the upper limb muscles were higher than those from the lower limb muscles. In Group 2, improvement of the neurological status occurred in all 48 patients. There was no case of a true positive decrease in the MEP amplitude. 1. Registration of MEPs is a highly sensitive and highly specific method for diagnosing corticospinal tract dysfunction in patients with intramedullary tumors of the cervical spinal cord. The sensitivity and specificity of MEPs recorded from the upper limbs are higher than those from the lower limb muscles. 2. The sensitivity of MEPs in patients with extramedullary intradural tumors was 0%, the diagnostic effectiveness of MEPs amounted to 86% from the upper limb muscles and 93% from the lower limb muscles. 3. When the MEP amplitude in patients with extra- and intramedullary tumors of the cervical spinal cord decreases, a change in the surgion's approach may reduce or completely eliminate surgically-induced damage to the spinal cord.

Clinicopathological Study of Patients with Intradural Extramedullary Spinal Tumours and Surgical Outcome

Clinicopathological Study of Patients with Intradural Extramedullary Spinal Tumours and Surgical Outcome

Intramedullary neuroenteric cyst: Case report and review of the literature

ResumenLos quistes neuroentéricos (QNE) son lesiones raras, congénitas y benignas, causadas por la comunicación persistente o anormal entre el neuroectodermo, la notocorda y el endodermo. Se presentan principalmente en pacientes pediátricos y adultos jóvenes, asociados a otras malformaciones vertebromedulares, gastrointestinales y respiratorias. Son lesiones intradurales extramedulares, siendo excepcional su presentación intramedular. El objetivo del presente artículo es reportar un caso de QNE intramedular cervical en un adulto joven, sin malformaciones concomitantes. El tratamiento quirúrgico es de elección según toda la bibliografía consultada, y por su alta tasa de recurrencia, el objetivo debe ser la resección total. El seguimiento con RMN es recomendado en resecciones subtotales.

Benefits of spinal meningioma resection.

Background:Spinal meningiomas account for approximately 40% of intradural extramedullary tumors. As they are usually slow growing, some patients are often diagnosed late in the clinical course when they have developed myelopathy.Methods:Here, we retrospectively studied a cohort of 51 patients undergoing surgery for spinal meningiomas. The median follow-up period was 45.9 months (range, 1–168 months). Assessment included evaluation of functional outcomes (e.g., comparison of the pre and postoperative status using the modified McCormick Functional Scale) and identification of prognostic factors.Results:Seventeen patients with grade IV (McCormick Scale) neurological deficits on admission underwent surgical resection; 4 of 5 grade III (McCormick Scale) and 14 patients (Grade IV) improved within 2.11 months (mean time) postoperatively. There was no surgical mortality and the morbidity rate was 16%.Conclusion:Patients with advanced neurological deficits/myelopathy (Grades III or IV on the McCormick Scale) improved following surgical resection of spinal meningiomas.