Intradural Spinal Cord Research Articles

Thoraco-lumbar high grade spinal cord astrocytoma: first documented case in a tertiary medical center and review of literature

<p class="abstract">This presents the first documented case of high grade spinal cord astrocytoma in a pediatric patient treated at a tertiary medical center and gives a comprehensive review of literature on the most current modes of diagnosis, treatment, and prognosis. We report the case of a 7-year-old male with complaints of inability to ambulate and associated low back pain, which rapidly deteriorated to complete paraplegia. Magnetic resonance imaging (MRI) of his spine revealed an intradural intramedullary spinal cord lesion extending from T11 to L5 vertebra, with considerations of spinal astrocytoma and ependymoma. The patient underwent en bloc laminectomy on T9-L3, partial resection of the intramedullary cord tumor, and subsequent laminoplasty with mini plates and screws. Histopathologic studies showed spinal cord astrocytoma, World Health Organization (WHO) grade 3 (anaplastic type). The patient’s neurologic status did not improve after the surgery and was advised to undergo chemo-radiation therapy but was lost to follow up. Ten months post-operation, patient sought consult due to severe back pain, generalized body weakness, and difficulty of breathing and was then admitted. Patient’s condition worsened that eventually resulted to his demise.</p><p class="abstract"> </p>

Functional Outcomes and Temporal Profile of Recovery in Patients with Intradural Extramedullary Spinal Cord Tumors with Poor Nurick Grade

Patients with spinal intradural extramedullary (IDEM) tumors usually have a good functional outcome after tumor excision. However, the literature is sparse on the functional outcome in patients with poor Nurick grade (NG 4 and 5). A retrospective review of 81 patients with IDEM tumors presenting with a poor NG was performed to determine postoperative functional outcome and the temporal pattern of recovery. The following risk factors were analyzed: preoperative NG, duration of symptoms, tumor location, peritumoral edema, presence of syrinx, and tumor type. Neurologic function started recovering soon after surgery, with >80% of the patients improving by ≥1 grade at the end of 1 week after surgery. Of the 66 patients available for follow-up of >6 months after surgery, 63 (95.5%) improved to NG 0-2 and 51 (77.2%) became asymptomatic (NG 0 or 1). Three patients had a poor functional outcome on follow-up of >31 months; 2 had improved from NG 5 to NG 4, whereas 1 patient continued to be in NG 4. Factors associated with a poor outcome were an upper thoracic location (P= 0.025) and presence of a syrinx (P= 0.004). None of the patients had bladder dysfunction at follow-up of >6 months. After excision of spinal IDEM tumors, in patients who present with a poor neurologic function (NG 4 and 5), good functional outcome (NG 0-2) can be expected in >95% of patients. No recovery can be anticipated beyond 1 year after surgery.

Comparison of the safety and outcomes between keyhole surgery and total laminectomy for resection of intradural extramedullary spinal cord tumors

Objective: To compare the safety and outcomes between keyhole surgery and total laminectomy for resection of intradural extramedullary spinal cord tumors. Methods: Retrospectively collected the clinical data of 102 patients with intradural extramedullary spinal cord tumors(≤3 cm) treated by surgery in Department of Orthopedics in Fujian Provincial Hospital from January 2014 to January 2017. Fifty cases underwent the keyhole surgery and the other 52 received total laminectomy. The operation time, volume of intraoperative bleeding, the leaving bed time, the length of postoperative hospital stay, drainage, postoperative complications, intraoperative neuroelectrophysiological monitoring (IONM), preoperative and postoperative visual analogue score (VAS), neck disability index (NDI), Oswestry disability index (ODI), McCormick spinal cord function grading were analyzed and compared between the two groups to evaluate the safety and clinical outcomes. The data of two groups were compared by t, χ(2) or rank sum test. Results: The keyhole group was followed up for (30±15) months and the total laminectomy group was followed up for (45±15) months. All the tumors were completely resected. All the incision healed well and no cerebrospinal fluid leakage occurred. There was no statistically significant differences in baseline data, operation time, the results of IONM, preoperative and 3 months, 6 months, 12 months postoperative VAS, NDI (cervical tumors), ODI (thoracic and lumbar tumors), McCormick spinal cord function grading, tumor recurrence between the two groups (all P>0.05). The keyhole group had less intraoperative bleeding than that in the total laminectomy group ((73±24) ml vs (136±26) ml, t=-12.610, P<0.05), earlier postoperative leaving bed time ((1.4±0.6) d vs (6.5±1.0) d, t=-31.822, P<0.05), and the postoperative hospital stay was shorter ((4.3±0.8) d vs (11.2±2.0) d, t=-22.319, P<0.05), and it was more advantageous in terms of drainage. The VAS, NDI and ODI in the keyhole group improved significantly compared with those in the total laminectomy group 2 weeks post operation (all P<0.05). Conclusion: Compared with the total laminectomy, keyhole surgery is suitable for the treatment of intradural extramedullary spinal cord tumors with small size and limited location, and it is equivalently safe with faster functional recovery.

Hydrocephalus in primary intradural spinal cord tumors: a systematic review of the literature in the pediatric population.

Hydrocephalus in children with primary intradural spinal cord tumors is exceedingly rare. Herewith, we performed a systematic literature review to address epidemiology, suggested pathophysiological mechanisms, prognostic factors, and treatment of such cases. We performed a systematic review with the best available evidence on cases of pediatric primary intradural tumors of the spinal cord presented with hydrocephalus. The patients were subjected to quantitative analysis on a basis of epidemiological features (age, sex, tumor type and location, clinical presentation, survival, dissemination). The possible pathophysiological theories are discussed in detail. Forty-four studies with a total of 121 patients were included in the study. Astrocytomas were the most frequent tumor (64.5%) type, while most tumors were located in cervical (31.4%) or cervicothoracic region (25.6%). About half of the cases concerned children under 6years of age. The block of subarachnoid CSF (cerebrospinal fluid) pathways from disseminated tumor cells and the neoplastic inflammation caused by tumor elements advocated to be the major pathogenetic mechanisms. Surgical excision of the tumor and hydrocephalus treatment is usually performed. Primary intradural spinal cord tumors should be considered in children with communicative hydrocephalus of unknown etiology. Onset of hydrocephalus after tumor removal is related to higher mortality.

Cerebrospinal fluid levels of GFAP and pNF-H are elevated in patients with chronic spinal cord injury and neurological deterioration

BackgroundYears after a traumatic spinal cord injury (SCI), a subset of patients may develop progressive clinical deterioration due to intradural scar formation and spinal cord tethering, with or without an associated syringomyelia. Meningitis, intradural hemorrhages, or intradural tumor surgery may also trigger glial scar formation and spinal cord tethering, leading to neurological worsening. Surgery is the treatment of choice in these chronic SCI patients.ObjectiveWe hypothesized that cerebrospinal fluid (CSF) and plasma biomarkers could track ongoing neuronal loss and scar formation in patients with spinal cord tethering and are associated with clinical symptoms.MethodsWe prospectively enrolled 12 patients with spinal cord tethering and measured glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase L1 (UCH-L1), and phosphorylated Neurofilament-heavy (pNF-H) in CSF and blood. Seven patients with benign lumbar intradural tumors and 7 patients with cervical radiculopathy without spinal cord involvement served as controls.ResultsAll evaluated biomarker levels were markedly higher in CSF than in plasma, without any correlation between the two compartments. When compared with radiculopathy controls, CSF GFAP and pNF-H levels were higher in patients with spinal cord tethering (p ≤ 0.05). In contrast, CSF UCH-L1 levels were not altered in chronic SCI patients when compared with either control groups.ConclusionsThe present findings suggest that in patients with spinal cord tethering, CSF GFAP and pNF-H levels might reflect ongoing scar formation and neuronal injury potentially responsible for progressive neurological deterioration.

Syringo-Subarachnoid Shunt Placement: A Minimally Invasive Technique Using Fixed Tubular Retractors-Three Case Reports and Literature Review.

Placement of a syringo-subarachnoid shunt as a surgical management for syringomyelia has been well described in the literature. Good results in terms of clinical and radiological improvement have been documented especially for posttraumatic syringomyelia. Traditionally, this has been performed using open approaches which are fraught with risks of cerebrospinal fluid leak, delayed wound healing, and increased postoperative pain. With the help of minimally invasive techniques that are currently being used to treat various degenerative spinal disorders, most of these complications may be minimized. However, few reports in literature describe similar approaches for accessing intradural intramedullary spinal cord lesions and especially for syringomyelia. Retrospective case review: using a 22-mm tubular retractor, a laminotomy was performed, durotomy done, and spinal cord identified. Myelotomy was performed at the dorsal root entry zone, syrinx visualized and entered, followed by placement of syringo-subarachnoid shunt. Three male patients aged 44, 57, and 37 underwent placement of syringo-subarachnoid shunts using minimally invasive fixed tubular retractors. Indications included posttraumatic or postsurgical spinal cord syrinx. Follow-up period was 1 year in all cases. There were no neurological or technique-related complications. All patients showed clinical improvement upon subsequent follow up. Our clinical experience on the treatment of syringomyelia via a minimally invasive fixed tubular retractor is presented. We find that this is an ideal approach for placement of syringo-subarachnoid shunts, as it provides direct access to the lesion with minimal collateral damage and wound-related complications. 4. Relevant - in demonstrating the effectiveness of an already established procedure through a novel, minimally invasive approach which has the potential to significantly reduce the overall morbidity, in view of the inherent approach-related benefits as compared to conventional open approaches.

Surgical outcome of intradural extramedullary spinal cord tumors - Our experience at a tertiary health care center

Introduction: To report the treatment results of 19 patients who underwent excision of intradural extramedullary (IDEM) spinal tumors.&#x0D; Materials &amp; Methods: This is a retrospective study. Patients’ records were retrieved from the electronic database of Grande International Hospital. There were 19 IDEM spinal tumors excised over a period of 6 years between January 2013 and August 2019 by a single surgeon. There were 11 (57.9%) males and 8 (42.1%) females with an average age of 48.37±21.87 years (range, 5-79 years). The mean postoperative follow-up period was 12.87±14.88 months (range, 15 days - 60 months). The histopathological findings, locations of the tumors, and clinical results were analyzed. Neurological findings were evaluated using ASIA grading system and pain was evaluated using VAS score.&#x0D; Results: Histopathologically the tumors were: 8 meningioma (42.1%), 4 schwannoma (21.1%), 4 neurofibroma (21.1%), 1 dermoid cyst (5.3%), 1 lipoma (5.3%), and 1 myxopapillary ependymoma (5.3%). Tumor locations were: dorsal in 10 (52.6%), lumbar in 5 (26.3%), lumbosacral in 2 (10.5%), dorsolumbar in 1 (5.3%), and cervical in 1 (5.3%) patient. Neurologic status of 7 patients was normal and 12 had neurologic involvement with 3 patients having Cauda Equina Syndrome (CES) preoperatively. At the final follow-up, 3-grade, 2-grade and 1-grade improvement in ASIA score was observed in 1, 6 and 1 cases, respectively. There was no change in the ASIA grade in 1 case. All 3 cases of CES achieved full neural recovery. Preoperative VAS score was 9.21±1.08 and improved significantly to 0.74±1.62 after surgery. Neurological improvement was seen in 91.67% with complete recovery in 75% of the cases and not a single case deteriorated neurologically post-surgery.&#x0D; Conclusion: Most intradural-extramedullary spinal cord tumors are mostly benign and good clinical results can be obtained when adequately treated with surgery.

Intradural spinal cord metastases: a report of five cases

Intradural spinal cord metastases: a report of five cases

Dural Repair by Direct Continuous Locking Sutures and Concomitant Insertion of Subfascial Tube in Planned Intradural Spinal Cord Tumor Surgery

Background: Durotomy induced cerebrospinal fluid (CSF) leakage is a terrible complication in spine surgery that could be occurred even with expertise. The estimated rate of CSF leakage in intentional durotomies varies from 5 to 13% in intradural spinal tumor resection to even higher rate for surgeries for tethered cord syndrome or Chiari I malformation. Different treatment modalities are utilized as conservative measures, direct sutures, autograft, dural substitutes and sealant agents to overcome this complication. Patient and method: This is a retrospective descriptive study of thirty patients were operated upon at neurosurgery department of Elsahil teaching hospital from November 2014 to November 2019. They were operated for intradural spinal cord tumor excision followed by primary direct sutural repair of the durotomy site augmented with autograft and concomitant insertion of subfascial tube as a drainage tube for seven to ten days. Aim: To evaluate the results of primary direct dural repair with continuous locking sutures and on lay gel foam layer augmented with autograft (fat or muscle) without sealant agents. With concomitant insertion of subfascial tube closed system as drainage in planned intradural surgery. Results: After subfascial tube removal three cases (10%) show persistent leakage that managed conservatively with tapering cessation within three weeks till complete cessation of the CSF leakage occur. One of the three cases developed pseudomeningocele (3.3%) after complete wound closure and cessation of the leakage. Conclusion: Direct sutural repair of the durotomy site with continuous locking sutural closure and on lay gel foam layer and fat or muscle graft without any sealant agents, and concomitant insertion of subfascial tube closed system as a drainage tube for seven to ten days, is effective and safe economic method for dural repair.

Durotomy Surrogate and Seals for Intradural Spinal Cord Stimulators: Apparatus and Review of Clinical Methods and Materials

We are developing a novel intradural spinal cord stimulator for treatment of neuropathic pain and spasticity. A key feature is the means by which it seals the dura mater to prevent leakage of cerebrospinal fluid (CSF). We have built and employed a test rig that enables evaluation of candidate seal materials. To guide the design of the test rig, we reviewed the literature on neurosurgical durotomies. The test rig has a mock durotomy slot with a dural substitute serving as the surrogate dura mater and water as the CSF. The primary experimental goal was to evaluate the effectiveness of candidate gasket materials as seals against CSF leakage in an implanted prototype device, at both normal and super-physiologic pressures. A secondary goal was to measure the transmembrane flows in a representative dural substitute material, to establish its baseline aqueous transport properties. The seals prevented leakage of water at the implantation site over periods of ≈ ten days, long enough for the scar tissue to form in the clinical situation. The seals also held at water pressure transients approaching 250 mm Hg. The residual volumetric flux of water through the dura substitute membrane (Durepair®) was δVT /A ≈ 0.24 mm3 /min/cm2 , consistent with expectations for transport through the porous membrane prior to closure and equalization of internal/external pressures. We have demonstrated the workability of obtaining robust seal against leakage at the implantation site of a novel intradural stimulator using a custom-designed test rig. Extension of the method to in vivo testing in a large animal model will be the next step.

NEUROPATHIC PAIN IN PATIENT WITH POST OPERATIVE SCHWANNOMA: A CASE REPORT PRIMARY INTRADURAL EXTRAMEDULLAR SPINAL CORD TUMOUR

Majority of spinal cord tumour is a benign tumour with symptoms are due to spinal cord compression. One of the symptoms that are often difficult to treat is a sensory deficit. The authors report a case of primary intradural extramedullar spinal cord tumour in 57-year-old man. This tumour was presenting symptoms of chronic low back pain, gradual progressive inferior paraplegia, and sensory deficit on both legs. MRI thoracal showed intradural lesion at Th 4-5-6, with isointensity on T1-weighted images and hyperintensity-isohomogen on T2-weighted images. The tumour was completely resected, and histopathology examination revealed schwannoma types. Patient showed a clinical improvement in motoric function noticeable after surgery, but showed sensory deficits sequelae requiring therapy for neuropathic pain.

Intraoperative Multispiral Computerized Tomography in the Surgical Treatment of Intradural Spinal Cord Tumors

This article addresses a novel technical solution in the surgical treatment of intradural spinal cord tumors – the use of intraoperative multispiral computerized tomography (IMSCT). The IMSCT method, as compared with pre-operative magnetic resonance tomograms, provides clear determination of tumor position levels and provides for minimization of the volumes of soft tissue dissection and bone resection, thus reducing the risk of various adverse events. This intraoperative navigation method can be recommended for use in the surgical treatment of intradural spinal cord tumors (IDSCT).

Natural history of spinal cord arteriovenous shunts: an observational study.

The natural history of intradural spinal cord arteriovenous shunts is unknown. We performed an observational study in a consecutive patient cohort with symptomatic intradural spinal cord arteriovenous shunts who were admitted to three institutes to investigate the clinical course of this complex disease, which would provide valuable evidence to inform clinical decision-making. The clinical course of patients with symptomatic intradural spinal cord arteriovenous shunts from initial presentation to occurrence of clinical deterioration, initiation of treatment, or last follow-up was analysed. Patients with at least 1 month of observation were included in this study. Clinical onset and deterioration patterns were divided into acute and gradual. Annual and cumulative rates of clinical deterioration as well as their risk factors were analysed using Kaplan-Meier life table analysis and Cox proportional hazards model. To assess risks and benefits of treatment, post-treatment clinical courses were further assessed. Four hundred and sixty-six patients with a mean observational period of 36.9 ± 58.8 months were included; 56.7% of patients presented with acute onset, of whom 77.3% experienced spontaneous recovery. Age of onset older than 28 years, initial modified Aminoff and Logue scale of >3, mid-thoracic lesions and non-ventral lesions were independent predictors of failure for spontaneous recovery. The annual risk of general, acute and gradual clinical deterioration after onset was 30.7%, 9.9% and 17.7%, respectively. Risk of deterioration was highest in the early period after initial onset. Acute onset was the only independent risk factor [hazard ratio 1.957 (95% confidence interval, CI 1.324-2.894); P = 0.0008] of acute deterioration and gradual onset was the strongest predictor [hazard ratio 2.350 (95% CI 1.711-3.229); P < 0.0001] of the gradual deterioration among all the stratifying factors. After invasive treatment, complete obliteration was achieved in 37.9% of patients (138 of 364) and improved or stable clinical status was noted in 80.8% of patients. Forty-two patients (11.5%) experienced permanent complications. Overall post-treatment deterioration rate was 8.4%/year, and 5.3%/year if permanent complications were excluded. The natural history of symptomatic spinal cord arteriovenous shunts is poor, especially in the early period after onset, and early intervention is thus recommended. Initial onset pattern significantly affects the natural history of the lesion, which prompts a differentiated treatment strategy.

Magnetic resonance image findings in pug dogs with thoracolumbar myelopathy and concurrent caudal articular process dysplasia

BackgroundA retrospective case series study was undertaken to describe the magnetic resonance imaging (MRI) findings in Pug dogs with thoracolumbar myelopathy and concurrent caudal articular process (CAP) dysplasia. Electronic clinical records were searched for Pug dogs who underwent MRI for the investigation of a T3-L3 spinal cord segment disease with subsequent confirmation of CAP dysplasia with computed tomography between January 2013 and June 2017. Clinical parameters age, gender, neuter status, body weight, urinary or faecal incontinence, severity and duration of clinical signs were recorded. MRI abnormalities were described. Univariable non-parametric tests investigated the association between the clinical parameters and evidence of extra- or intra-dural spinal cord compression on MRI.Results18 Pug dogs were included. The median age was 106 months with median duration of clinical signs 5 months. All presented with variable severity of spastic paraparesis and ataxia; 50% suffered urinary/faecal incontinence. In all cases, MRI revealed a focal increase in T2-weighted signal intensity within the spinal cord at an intervertebral level where bilateral CAP dysplasia was present; this was bilateral aplasia in all but one case, which had one aplastic and one severely hypoplastic CAP. MRI lesions were associated with spinal cord compression in all but one case; intervertebral disc protrusion resulted in extra-dural compression in 10 (56%) cases; intra-dural compression was associated with a suspected arachnoid diverticulum in 4 (22%) cases and suspected pia-arachnoid fibrosis in 3 cases (17%). There was no association between clinical parameters and a diagnosis of intra-dural vs extra-dural compression. CAP dysplasia occurred at multiple levels in the T10–13 region with bilateral aplasia at T11–12 most often associated with corresponding spinal cord lesions on MRI.ConclusionsAll Pugs dogs in this study were presented for chronic progressive ambulatory paraparesis; incontinence was commonly reported. Although intervertebral disc disease was the most common radiologic diagnosis, intra-dural compression associated with arachnoid diverticulae/fibrosis was also common. Bilateral CAP aplasia was present in all but one Pug dog at the level of MRI detectable spinal cord lesions. A causal relationship between CAP dysplasia and causes of thoracolumbar myelopathy is speculated but is not confirmed by this study.

Intradural extramedullary cystic schwannoma of the cervical spine

Giant cervical intradural extramedullary schwannoma with severe spinal cord compression is a rare entity. Tumor spread and size are very important for surgical approach. In this case, we report a 55-years-old male patient with a giant intradural-extramedullary cervical schwannoma extending between C5 and T1 and causing spinal cord compression that underwent total resection with laminoplasty at C5-6-7 levels. The patient developed no additional deficit. To preserve the cervical lordosis, the patient used a cervical collar for three months. There has been no recurrence during two years of follow-up. Using the appropriate surgical method is essential in patients with spinal tumor in order to avoid additional neurological deficits and achieve cure.

Contemporary Approaches to Preventing and Treating Infections of Novel Intrathecal Neurostimulation Devices

Contemporary approaches to surgical site infections have evolved significantly over the last several decades in response to the economic pressures of soaring health care costs and increasing patient expectations of safety. Neurosurgeons face multiple unique challenges when striving to avoid as well as manage surgical implant infections. The tissue compartment, organ system, or joint is characterized by biological factors and physical forces that may not be universally relevant. Such implants, once rare, are now routine. Although the prevention, diagnosis, and treatment of surgical site infections involving neural implants has advanced, guidelines are ever changing, and the incidence still exceeds acceptable levels. We assess the impact of these factors on a new class of implantable neuromodulation devices. The available evidence along with practice patterns were examined and organized to establish relevant groupings for continuing evaluation and to propose justifiable recommendations for the treatment of infections that might arise in the case of intradural spinal cord stimulators. Few studies in the modern era have systematically evaluated preventive behaviors that were applied to intradural neural implants alone. We anticipate that future efforts will focus even more on the investigation of modifiable factors along a continuum from bacterially repellant implants to weight management. Early diagnosis could offer the best hope for device salvage but to date has been largely understudied. Historically, prevention is the cornerstone to infection mitigation. However, immediate diagnosis and hardware salvage have not received the attention deserved, and that approach may be especially important for intradural devices.

Updates in the management of intradural spinal cord tumors: a radiation oncology focus.

Primary spinal cord tumors represent a hetereogeneous group of central nervous system malignancies whose management is complex given the relatively uncommon nature of the disease and variety of tumor subtypes, functional neurologic deficits from the tumor, and potential morbidities associated with definitive treatment. Advances in neuroimaging; integration of diagnostic, prognostic, and predictive molecular testing into tumor classification; and developments in neurosurgical techniques have refined the current role of radiotherapy in the multimodal management of patients with primary spinal cord tumors, and corroborated the need for prospective, multidisciplinary discussion and treatment decision making. Radiotherapeutic technological advances have dramatically improved the entire continuum from treatment planning to treatment delivery, and the development of stereotactic radiosurgery and proton radiotherapy provides new radiotherapy options for patients treated in the definitive, adjuvant, or salvage setting. The objective of this comprehensive review is to provide a contemporary overview of the management of primary intradural spinal cord tumors, with a focus on radiotherapy.

Intradural Spinal Cord Stimulation: Performance Modeling of a New Modality.

Introduction: Intradural spinal cord stimulation (SCS) may offer significant therapeutic benefits for those with intractable axial and extremity pain, visceral pain, spasticity, autonomic dysfunction and related disorders. A novel intradural electrical stimulation device, limited by the boundaries of the thecal sac, CSF and spinal cord was developed to test this hypothesis. In order to optimize device function, we have explored finite element modeling (FEM).Methods: COMSOL®Multiphysics Electrical Currents was used to solve for fields and currents over a geometric model of a spinal cord segment. Cathodic and anodic currents are applied to the center and tips of the T-cross component of the electrode array to shape the stimulation field and constrain charge-balanced cathodic pulses to the target area.Results: Currents from the electrode sites can move the effective stimulation zone horizontally across the cord by a linear step method, which can be diversified considerably to gain greater depth of penetration relative to standard epidural SCS. It is also possible to prevent spread of the target area with no off-target action potential.Conclusion: Finite element modeling of a T-shaped intradural spinal cord stimulator predicts significant gains in field depth and current shaping that are beyond the reach of epidural stimulators. Future studies with in vivo models will investigate how this approach should first be tested in humans.

Intradural spinal cord arteriovenous shunts in the pediatric population: natural history, endovascular management, and follow-up.

Intradural spinal cord arteriovenous shunts represent a rare entity, particularly in the pediatric population, and clinical diagnosis can be challenging. We report the analysis of clinical, angioarchitectural, procedural, and follow-up data in a population of 36 children managed by our team between 2002 and 2017. Hemorrhage occurred in 26 children (72%). Age at onset was 9.22 ± 3.65 years. Lesions were located at the thoracic level in 16 cases, at the cervical level in 15 cases, and the thoraco-lumbar region in 5 cases. A genetic or metameric syndrome was associated in 18 children (50%). Glue embolization provided complete occlusion in 5 children, subtotal in 7, and extensive in 14 without intraprocedural complications. We observed clinical normalization in 11 children, improvement in 11 cases, and stability in 3. Four children worsened during the follow-up, and one child died. Endovascular staged glue embolization performed in experienced centers is safe in the treatment of pediatric intradural spinal cord arteriovenous shunts. Clinical and neuroradiological follow-up is mandatory, especially for pediatric patients.

Resection of a Thoracic Hemangioblastoma in a Patient With Von Hippel-Lindau: 3-Dimensional Operative Video.

This 3-dimensional operative video illustrates resection of a thoracic hemangioblastoma in a 30-year-old female with a history of Von Hippel-Lindau disease. The patient presented with right lower extremity numbness and flank pain. Magnetic resonance imaging (MRI) demonstrated an enhancing intradural intramedullary lesion at T 7 consistent with a hemangioblastoma. The patient underwent a thoracic laminectomy with a midline dural opening for tumor resection. This case demonstrates the principles of intradural intramedullary spinal cord tumor resection. In this particular case, internal debulking was untenable owing to the vascular nature of hemangioblastomas. The operative video demonstrates en bloc tumor removal. Postoperative MRI demonstrated gross total resection. The postoperative course was uneventful. The natural history of this disease, treatment options, and potential complications are discussed.