Intramedullary Lesion Research Articles

Convection-Enhanced Delivery of Nimustine Hydrochloride for Recurrent Spinal Cord High-grade Glioma

Abstract INTRODUCTION Spinal cord high-grade glioma has poor prognosis. Especially, no treatment protocols have been established for recurrent cases.This paper describes a novel treatment method, convection enhanced delivery (CED), for recurrent high-grade glioma. CED can deliver chemotherapeutic agents directly into the intramedullary lesion and possibly lead remarkable regression of enlarging tumors that are otherwise difficult to control. METHODS Two patients developed high-grade glioma in the thoracic spinal cord. Partial resection and chemo- and radiotherapy-induced remission of the disease. However, following the initial treatment, recurrence was noted in the spinal cord 6 and 12 mo, respectively. No effective treatment was available for these recurrent lesions. Therefore, the authors decided to use CED to infuse nimustine hydrochloride (ACNU) directly into the spinal cord. During the procedure, the infusion cannula was inserted into the spinal cord lesion under intraoperative computed tomography scan. RESULTS After ACNU CED, successive magnetic resonance imaging confirmed remarkable shrinkages of the tumors in both cases. However, the patient's preinfusion symptoms including bilateral lower extremity weakness, did not change after the treatment. Importantly, overall survivals of the two patients were as long as 67 and 33 mo. CONCLUSION The authors report the first 2 cases of recurrent spinal cord high-grade glioma. ACNU CED dramatically regressed enhanced mass lesions and provided local tumor controls in the spinal cord.

Magnetic Resonance Imaging Evidence of Therapeutic Efficacy of Timing of Decompression in American Spinal Injury Association Impairment Scale Grades A to C Cervical Spinal Cord Injury Patients

Abstract INTRODUCTION In traumatic cervical spinal cord injury (SCI), the therapeutic effect of surgery and its timing as neuroprotective measures remain uncertain. Additionally, the relationship between timing of decompression, extent of decompression, imaging biomarkers evidence of injury severity, and outcome are incompletely understood. METHODS We investigated the effect of timing of decompression and long-term neurological outcome in patients with postoperatively confirmed decompression using computed tomography (CT) and magnetic resonance imaging (MRI) studies. A total of 6 mo after cervical SCI, American Spinal Injury Association Impairment Scale (AIS) grade conversion was determined in 72 AIS grades A, B, and C patients whose postoperative CT and MRI confirmed spinal cord decompression. A total of 32 patients underwent decompressive surgery less than 12 hr from injury, 25 within 12 to 24 hr, and 15 more than 24 hr after trauma. RESULTS Age, gender, injury mechanism, intramedullary lesion length (IMLL) on MRI, admission American Spinal Injury Association (ASIA) motor score, and surgical technique were not statistically different in-between groups. Motor complete patients (P = .009) and those with fracture dislocations (P = .01) tended to be operated earlier. One or more grade improvement was 55.6% in AIS grade A, 60.9% in AIS grade B, and 86.4% in AIS grade C patients. Admission AIS motor score (P = .0004) and preoperative IMLL (P = 0001) were the strongest predictors of neurological outcome. AIS grade improvement was 65.6% in patients undergoing decompressive surgery within 12 hr after trauma, 60% in patients undergoing surgery within 12 to 24 hr, and 80% when decompression was performed more than 24 hr after injury (P = .424). Multiple regression analysis of all significant and marginally significant variables revealed that the only significant variable predictive of AIS grade conversion to a better grade was IMLL (odds ratio 133.51, CI 11.68-1525.71, P < .0001). CONCLUSION In patients with postoperative CT and MRI confirmation of decompression following traumatic cervical SCI, preoperative IMLL and not the timing of surgery appears to determine long-term neurological outcome.

Use of intraoperative sodium fluorescein for diagnostic tissue biopsy of spinal cord lesions

BackgroundRecent evidence suggests that fluorescein-guided microsurgery facilitates resection of intrinsic and metastatic lesions in the brain. Use of sodium fluorescein for angiography has previously been reported without non-specific diffusion into the adjacent spinal parenchyma. Diagnostic biopsy of spinal cord lesion is often challenging and the localization of such lesions intraoperatively is paramount. We present the first known report of use of sodium fluorescein for localization and diagnostic biopsy of intrinsic spinal cord lesions. MethodsThree patients with spinal cord lesions received fluorescein sodium 10% (Alcon Laboratories INC, Fort Worth, TX, USA) at 3 mg/kg prior to surgical resection. Intraoperative visualization of fluorescence was performed using a Zeiss Pentero (Carl Zeiss AG, Oberkochen, Germany) microscope equipped with a Yellow560 filter or a Leica OH6 (Leice Microsystems, Wetzlar, Germany) equipped with a FL560 filter. ResultsAdministration of sodium fluorescein resulted in lesional fluorescent contrast extravasation and facilitated surgical resection. The addition of sodium fluorescein allowed for identification and facilitated biopsy in three patients. In patients undergoing biopsy, tissue samples were positive for a diagnostic pathology. ConclusionFluorescein may be a helpful microsurgical tool in guiding resection and localization for tissue biopsy of intramedullary spinal lesions. Further research is necessary to explore fluorescein sodium applications in the resection of spinal cord lesions.

Enhanced recovery after surgery in intramedullary and extramedullary spinal cord lesions: perioperative considerations and recommendations.

Enhanced recovery after surgery (ERAS) is an evidence-based approach developed to ameliorate the patient recovery process following surgical procedures. Employing a multimodal, multidisciplinary approach, ERAS implements strategies and treatment paradigms that have been shown to improve patient outcomes, reduce hospital length of stay, and ultimately reduce healthcare costs. With a substantial body of the literature supporting the implementation of ERAS in other surgical specialties, ERAS has only recently made its foray into spine surgery. Despite this, current studies are limited to spinal deformity and degenerative disease, with limited data regarding spinal cord surgery. This is due in part to the complex nature and rarity of spinal cord lesions, making the establishment of a formal ERAS protocol difficult. In developing an ERAS protocol, there must be a consensus on what factors are important to consider and implement. To address this, we reviewed the most recent advances in intramedullary and extramedullary spinal cord surgery in order to identify elements that influence patient outcomes. Using this information, the authors provide evidence-based recommendations with the intent of introducing a framework for future ERAS protocols with respect to treating spinal cord lesions.

Intraoperative neurophysiological mapping & localization of posterior median sulcus during intramedullary spinal cord tumor resection_technical communication

ObjectivesTo assess orthodormic stimulation mapping technique for posterior median sulcus with some variation in parameters from that used in Simon study model. MethodsA Case study of 51 years old female patient diagnosed with intramedullary lesion in the cervical segment, the patient was assigned for laminectomy, tumor exploration and biopsy.We used custom made bipolar stimulator for mapping; it allows variable flexible distance stimulation along the longitudinal axis of the posterior columns and recording from cortical somatosensory evoked potentials SSEPs C3-Fpz and C4-FPz and Cz-FPz channels. We used lateralization rather than phase reversal in localization of posterior median sulcus. ResultsWe were able to identify the functional median sulcus with lateralization to contralateral side rather than phase reversal, the mapping was helpful method to identify PMS, which corresponded to the proposed radiological image's location. ConclusionBipolar orthodormic stimulation can be done using lateralization rather than phase reversal technique. Using Higher Repetition Rate and intensity between 2 and 3 mA can decrease time needed to store averages without compromising evoking the potentials. Stimulation Intensity above 5 to 6 mA can stimulate motor tracts as well in cervical region.

Abstracts from The 37th Annual National Neurotrauma Symposium June 29–July 3, 2019 Pittsburgh, Pennsylvania

Abstracts from The 37^th Annual National Neurotrauma Symposium June 29–July 3, 2019 Pittsburgh, Pennsylvania

Intraoperative Computed Tomography Navigation-Assisted Resection of Symptomatic Intramedullary Spinal Cord Cavernoma: A Technical Note and Case Report

Intramedullary spinal cord cavernous malformations (ISCCMs) are a rare entity. Most commonly, ISCCMs present with neurologic decline from lesion hemorrhage, which can be catastrophic and irreversible irrespective of surgical intervention. Given the challenging anatomic location of these lesions in highly critical neurologic areas, precise surgical localization and visualization is necessary to limit collateral damage during resection particularly for deep ISCCMs that do not present to a pial surface. We present a case of a 54-year-old man who presented with incomplete paraplegia after hemorrhage of a deep ISCCM at T11. Surgical resection was undertaken using intraoperative computed tomography (CT) navigation assistance autofused with high-resolution preoperative magnetic resonance imaging for precise intramedullary lesion targeting and localization for myelotomy. Complete resection was demonstrated on postoperative imaging. At a 6-week follow-up appointment, the patient endorsed return of his bladder function and was noted to have some return of motor function to his left foot with 3 of 5 dorsiflexion. At 4 months, he had improved to 3 of 5 proximal, 4 of 5 distal on the left and 2 of 5 proximal, and 3 of 5 distal on the right. The approach represents a novel application of intraoperative CT navigation assistance in the resection of deep ISCCMs.

AOSpine Subaxial Cervical Spine Injury Classification System: The Relationship Between Injury Morphology, Admission Injury Severity, and Long-Term Neurologic Outcome

The AOSpine Subaxial Cervical Spine Injury Classification System was introduced to improve communication, clinical management, and research. Here, the system was studied in relation to injury severity along with admission and long term neurologic follow-up. A retrospective study was performed in subaxial cervical spine injury patients. Morphology was classified using the AOSpine Subaxial Cervical Spine Injury Classification System. Six major morphology subtypes were selected for analysis. The American Spinal Injury Association (ASIA) motor and Abbreviated Injury Severity (AIS) scores were recorded at admission and at follow-up >6 months. Admission intramedullary lesion length (IMLL) on MRI was recorded. In all, 82 patients met criteria for analysis. The mean follow-up time was 11 months (range, 6-33 months). The were 36 patients with morphology subtypes A0, 4 with A1/A2, 9 with A3/A4, 8 with B2, 11 with B3, and 14 with C. The A1/2 subtype had the least severe injuries on admission. The C and A3/A4 subtypes had the most severe injuries. The subtype C had the lowest ASIA Motor Score (AMS) and second highest percentage of complete injuries. A3/A4 patients had the highest percentage of complete injuries on admission. At follow-up, A3/A4 patients had the lowest AMS, and 33% of patients continued to have complete injuries. C subtype injuries all converted to AIS incomplete injuries on follow-up (P= 0.04). IMLL was found to be significantly different compared across multiple morphologic subtypes. Surgical management for each morphology subtype was reported. The AOSpine Subaxial Cervical Spine Injury Classification System successfully associated injury morphology with IMLL along with admission and long-term neurologic function and recovery.

Coexistence of Intracranial and Spinal Cord Cavernous Malformations Predict Aggressive Clinical Presentation.

Background: Patients with spinal cord cavernous malformations (CMs) are at increased risk for multiple neuraxis CMs. Few studies focused on the natural history of patients with coexistence of intracranial and spinal cord CMs.Methods: Forty patients who underwent both intracranial and spinal MR imaging from a single center were reviewed retrospectively. American Spinal Injury Association (ASIA) impairment scale was used to evaluate neurological and disability status.Results: The median age of the 40 patients was 40.6 years old (range 9–69), and the male-to-female ratio was 2.1:1. The mean size of the intramedullary lesions was 10.1 ± 5.8 mm (range, 3.0–34.0 mm). Six patients (15%) harbored at least one intracranial lesion. Five of the 6 patients (83.3%) suffered aggressive clinical presentations with severe neurological and disability status; in patients with sporadic spinal CMs, the proportion was 26.5% (9 of 34). Coexistence of intracranial and spinal cord CMs is more likely to follow an aggressive course (P = 0.031, OR = 19.547, 95% CI = 1.322–289.123). In the postoperative long-term follow up, the unfavorable rate of patients with associated intracranial CMs was significantly higher than that of patients with sporadic spinal cord CMs (P = 0.049).Conclusions: The prevalence of associated intracranial CMs in patients with spinal cord CMs was 15%. Coexistence of intracranial and spinal cord CMs is more likely to follow an aggressive course. This study highlights the necessity of intracranial MR imaging for patients with spinal cord CMs to benefit to the predicting prognosis and selection of treatment strategies.

Transverse Myelitis Caused by Varicella Zoster Virus

Introduction The varicella zoster virus (VZV) infection causes chickenpox and herpes zoster. Primary infection occurs more frequently in the pediatric age as chickenpox. Virus can be latent in cranial nerve or dorsal root ganglia and reactivate several decades later as the form of herpes zoster generally in immunosuppressed patients. Varicella zoster virus is associated with severe neurological complications, including post herpetic neuralgia, aseptic meningitis, polyneuropathy, cranial nerve palsy, meningoencephalitis, vasculopathy, encephalitis, and transverse myelitis. The transverse myelitis caused by VZV is reported rarely. Case Report A 77-year-old immunocompetent patient presented with muscle weakness and sensation loss due to the demyelinating lesion caused by VZV on C5 dermatome. Proprioception and vibratory sensation loss were also marked. Cervical spinal magnetic resonance imaging showed expansive intramedullary high-signal intensity lesion on C5 with focal swelling on T2-weighted images and gadalinium enhancement on T1-weighted images. cerebrospinal fluid viral antibody test was positive for immunoglobulin G of VZV but negative for VZV DNA. The patient was treated with oral valacyclovir (1 g) 3 times daily for 7 days and with methylprednisolone (1.0 g) every day for 5 days. After treatment, his muscle strength increased but sensorial loss and neuropathic pain did not recover. Conclusions About 40% of transverse myelitis cases are caused by viral infections, some of them are herpes viruses and poliovirus. Varicella zoster infection is a common disease but not a common cause of transverse myelitis particularly in immuncompetent patients. The clinicians must be aware of this rare complication of VZV.

The relevance of MRI for predicting neurological recovery following cervical traumatic spinal cord injury.

Retrospective cohort study of 82 patients with cervical traumatic spinal cord injury (TSCI). Determine the relevance of preoperative MRI to predict neurological recovery following cervical TSCI. Level I trauma center specialized in TSCI. The following three MRI parameters were assessed: presence of an intramedullary hemorrhage, intramedullary lesion length and maximal compression of the spinal cord compression (MSCC). Analyses were performed to assess the relationship between MRI parameters and three neurological outcomes: ASIA motor score (AMS), improvement by at least one ASIA impairment scale (AIS) grade (conversion of AIS grade), and reaching AIS grade D or E. Predicting AMS based on initial AIS grade and intramedullary hemorrhage resulted in a validation R-squared of 0.662, and of 0.636 when using only the initial AIS grade. Predicting conversion of AIS grade based on initial AIS grade, intramedullary hemorrhage and lesion length resulted in a validation c-index of 0.704, and of 0.727 when using only the initial AIS grade. Predicting the likelihood of a follow-up AIS grade D or E based on initial AIS grade and intramedullary hemorrhage in a validation c-index of 0.903, and of 0.873 when using only the initial AIS grade. Intramedullary hemorrhage and lesion length assessed from preoperative MRI were predictors of the neurological recovery following cervical TSCI. However, the clinical benefit of these MRI parameters to predict the neurological recovery remains limited when the initial AIS grade is available, confirming that the initial neurological status remains the most important predictor of the neurological outcome.

Pediatric spinal cord biopsy: A case series from a high-volume referral center

Pediatric patients presenting with intramedullary spinal cord lesions often require specific diagnoses to guide their treatment plans. Though results from magnetic resonance imaging and lumbar puncture may narrow the differential diagnosis, these tests cannot always provide a definitive diagnosis. In such cases, spinal cord biopsy may be undertaken to provide a specific histopathologic diagnosis for guiding treatment. Data from the adult population show 24% of spinal cord biopsies can be nondiagnostic and the procedure may carry a 21% complication rate. Therefore, spinal cord biopsy may portend a similar high risk-to-benefit ratio in the pediatric population. Here, we review spinal cord biopsy cases scheduled for diagnosis, and not debulking, at a high volume pediatric referral center during a seventeen-year period. We report our experience with five patients who met our inclusion criteria. Due to the rarity of the procedure, statistically significant factors associated with improved diagnostic yield or peri-operative complication could not be identified. A definitive diagnosis which guided the post-operative treatment plan was obtained in four of our five patients. None of our patients developed post-operative motor deficits. However, these patients were susceptible to the same risks of open spine surgery, such as wound infections and spinal deformities. Our case series shows that intramedullary spinal cord biopsies may provide tissue for obtaining histopatholgic diagnoses. However, the potential risks of complication, and the possibility of obtaining nondiagnostic tissue, should be discussed with patients, families and their medical treatment teams.

Case report: an area postrema syndrome revealing a neuromyelitis optica spectrum disorder associated with central nervous system tuberculosis in a young Togolese (black African) woman

BackgroundArea postrema syndrome (APS) is considered to be one of the most specific clinical presentations of neuromyelitis optica spectrum disorders (NMOSDs). In sub-Saharan Africa, NMOSDs and even more so those revealed by an APS, are rarely reported. However, studies among mixed populations have shown that NMOSDs disproportionately affect black people with relatively more frequent encephalic involvement. We report a case of APS revealing an NMOSD associated with central nervous system (CNS) tuberculosis in a young Togolese woman residing in Togo (West Africa).Case presentationA 28-year-old Togolese woman was admitted for left hemibody sensory problems with ataxia. These problems were observed while the patient was hospitalized for a few days in the hepato-gastroenterology department for persistent vomiting, abdominal pain and hiccups lasting for about a month. The examination confirmed left hemibody ataxia with nystagmus when looking to the left, pronounced left osteotendinous reflexes, and left hemibody hypoesthesia up to the base of the neck. Encephalic magnetic resonance imaging (MRI) showed a hypersignal lesion in the bulbar more lateralized on the left in the fluid-attenuated inversion recovery sequence, not enhanced after a gadolinium injection. Biological assessment showed the presence of Mycobacterium tuberculosis deoxyribonucleic acid in the cerebrospinal fluid and a sedimentation rate of 120 mm in the 1st hour. The result of the anti-AQP4 antibody test was positive. Two months from the onset of digestive problems with Lhermitte’s sign and hand and foot contracture access without vesico-sphincter problems were established. Cervical medullary MRI showed an additional intramedullary hypersignal lesion in the T2 sequence at the C2 level, not enhanced after a gadolinium injection. A second course of intravenous corticosteroids was administered, and anti-tuberculosis treatment was continued. The outcome was favorable. After 8 months of anti-tuberculosis treatment, the patient started immunosuppressive therapy (azathioprine 50 mg twice daily) to limit the risk of recurrence of NMOSD.ConclusionThe recognition of an APS is an additional challenge for the diagnosis of NMOSDs, especially in countries with limited resources. CNS tuberculosis must be tested when faced with an NMOSD because it seems to be a major cause.

Convolutional Neural Network-Based Automated Segmentation of the Spinal Cord and Contusion Injury: Deep Learning Biomarker Correlates of Motor Impairment in Acute Spinal Cord Injury.

Our aim was to use 2D convolutional neural networks for automatic segmentation of the spinal cord and traumatic contusion injury from axial T2-weighted MR imaging in a cohort of patients with acute spinal cord injury. Forty-seven patients who underwent 3T MR imaging within 24 hours of spinal cord injury were included. We developed an image-analysis pipeline integrating 2D convolutional neural networks for whole spinal cord and intramedullary spinal cord lesion segmentation. Linear mixed modeling was used to compare test segmentation results between our spinal cord injury convolutional neural network (Brain and Spinal Cord Injury Center segmentation) and current state-of-the-art methods. Volumes of segmented lesions were then used in a linear regression analysis to determine associations with motor scores. Compared with manual labeling, the average test set Dice coefficient for the Brain and Spinal Cord Injury Center segmentation model was 0.93 for spinal cord segmentation versus 0.80 for PropSeg and 0.90 for DeepSeg (both components of the Spinal Cord Toolbox). Linear mixed modeling showed a significant difference between Brain and Spinal Cord Injury Center segmentation compared with PropSeg (P < .001) and DeepSeg (P < .05). Brain and Spinal Cord Injury Center segmentation showed significantly better adaptability to damaged areas compared with PropSeg (P < .001) and DeepSeg (P < .02). The contusion injury volumes based on automated segmentation were significantly associated with motor scores at admission (P = .002) and discharge (P = .009). Brain and Spinal Cord Injury Center segmentation of the spinal cord compares favorably with available segmentation tools in a population with acute spinal cord injury. Volumes of injury derived from automated lesion segmentation with Brain and Spinal Cord Injury Center segmentation correlate with measures of motor impairment in the acute phase. Targeted convolutional neural network training in acute spinal cord injury enhances algorithm performance for this patient population and provides clinically relevant metrics of cord injury.

Neuromyelitis optic with positive Anti-AQP4 and Anti-SSA/Ro antibody.

Neuromyelitis Optic (NMO) is an inflammatory disorder involving central nervous system which often co-exists with other autoimmune diseases such as Sjögren’s syndrome (SS). NMO manifestation could precede or follow SS, but the role of anti-SSA in the pathogenesis of NMO remains unclear. We present a case of NMO with anti-AQP4 anti-SSA antibody positive. A-44-year-old female presented with right side weakness. The symptoms began with numbness that improved spontaneously. She also complained pain and dry sensations on her eyes. Schirmer test on her left eye, antinuclear antibody (ANA) and anti-SSA antibody were positive. Cervical MRI revealed intramedullary lesion on T2-weighted-image at C2-C5 level. She was diagnosed as NMO with positive anti-AQP4 and probable SS. She received 1g methylprednisolone for 5 days proceeded with mycophenolic acid. One-year observation showed clinical improvement. Systemic autoantibodies must substansially be evaluated in NMO. Comprehensive diagnosis and providing appropriate immuno-suppressant might prevent further disability and relapse.

Clinical presentation, magnetic resonance imaging features, and outcome in 6 cats with lumbar degenerative intervertebral disc extrusion treated with hemilaminectomy.

To describe the clinical presentation, magnetic resonance imaging features, and outcome of cats treated with hemilaminectomy for intervertebral disc extrusion (IVDE). Short case series. Six cats. Medical records were reviewed for signalment, onset, duration, and severity of clinical signs, magnetic resonance imaging features, surgical findings, and clinical outcome with a minimum postoperative follow-up of 4 weeks. Our population included 6 cats with a median age of 8.6 years, consisting predominantly of males (n = 5) and purebred cats (n = 4). An acute onset and short duration of progressive clinical signs of myelopathy was the most common presentation; spinal hyperesthesia was present in 3 cats. A large volume of extradural material was identified by MRI within the lumbar vertebral column of each cat, causing marked spinal cord compression. The most common sites affected were L2-L3 (n = 2) and L6-L7 (n = 2). Follow-up after hemilaminectomy was available in 5 cats: 4 had normal voluntary motor function, and 1 had recurrence of acute paraplegia, compromised nociception, and an extensive T2w hyperintense intramedullary lesion according to MRI. All 4 cats with preoperative urinary incontinence remained incontinent for at least 1 week despite good voluntary motor function of pelvic limbs. Intervertebral disc extrusion was diagnosed by MRI in all 6 cats, most commonly at L2-3 and L6-7. Hemilaminectomy resulted in a good to excellent outcome in 4 of 5 cats. Feline IVDE can be diagnosed by MRI and carry a good prognosis after surgical decompression, although urinary continence may be delayed despite good pelvic limb voluntary motor function.

Intramedullary Subependymoma of the Cervical Spinal Cord: A Case Report and Review of the Literature

AbstractSubependymoma is a rare tumor of the central nervous system, representing 0.2 to 0.7% of all intracranial tumors. They are usually found in the fourth ventricle or in the walls of the lateral ventricles, often remaining asymptomatic. Subependymomas occur rarely in the cervical or thoracic spinal cord. Since its first description in the spinal cord by Boykin et al in 1954, only 47 cases have been reported. A 49-year-old man presented with a 4-year-long-lasting neck pain, which radiated to the upper right extremity for 4 years. It was insidious at onset and revealed gradual progression, difficulty in performing fine hand movements, and hyperalgesia. Magnetic resonance imaging revealed irregular hyperintensity of T2 and dilatation of the spinal cord from C4 to T1 with associated edema and an intramedullary lesion with central location. During the surgical event, a transoperative biopsy was performed that revealed loose fibrillary networks and groups of nuclei showing mild pleomorphism and microcystic formations. Histologically, we observed groups of cells with mild nuclear pleomorphism embedded in a dense, thin, glial fibrillar fundus, and microcystic formations. Immunohistochemical staining revealed diffuse positivity for the glial fibrillary acidic protein, and negative for the epithelial membrane antigen. Subependymoma accounts for 8.3% of all ependymal tumors. There are few descriptions of the cytologic features of the subependymoma because this neoplasm is rare and most commonly found incidentally in autopsies.

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.

The role of magnetic resonance imaging in acute trauma of the cervical spine in children

Aim.To evaluate the role of magnetic resonance imaging (MRI) as a diagnostic method in children with acute trauma of the cervical spine and spinal cord, to compare the correspondence of MRI results with neurologic symptoms in accordance with the ASIA scale.Materials and methods.156 children with acute trauma of spine and spinal cord at the age from 6 months up to 18 years were studied. MRI was performed on a Phillips Achieva 3T scanner. The standard protocol included MYUR (myelography) in coronal and sagittal projections, STIR and T2VI FS SE in sagittal projection, T2VI SE or T2 * VI FSGE (axial projection), 3D T1VI FSGE before and after contrast enhancement. Contrast substance was injected intravenously in the form of a bolus at the rate of 0.1 mmol/kg (equivalent to 0.1 ml/kg) at a rate of 3 to 4 ml.Results.The causes of cervical spine blunt trauma were: road accidents (55), catatrauma (60), “diver” trauma (21), blunt trauma (20). Intramedullary lesions of the spinal cord were detected: concussion (49), bruising / crushing (27), hematomia (34), disruption with divergence of segments (21), accompanied by edema (141); extramedullary lesions: epi- and subdural, intralesive and sub-connective and soft tissues hematomas (68), ruptures of bundles (48), fractures (108), dislocation and subluxation of the vertebrae (35), traumatic disc herniation (37), spinal cord compression and/or rootlets (63), statics violation (134), instability (156).Conclusion.MRI is the optimal method for spinal cord injury diagnostics. In the acute period of injury this technique has limited application, but it can however serve as a primary diagnostic method in these patients. MRI should be performed no later than the first 72 hours after injury. The most optimal for visualization of cervical spine trauma and spinal cord are T2VI SE and STIR in sagittal projection with suppression of signal from fat. MRI results correlate with neurologic symptoms at the time of performance according to the ASIA scale, and therefore MRI should be performed in all patients with acute cervical spine trauma, whenever possible.

Intramedullary spinal cord metastases: an institutional review of survival and outcomes.

Intramedullary spinal cord metastases (ISCMs) are rare lesions affecting the spinal cord in patients with disseminated malignancy. Today, due to increased survival, these lesions are more frequently diagnosed. Literature on survival and neurologic outcomes is sparse. Herein, we describe a single institutional case series on ISCMs reported to date in the English literature. We retrospectively analyzed the medical records of patients diagnosed with intramedullary metastatic lesions at our institution between 1997 and 2016. We analyzed different approaches to management and factors influencing survival and neurologic outcomes. A total of 70 patients (86 lesions) were analyzed. Most lesions were found in thoracic spinal cord (50%) followed by cervical (34%) and conus medullaris (14%). Mean age at diagnosis was 55.6 ± 10.6years with 60% (n = 42) being females. Median survival was 104.5days (range 1-888days). Twenty-three patients (33%) received conservative management, 39 (56%) received palliative radiotherapy, whereas 8 (11%) underwent surgery with one patient receiving only a biopsy. Age, sex, presence of concomitant brain and other systemic metastasis didn't influence survival. Patients with solitary metastases had longer survival compared to multiple lesions (3.6 vs. 2.2months, p = 0.01). In patients with solitary lesions without brain metastasis, surgical resection was associated with significantly longer survival (6months vs. 3 months, p = 0.02). The overall survival in patients with intramedullary metastasis remains poor. Surgical management may contribute to improved survival and neurologic outcomes in selected patients. Intramedullary metastasis may have a greater role on overall survival compared to systemic metastatic burden.