Intramedullary Location Research Articles

Predictive modeling of long-term opioid and benzodiazepine use after intradural tumor resection

BACKGROUND CONTEXTDespite increased awareness of the ongoing opioid epidemic, opioid and benzodiazepine use remain high after spine surgery. In particular, long-term co-prescription of opioids and benzodiazepines have been linked to high risk of overdose-associated death. Tumor patients represent a unique subset of spine surgery patients and few studies have attempted to develop predictive models to anticipate long-term opioid and benzodiazepine use after spinal tumor resection. METHODSThe IBM Watson Health MarketScan Database and Medicare Supplement were assessed to identify admissions for intradural tumor resection between 2007 and 2015. Adult patients were required to have at least 6 months of continuous preadmission baseline data and 12 months of continuous postdischarge follow-up. Primary outcomes were long-term opioid and benzodiazepine use, defined as at least 6 prescriptions within 12 months. Secondary outcomes were durations of opioid and benzodiazepine prescribing. Logistic regression models, with and without regularization, were trained on an 80% training sample and validated on the withheld 20%. RESULTSA total of 1,942 patients were identified. The majority of tumors were extramedullary (74.8%) and benign (62.5%). A minority of patients received arthrodesis (9.2%) and most patients were discharged to home (79.1%). Factors associated with postdischarge opioid use duration include tumor malignancy (vs benign, B=19.8 prescribed-days/year, 95% confidence interval [CI] 1.1–38.5) and intramedullary compartment (vs extramedullary, B=18.1 prescribed-days/year, 95% CI 3.3–32.9). Pre- and perioperative use of prescribed nonsteroidal anti-inflammatory drugs and gabapentin/pregabalin were associated with shorter and longer duration opioid use, respectively. History of opioid and history of benzodiazepine use were both associated with increased postdischarge opioid and benzodiazepine use. Intramedullary location was associated with longer duration postdischarge benzodiazepine use (B=10.3 prescribed-days/year, 95% CI 1.5–19.1). Among assessed models, elastic net regularization demonstrated best predictive performance in the withheld validation cohort when assessing both long-term opioid use (area under curve [AUC]=0.748) and long-term benzodiazepine use (AUC=0.704). Applying our model to the validation set, patients scored as low-risk demonstrated a 4.8% and 2.4% risk of long-term opioid and benzodiazepine use, respectively, compared to 35.2% and 11.1% of high-risk patients. CONCLUSIONSWe developed and validated a parsimonious, predictive model to anticipate long-term opioid and benzodiazepine use early after intradural tumor resection, providing physicians opportunities to consider alternative pain management strategies.

Spinal Seeding Metastasis of Myxopapillary Ependymoma: Report of Three Pediatric Patients and a Brief Literature Review

Objective: Myxopapillary ependymomas (MPEs) in children are rarely reported low-grade glial tumors; however, MPEs sometimes possess malignant characteristics such as spinal seeding/drop metastasis (SSM). We aimed to present 3 pediatric MPE cases that experienced SSM at 2 neurosurgical centers. Materials and Methods: We retrospectively reviewed the medical records of 38 primary spinal MPE cases who underwent surgery at 2 neurosurgical centers spanning 16 years, from 2004 to 2019. All pediatric cases (patient age <18 years) who were diagnosed with MPE and re-presented with SSM were selected as the core sample for this study. Relevant literature was briefly reviewed. Results: Three pediatric MPE cases (2 females and 1 male) experienced SSM. The mean age at first presentation was 12.0 ± 1.0 years. The mean preoperative course was 2.9 ± 1.2 months. The predominant location was the lumbar spine in 2 tumors (both originated from terminal filum [TF]). Two tumors were located intradural intramedullary. Gross-total resection was achieved in 2 patients. No patient had neurofibromatosis type 2. No adjuvant treatment was given after the first surgery. The mean period between the first diagnosis and diagnosis of SSM was 44.0 ± 31.5 months. The location of SSM in all patients was the sacral spine (1 patient experienced distant metastasis in her brain besides her sacral metastasis). The mean follow-up was 68.3 ± 53.7 months. Conclusions: We found a statistically significant relationship between SSM in pediatric MPEs and the intramedullary location, TF origin, and number of affected segments. Close clinical and radiological follow-up is essential for pediatric MPE patients.

Spinal Haemangioblastomas in Nigerians: A Report of Two Cases

Background: Spinal haemangioblastomas are rare benign but potentially devastating vascular tumours.They may occur sporadically or as a component of Von Hippel-Lindau (VHL) disease. There is a dearth of information on these tumours among Nigerians. This study aims to evaluate the clinical profile and outcome of surgery as well as the challenges of the management of these tumours in a resource-limited country.&#x0D; Methods: We retrospectively analysed data from the records of patients who had surgery for spinal haemangioblastoma at our centre between January 2004 and December 2018.&#x0D; Results: We operated 2 cases of spinal haemangioblastomas during the study period (1 male, 1 female). The patients were aged 25 and 50 years. The onset of symptoms was 2 weeks in one patient and 18 months in the other. The tumour was located in the thoracic region in the 2 patients. One patient had extramedullary tumour. Both individuals were paraplegic at the time of surgery, which was 3 days in one patient and more than 4 months in the other. Whereas gross total tumour resection was achieved patient with shorter duration of symptoms and While both patients had thoracic lesions and presented with sensorimotor deficits, only one had sphincteric dysfunction. Patient had an intramedullary tumour location both instances, the extramedullary tumour made a rapid-post operative neurological improvement, while the one with the longer duration of symptoms and intramedullary tumour remained paraplegic until his death nine months after surgery.

Central atlantoaxial instability as a cause of syringomyelia mimic intramedullary lipoma

A case of a 32-year-old male patient is reported. He was admitted with complaints of burning dysesthesias over his right upper limb and chest and spasticity in the legs. Investigations revealed a long segment intramedullary tumor, image intensity of which matched lipoma. Imaging of craniovertebral junction suggested atlantoaxial “facetal” instability. Atlantoaxial fixation was done, and the intramedullary lipoma was not physically handled or manipulated during surgery. The patient improved in his neurological condition following surgery. The follow-up imaging showed that the intramedullary lipoma reduced significantly in its dimensions. From the case, it appears that the presence of “fat” and “water” in the intramedullary location might have similar pathogenesis.

Spinal Haemangioblastomas in Nigerians: A Report of Two Cases

Background: Spinal haemangioblastomas are rare benign but potentially devastating vascular tumours.They may occur sporadically or as a component of Von Hippel-Lindau (VHL) disease. There is a dearth of information on these tumours among Nigerians. This study aims to evaluate the clinical profile and outcome of surgery as well as the challenges of the management of these tumours in a resource-limited country.&#x0D; Methods: We retrospectively analysed data from the records of patients who had surgery for spinal haemangioblastoma at our centre between January 2004 and December 2018.&#x0D; Results: We operated 2 cases of spinal haemangioblastomas during the study period (1 male, 1 female). The patients were aged 25 and 50 years. The onset of symptoms was 2 weeks in one patient and 18 months in the other. The tumour was located in the thoracic region in the 2 patients. One patient had extramedullary tumour. Both individuals were paraplegic at the time of surgery, which was 3 days in one patient and more than 4 months in the other. Whereas gross total tumour resection was achieved patient with shorter duration of symptoms and While both patients had thoracic lesions and presented with sensorimotor deficits, only one had sphincteric dysfunction. Patient had an intramedullary tumour location both instances, the extramedullary tumour made a rapid-post operative neurological improvement, while the one with the longer duration of symptoms and intramedullary tumour remained paraplegic until his death nine months after surgery.&#x0D; Conclusion: Spinal haemangioblastomas are rare tumours. Long duration of symptoms and intramedullary tumour location may be predictors of unfavorable surgical outcome.

Intramedullary Cavernoma: Case Report and Literature Review

Introduction: Cavernomas are benign vascular anomalies consisting of cavities where the blood circulates at low flow and at low pressure. Intramedullary localization is unusual, represents approximately 5 to 12% of spinal vascular malformations and 3% of intra-dural vascular malformations (5% of medullary vascular lesions). Observation: A patient, aged 59, consulted for the abrupt installation of moderate back pain followed by predominant muscle weakness in the two lower limb of progressive worsening, responsible for gait disorders. The patient reported thermal hypoesthesia and heaviness of the two lower limbs that had been evolving for two years. The examination found a dorsal spinal cord compression syndrome. On the MRI, there were abnormalities of intramedullary signal of the dorsal (D11) spinal cord with bleeding stigmas suggestive of intramedullary cavernomas. Conclusion: The management of the medullary cavernoma is essentially neurosurgical with complete microsurgical resection of the malformation. In the absence of surgical treatment, evolution can be to chronic myelopathy or neurological aggravation.

Spinal haemangioblastomas in Nigerians: a report of two cases

Background: Spinal haemangioblastomas are rare benign but potentially devastating vascular tumours. They may occur sporadically or as a component of Von Hippel-Lindau (VHL) disease. There is a dearth of information on these tumours among Nigerians. This study aims to evaluate the clinical profile and outcome of surgery as well as the challenges of the management of these tumours in a resource-limited country. Methods: We retrospectively analysed data from the records of patients who had surgery for spinal haemangioblastoma at our centre between January 2004 and December 2018. Results: We operated 2 cases of spinal haemangioblastomas during the study period (1 male, 1 female). The patients were aged 25 and 50 years. The onset of symptoms was 2 weeks in one patient and 18 months in the other. The tumour was located in the thoracic region in the 2 patients. One patient had extramedullary tumour patient had an intramedullar tumour location. Both individuals were paraplegic at the time of surgery, which was 3 days in one patient and more than 4 months in the other. Whereas gross total tumour resection was achieved both instances, the patient with shorter duration of symptoms and While both patients had thoracic lesions and presented with sensorimotor deficits, only one had sphincteric dysfunction extramedullary tumour made a rapid-post operative neurological improvement, while the one with the longer duration of symptoms and intramedullary tumour remained paraplegic until his death nine months after surgery. Conclusion: Spinal haemangioblastomas are rare tumours. Long duration of symptoms and intramedullary tumour location may be predictors of unfavorable surgical outcome. Keywords: Haemangioblastoma, Spinal cord, Nigerian, Surgery, Outcome

Intramedullary Cavernoma: Case Report and Literature Review

Introduction: Cavernomas are benign vascular anomalies consisting of cavities where the blood circulates at low flow and at low pressure. Intramedullary localization is unusual, represents approximately 5 to 12% of spinal vascular malformations and 3% of intra-dural vascular malformations (5% of medullary vascular lesions). Observation: A patient, aged 59, consulted for the abrupt installation of moderate back pain followed by predominant muscle weakness in the two lower limb of progressive worsening, responsible for gait disorders. The patient reported thermal hypoesthesia and heaviness of the two lower limbs that had been evolving for two years. The examination found a dorsal spinal cord compression syndrome. On the MRI, there were abnormalities of intramedullary signal of the dorsal (D11) spinal cord with bleeding stigmas suggestive of intramedullary cavernomas. Conclusion: The management of the medullary cavernoma is essentially neurosurgical with complete microsurgical resection of the malformation. In the absence of surgical treatment, evolution can be to chronic myelopathy or neurological aggravation.

Spinal haemangioblastomas: a report of two cases

Background: Spinal haemangioblastomas are rare benign but potentially devastating vascular tumours. They may occur sporadically or as a component of Von Hippel-Lindau (VHL) disease. There is a dearth of information about these tumours among Nigerians. This study aims to evaluate the clinical profile and outcome of surgery as well as the challenges of management of these tumours in a resource-limited country.&#x0D; Methods: We retrospectively analysed data from the records of patients who had surgery for spinal haemangioblastoma at our center between January 2004 and December 2018.&#x0D; Results: We operated 2 cases of spinal haemangioblastomas during the study period (1 male, 1 female). The patients were aged 25 and 50 years. Both patients presented with sensorimotor deficits but only one them had sphincteric dysfunction. The duration of symptoms was 2 weeks in one patient and 18 months in the other. The tumour was located in the thoracic region in both of them. One patient had extramedullary tumour while the had an intramedullary spinal tumour. Both patients were paraplegic at the time of surgery, for 3 days in one patient and more than 4 months in the second patient. Gross total tumour resection was achieved in both individual. The patient with short duration of symptoms and extramedullary tumour made a rapid post-operative neurological improvement while the one with long duration of symptoms and intramedullary tumour remained paraplegic until his demise 9 months after surgery.&#x0D; Conclusion: Spinal haemangioblastomas are rare tumours. Long duration of symptoms and intramedullary tumour location are predictors of unfavorable surgical outcome

Spinal Haemangioblastomas: A Report of Two Cases

Background: Spinal haemangioblastomas are rare benign but potentially devastating vascular tumours.They may occur sporadically or as a component of Von Hippel-Lindau (VHL) disease. There is a dearth of information about these tumours among Nigerians. This study aims to evaluate the clinical profile and outcome of surgery as well as the challenges of management of these tumours in a resource-limited country.&#x0D; Methods: We retrospectively analysed data from the records of patients who had surgery for spinal haemangioblastoma at our center between January 2004 and December 2018.&#x0D; Results: We operated 2 cases of spinal haemangioblastomas during the study period (1 male, 1 female). The patients were aged 25 and 50years. Both patients presented with sensorimotor deficits but only one them had sphincteric dysfunction. The duration of symptoms was 2 weeks in one patient and 18 months in the other. The tumour was located in the thoracic region in both of them. One patient had extramedullary tumour while the had an intramedullary spinal tumour. Both patients were paraplegic at the time of surgery, for 3 days in one patient and more than 4 months in the second patient. Gross total tumour resection was achieved in both individual. The patient with short duration of symptoms and extramedullary tumour made a rapid post-operative neurological improvement while the one with long duration of symptoms and intramedullary tumour remained paraplegic until his demise 9 months after surgery.&#x0D; Conclusion: Spinal haemangioblastomas are rare tumours. Long duration of symptoms and intramedullary tumour location are predictors of unfavorable surgical outcome.

Stratification of Grade of Spinal Cord Non-Ependymal Gliomas by Magnetic Resonance Imaging

The purpose of this study was to demonstrate the usefulness of conventional magnetic resonance imaging (MRI) in stratification of spinal cord non-ependymal gliomas. Forty-one patients (mean age, 29.9 ± 16.8 years; 27 men) with first-diagnosed spinal cord non-ependymal gliomas underwent conventional MRI including T1-weighted, T2-weighted (T2W) and contrast-enhanced T1-weighted imaging sequences. The tumors were removed by surgery and processed by histology 1 week after MRI. Patients were divided into low-grade and high-grade groups according to histological findings. The MRI features of gliomas including signal-to-noise-ratio (SNR), margins, heterogeneity, edema, enhancement, tumor size, longitudinal location, and presence of syrinx were measured and compared between low-grade and high-grade groups using the χ2 test and the Mann-Whitney U test. The SNR of low-grade gliomas on T2W images was significantly higher than that of high-grade gliomas (165.0 ± 108.7 vs. 98.6 ± 44.4; P= 0.016 by the Mann-Whitney U test). The margins of low-grade gliomas were found to be clearer compared to that of high-grade gliomas (54.5% vs. 5.3%; P=0.001). Receiver-operating-characteristic analysis revealed that the area under the curve of 1/SNR, margin and the combination of 1/SNR and margin was 0.722 (95% confidence interval [CI], 0.564-0.880), 0.736 (95% CI, 0.578-0.894), and 0.845 (95% CI, 0.717-0.973), respectively. No significant differences were found in the heterogeneity, edema, enhancement level,enhancement SNR, size, longitudinal location, cyst, hemorrhage, and intramedullary location between low-grade and high-grade non-ependymal gliomas (all P > 0.05). The characteristics of signal intensity and margin on T2W imaging are valuable in stratification of spinal cord non-ependymal gliomas.

Intramedullary arachnoid cysts – Report of three cases and literature review

Arachnoid cysts are rare lesions of the spine and occur most commonly in the extradural location. Intramedullary location is a very rare site, and only 15 cases have been reported in literature till date. We report a series of three cases with intramedullary arachnoid cysts having diverse etiopathogenesis and clinical presentations. Recurrent cyst and cyst associated with tethering of the cord are unique to our series and have not been reported previously.

Intramedullary schwannoma of conus medullaris: rare site for a common tumor with review of literature.

Schwannomas at an intramedullary location constitute only 0.3% of primary spinal tumors. Those in the conus are extremely rare, especially in the absence of neurofibromatosis, with only 12 cases reported in the literature so far, excluding the present case. We report the case of a 27-year-old female who presented with complaints of backache since 1 year, weakness in both lower limbs with tingling and numbness since 6 months, and urinary incontinence since 1 month. There was no history of trauma or any skin lesions. Magnetic resonance imaging (MRI) of the spine provided a provisional diagnosis of ependymoma. The patient was operated upon, histopathology revealed it to be a schwannoma. Intramedullary schwannomas without neurofibromatosis are extremely rare at the conus and can be completely resected unless there is infiltration. Gliomas and ependymomas are commoner entities at this site, which are usually subtotally resected. This case highlights that although extremely rare, the possibility of a schwannoma may be considered in the differentials of an intramedullary spinal lesion.

Intramedullary Dermoid Cyst of the Cervical Spinal Cord – C5–C7 Level

Introduction Inclusion cysts of the spinal cord are rarely intramedullary. Such cysts are commonly located in the lumbar and thoracic regions and are usually associated with congenital spinal dysraphism and dermal sinus. Intramedullary dermoid cysts in the cervical region without spinal dysraphism are extremely rare. To our knowledge, only seven such cases are reported in the literature to date. Materials and Methods An 18-year-old female patient presented with weakness in all four limbs, more distal than proximal muscle weakness, that had been progressing for 3 years. The magnetic resonance imaging (MRI) showed an intramedullary lesion from C5– C7 with peripheral ring enhancement. “Whorls” were observed within the lesion on T2 weighted image, with associated excavation of vertebral bodies C5– C7. Operative procedure and findings: partial laminectomy of C5– D1was performed. The dura was opened. A small myelotomy was made in the root entry zone. About 1.5 ml of yellowish colored fluid was drained. White shiny debris with hair, whitish pultaceous content and teeth were removed. Complete excision of cyst and its wall was performed. Results The histopathological examination revealed that the cyst wall was lined by stratified squamous epithelium with underlying dermis showing hair follicles, sebaceous glands, adipose tissue and cyst filled with keratin debris suggestive of dermoid cyst. Conclusion The intramedullary location of the dermoid cyst in the cervical cord and the absence of any congenital spinal dysraphism make this case a very unique and rare entity and warrants its inclusion in the reported cases of rare intramedullary space occupying lesions.

Application of individualized navigation template in the location of femoral and tibial prosthesis in Oxford single condylar replacement

Objective To investigate the accuracy of the positioning of the prosthesis of the femur and tibia by the individual navigation template assisted Oxford unicompartmental arthroplasty and to evaluate of the value of navigation template in unicompartmental arthroplasty. Methods Twenty cadaveric legs were randomly divided into two groups (n=10), group 1 for navigation template and 2 for conventional method. A CT scan was performed preoperatively on the lower limb for navigational group. Geomagic software was used to process the CT data. A navigational template was constructed as the inverse of the distal femur and proximal tibia surface with an osteotomy gap. Two drills were used to define the rotational alignment of the femur in the computer. The navigational templates were produced using a rapid prototyping (RP) technique to assist UKA. The traditional method group was guided by the tibial extramedullary localization and the femoral intramedullary localization for the osteotomy and prosthesis placement. Both groups were performed according to the same standard. The position of the single condyle was evaluated by the anteroposterior X-ray films of the knee joint. The vertical relationship between the osteotomy surface and its mechanical axis was evaluated by CT. The parallel relationship between the central placement of femoral prosthesis and the posterior femoral cortex was also evaluated. Results The navigation template was close to the femoral condyle and tibial plateau without obvious movement. The mean operative duration of the navigation template group were 50.75±2.3 min and the traditional method group were 58.57±1.5 min (P>0.05). The postoperative femoral prosthesis flip angles of the navigation template group and the traditional group were 2.5°±-0.65° and -7.8°±3.26° respectively (P<0.05). The femoral prosthesis flexion angles were -2.9°±4.18° and-6.5°±4.25° (P<0.05), and the tibial prosthesis varus and valgus angles were -1.5°±0.50° and -5.8°±3.15° respectively (P<0.05). The tibial implant posterior inclination angles were 4.50°±1.55°and 3.05°±3.63° respectively (P<0.05). The average angles between navigational group distal femoral osteotomy surface and mechanical shaft were 89.5°±2.3° (range 87.5°-91.8°). The average angle between the proximal tibial resected surface and the mechanical axis was 90.3°±0.5° (range 89.4°-90.7°). There were 17 specimens of central column of femoral prosthesis parallel with the posterior femoral cortex. However, the angle of remaining 3 samples were less than 5°. In the traditional method group, the osteotomy surface and its mechanical axis were all angled. The deviation of distal femur distal surface in 7 specimens from the mechanical axis was larger than 10°, while that in 5 specimens was larger than 5°. Conclusion The navigation template can improve the accuracy of the femoral prosthesis localization, orientation and tibial prosthesis implants in the direction of valgus and valgus. However, there was no significant effect on the tibial prosthesis in the direction of posterior inclination. Key words: Arthroplasty, replacement, knee; Computer-aided design; Imaging, three-dimensional

Intramedullary epidermoid cysts in adults: Case report and updated literature review

Epidermoid cysts are classical tumors in neurosurgery, but spinal locations are rare and intramedullary locations represent only approximately 80 cases in the literature. Intramedullary epidermoid cysts arise from ectodermic tissue inclusion during neural tube closure. Intramedullary epidermoid cysts are more frequent in young patients and in a thoracic location. We report the case of a 61-year-old patient consulting for bilateral asymmetrical progressive paraparesis and proprioceptive ataxia revealing a T3–T4 exophytic medullar epidermoid cyst. The tumor was surgically removed with a favorable outcome. The capsule was partially removed. The authors present an updated literature review of intramedullary epidermoid cyst diagnosis, management and recommendations.

Stereotactic radiosurgery as a feasible treatment for intramedullary spinal arteriovenous malformations: a single-center observation.

Spinal cord intramedullary arteriovenous malformations are rare. For patients suffering from either hemorrhage or myelopathy, surgical or endovascular interventions are indicated. However, complete eradication of the nidus is often difficult because of its intramedullary location and complex angioarchitecture. In this report, we evaluate the feasibility and safety of stereotactic radiosurgery as a treatment modality for intramedullary spinal arteriovenous malformations (AVMs). Between 2010 and 2014, we performed stereotactic radiosurgery to treat four patients with intramedullary AVM and one with spinal arteriovenous metameric syndrome (one woman and four men; age range, 31-66years). Three patients presented with myelopathy, and two suffered hemorrhages. Nidi were located in the cervical (three cases) and thoracic (two cases) spinal cord regions. Based on the angioarchitecture, surgery and endovascular embolization were indicated. When both modalities were deemed hazardous, radiosurgery using CyberKnife™ was offered. Radiation using marginal doses of 18Gy was administered in three fractions. The mean follow-up period was 37.2months (range, 16-62months). After treatment, two of the three patients with myelopathy experienced either improvement or stabilization of their symptoms and one experienced worsening of dysesthesia. In two patients with hemorrhage, symptoms improved in one and remained stable in the other. No further hemorrhagic episodes were evident during follow-up. Follow-up angiograms showed marked shrinkage of the nidus located in the thoracic spinal cord in one case and angiographic stabilization in the others. As a treatment modality for intramedullary AVMs, CyberKnife™ is safe and can be considered when surgery or endovascular therapy is not indicated. To determine optimum radiation doses and protocols for treating spinal AVMs, further studies with more patients and long-term follow-up are required.

Periprosthetic fracture fixation in osteoporotic bone

Fixation techniques of periprosthetic fractures are far from ideal although the number of this entity is rising. The presence of an intramedullary implant generates its own fracture characteristics since stiffness is altered along the bone shaft and certain implant combinations affect load resistance of the bone. Influencing factors are cement fixation of the implant, intramedullary locking and extramedullary or intramedullary localization of the implant and the cortical thickness of the surrounding bone. Cerclage wires are ideally suited to fix radially displaced fragments around an intramedullary implant but they are susceptible to axial and torsional load. Screws should be added if these forces have to be neutralized. Stability of the screw fixation itself can be enhanced by embracement configuration around the intramedullary implant. Poor bone stock quality, often being present in metaphyseal areas limits screw fixation. Cement augmentation is an attractive option in this field to enhance screw purchase.

Spinal Intradural, Extramedullary Ependymoma with Astrocytoma Component: A Case Report and Review of the Literature.

Ependymomas are common spinal lesions, with the vast majority arising in an intramedullary location. Several cases have been described in the literature of ependymomas in an intradural, extramedullary location. The authors present a case of a 56-year-old female who presented with several weeks of lower back pain and weakness. MRI revealed an intradural, extramedullary enhancing mass at L1-L2. The mass was successfully resected surgically. Pathologic evaluation revealed a low grade glioma with components of both ependymoma and pilocytic astrocytoma with MUTYH G382D mutation. Extramedullary ependymomas are very rare tumors. To the authors' knowledge, this is the first case of ependymoma/astrocytoma collision tumors described in an extramedullary location.

Neuroenteric cyst: A rare cause of childhood hemiparesis

Neuroenteric cysts are rare congenital anomalies derived from the displaced endodermal tissue at around third embryonic week. These are commonly encountered in the mediastinum and rarely seen in the spinal canal in the intradural extramedullary and at times in intramedullary location. We report a case of neuroenteric cyst of spinal canal presenting with hemiparesis in a 12 years old female child. The patient had no associated underlying occult spinal deformity. On investigation her magnetic resonance imaging, revealed evidence of well-defined, intradural extramedullary cystic lesions at C6 to D2 vertebral level, situated anterior and right to the cord causing posterior and leftward displacement with marked cord compression at this level. The child underwent posterior laminectomy and excision of cyst with complete recovery and no residual deficit.