Spinal Extradural Space Research Articles

A dumbbell-shaped malignant lymphoma of the spinal extradural space presenting as symptoms of spinal cord compression

A dumbbell-shaped malignant lymphoma of the spinal extradural space presenting as symptoms of spinal cord compression

Spinal extradural angiolipoma manifested after normal vaginal delivery

BackgroundExtradural spinal angiolipomas are extremely rare benign neoplasms made up of mature lipocytes with abnormal blood vessels. Spinal angiolipomas represent only 0.14–1.2 % of all spinal axis tumours.Case presentationA case of thoracic spinal extradural angiolipoma producing acute spinal cord compression in a 35-year old housewife is presented. Patient presented with sudden onset of lower limbs paralysis and urinary incontinence for 1 month after vaginal delivery. Patient was diagnosed as dorsal spine angiolipoma which was treated surgically with excellent outcome.ConclusionsSpinal angiolipomas are rare tumours but it is mandatory to include it in the differential diagnosis of the spinal extradural space occupying lesions. Pregnancy and vaginal delivery may suddenly exacerbate the condition. The best investigation to choose to diagnose these lesions is definitely magnetic resonance imaging of the spine. The aim of treatment of extradural angiolipomas of the spine is to resect the tumour in Toto surgically with no need of adjuvant therapy, surgery alone can lead to excellent outcome.

A huge extradural ganglioneuroma of the lumbar spine

Summary Ganglioneuromas are benign tumors that arise from the ganglion cells of the sympathetic nervous system. They are most commonly localized in the posterior mediastinum, followed by the retroperitoneum, cervical region, and adrenal gland. We encountered a rare paraspinal neurogenic tumor with extension into the spinal extradural space that presented with a dumbbell shape and bony indentation. The clinical features, radiographic analysis, and surgical approach are briefly discussed.

Extradural vascular lesion of the spine mimicking a nerve sheath tumour

Benign vascular lesions located in the spinal extradural space are rare, representing up to 4% of all spinal neoplasms. They are often misdiagnosed as nerve sheath tumours or meningiomas, based on their clinical and radiological features. In particular, only two cases of angioleiomyoma in the posterior mediastinum have ever been reported in the literature. We present the case of a 60-year-old man with a 12 month history of lower thoracic back pain radiating around the front of his ribcage to his epigastrium. MRI showed a solid, homogenous left para-spinal mass adjacent to the T11 vertebra, with no evidence of destructive changes or bony infiltration. Based on MRI, CT and FDG-PET studies this lesion was provisionally diagnosed as a benign nerve sheath tumour. He underwent successful surgical resection with remission of symptoms. Histological examination corroborated with immunohistochemis-try and special stains revealed a complex vascular lesion which, according to our knowledge has never been described before. Microscopic examination showed a circumscribed nodular lesion with vascular spaces of varying size. There were large muscular arteries with adjacent bundles of smooth muscle in the stroma. Other areas showed ectatic vascular spaces lacking a smooth muscle layer, lined by flattened endothelial cells, in myxoid stroma. These features clearly indicate the presence of an arteriovenous malformation with an extensive cavernous component, as well as a prominent angioleiomyomatous component. Besides highlighting the importance of histopathology in the diagnosis of these rare mimickers and the pitfalls of the differential diagnosis, we believe this case sheds relevant light on the hamartomatous nature of these rare and poorly understood entities.

Primary spinal extradural Ewing′s sarcoma (primitive neuroectodermal tumor): Report of a case and meta-analysis of the reported cases in the literature

Background:Primary spinal primitive neuroectodermal tumors (PNET) and/or spinal extraskeletal Ewing's sarcoma family tumors (ESET) are rare lesions appearing in the spinal extradural space. One hundred forty-one primary spinal PNETs, including 29 intramedullary lesions, have been reported in the literature. Encountering a case of primary epidural EES/peripheral PNET (pPNET) in sacral level, which is the fifth one occurring at this level in the literature, we have tried to conduct a meta-analysis of the reported cases.Case Description:A 44-year-old lady with epidural EES/pPNET is reported here. She was once operated for L5/S1 herniated disc, which did not ameliorate her symptoms. The clinical, imaging, surgical, and histopathologic characteristics of our case are presented and wide search of the literature is also done. All the reports were level 3 or less evidences and most of the series had missing parts. 106 cases of primary intraspinal (extradural/extramedullary-intradural) EES/pPNET and 29 cases of primary intramedullary PNET (CNS-PNET) have been reported in the literature. The most common clinical presentation in both entities was muscle weakness proportionate to the tumor location. Distant metastasis occurred in 38 of 99 (38%) cases of primary intraspinal EES/pPNET, while the rate of metastasis was 48% in patients with PNETs occurring in the intramedullary region (P > 0.05). One-year survival rate of the patients who underwent chemo-radiation after total or subtotal resection was better than those who did not receive chemotherapy or radiotherapy, or did not have total or subtotal resection. However, this difference was not repeated in 2-year survival rate in any of the tumor groups.Conclusion:It seems that total or subtotal removal of the tumor and adjuvant chemo- and radiation therapy can improve the outcome in these patients.

Letters to the Editor

Letters to the Editor

Compresión medular por lipoma epidural dorsal

The spinal extradural space is normally occupied by adipose tissue and a venous plexus, so it should be not surprising that lipomas arise and reach sufficient size to compress symptomatically the spinal cord. Nevertheless, the spinal epidural lipomas are rare and benign tumours may present as a progressive spinal cord compression syndrome. Magnetic resonance imaging is useful in demonstrating the full extent and characteristics of these lesions, the severity of cord compression and the location in the canal. Usually, the lesion is amenable to total surgical extirpation and the functional prognosis is good. Histopathologically the tumour consists of a mature adipose cells matrix intermixed with vascular endothelial channels, that is the reason why it is also named angiolipomas. A 47 year-old woman complained of dorsal and bilateral submamarian pain lasting two years and progressive loss of sensibility and weakness in her legs. Following magnetic resonance studies a posterior spinal cord compression by an extradural tumour at T3-T7 levels was observed. She was operated on and we found an extradural yellow tumour easily to dissect and it was completely removed. One year later she is asymptomatic. Spinal epidural lipoma is a benign tumour which initially presents itself with local or radicular pain accompanied by progressive spinal cord compression syndrome. The choice treatment is laminectomy and total excision. Probably, this is one of the easiest tumours to remove of the spinal canal and a source of satisfaction because a complete recovery can usually be achieved.

Thoracic spine extradural arteriovenous fistula: Case report and review of the literature

Background Spinal extradural arteriovenous fistula is a rare, disabling, but potentially treatable disease. Only 27 cases have been reported so far in the past 40 years. Case Description An 18-year-old adolescent girl developed repeated back pain and mild paraplegia after a training course. Magnetic resonance imaging revealed a vessel-like lesion at the spinal extradural space, compressing the spinal medulla at the T5 level. Angiography disclosed a focal fistula fed by branches of the intercostal artery. The vascular mass was surgically removed and confirmed pathologically. Conclusion Spinal extradural arteriovenous fistulas have an arterial supply that originates outside the spinal dura, with venous draining into the spinal extradural venous plexus. They may lead to myelopathy, radiculopathy, or spontaneous extradural hematoma, due to dilated vein compression, blood stealing, or spinal venous hypertension. Extradural hematoma needs emergency laminectomy and clot evacuation. And extradural arteriovenous fistulas should be treated actively by embolization, surgical resection, or both. Appropriate treatment will stabilize the patient or result in neurological improvement.

Compromiso epidural espinal como presentación de los linfomas no hodgkinianos: aportación de 6 casos

Spinal cord compression and radicular involvement are infrequent events in the natural history of non-Hodgkin's lymphoma, which usually are secondary to invasion of spinal extradural space, and rarely are the presenting manifestations of this condition. Thoracic segment is predominantly affected, but any spinal region can be affected. Histologically, the spinal tumour are frequently a high-grade B lymphoma with aggressive behaviour. The aim of this work was to describe six new cases of non-Hodgkin's lymphoma in adults (five woman and one men), presenting with spinal neurological complications. The medical literature about this entity are revised.

Radiculopatía cervical como forma de presentación de un linfoma No Hodgkin

Neurological involvement in no-Hodgkin lymphoma is usually a serious problem leading to subacute compression of the spinal cord secondary to invasion of the spinal extradural space. This condition may be the presenting form of the illness, although relatively infrequently. Onset with involvement of the cauda equina or as an isolated radiculopathy is even rarer and has mainly been described at lumbar level. We present the case of a 27 year old man with no significant previous clinical history who had progressive, insidious onset of moderate-serious senso-motor radiculopathy at C8. On MR there was an infiltrating mass affecting the nerve root and reaching the spinal extradural space. Following decompression laminectomy the patient's leg recovered and on histology there was a large cell B lymphoma. The other complementary tests showed disseminated disease, although analysis of the cerebro-spinal fluid (including cytology) was normal. HIV seriology was also normal. Although isolated nerve root involvement is unusual in the presentation of lymphoma it should be considered to be part of the differential diagnosis of nerve root syndromes in young patients with no history of trauma or degenerative lesions.

Magnetic resonance imaging of spinal cord compression in thalassaemia before and after radiation treatment

Thalassaemia is a genetic disorder of haemoglobin synthesis, characterized by anaemia and haemosidirosis [1]. A complication of this disease is extramedullary haemopoiesis in the spinal extradural space, causing compression of the spinal cord. The rapid onset of neurological deficit prompts immediate neuroradiological investigation and early treatment [2]. The magnetic resonance imaging (MRI) findings in such lesions have been described previously by some of the present authors [3]. A further case is presented to illustrate the value of spinal MRI before and after radiation treatment of extramedullary haemopoiesis.

Clinical features and results of therapy for children with paraspinal soft tissue sarcoma: a report of the Intergroup Rhabdomyosarcoma Study.

Soft tissue sarcomas of the paraspinal region comprised 3.3% (56 of 1,688) of the patients entered and eligible on Intergroup Rhabdomyosarcoma Studies I (IRS-I) and II (IRS-II) (1972 to 1984). These lesions tended to be greater than 5 cm in diameter at diagnosis, invaded the spinal extradural space, and were of the extraosseous Ewing's sarcoma or undifferentiated sarcoma subtype in 55% (30 of 56) of the cases. Patients with tumors in clinical groups II, III, and IV were treated with radiotherapy (XRT) and vincristine-dactinomycin (VA) or VA plus cyclophosphamide (VAC) +/- doxorubicin. Clinical group I patients treated on IRS-II did not receive XRT, while those on IRS-I were randomized to receive VAC +/- XRT. Forty-four of the paraspinal patients (79%) achieved a complete response (CR) compared with 77% (1,260 of 1,632) for patients with disease in other sites. Twenty-seven patients (55%) subsequently relapsed (five local, three regional, four local and distant, and 14 distant). The proportion of patients surviving 5 years by clinical group (stage) from I to IV were 50%, 50%, 62%, and 27%, respectively. Paraspinal patients had somewhat poorer survival than patients with disease in other sites, both in IRS-I and IRS-II; the percentage of paraspinal patients surviving 5 years was 50% and 52% for IRS-I and IRS-II, respectively, whereas these percentages were 55% and 63% for patients with disease in other sites. Histology did not influence the CR rate, but unexpectedly, patients who had embryonal rhabdomyosarcoma (RMS) had the poorest overall survival rate. We concluded that patients with paraspinal lesions may require extended-field radiation therapy to reduce the high local failure rate and more intensive chemotherapy to achieve better local and systemic tumor control.

LOW-FREQUENCY, WEAK EXTRADURAL STIMULATION IN THE MANAGEMENT OF INTRACTABLE PAIN

Low-frequency (1.6-2.2 Hz) and weak-intensity electrical stimulation in the spinal extradural space produced complete to partial pain relief in a majority of patients (22 of 25) who suffered from intractable pain. Also it produced analgesia or hypoalgesia over a wide area of the body surface in 19 of the 25.

A Case of Spinal Extradural Tumor

A sixty-three years old man have complained the low back pain with the radiation pain to the right thigh since January 1968. He admitted to our hospital with the limitation of extension of the right hip due to the pain in February 1968.After two weeks of hospitalization, he had dysuria motor loss of both legs and saddle block sensory disturbance. The spinal tumor was suspected and the blockage below the third lumbar vertebra was demonstrated on myelogram. On march 21, 1968, the operation was performed. The tumor was placed in extradural space (L3-L5) and removed.Microscopic examination revealed the reticulum cell sarcoma. The patient's postoperative course was becoming worse and died forty days after operation. At autopsy same tumor in the origin of right Psoas Major Muscle from 4th lumbar vertebral body to the 5th was found. But the tumor was not demonstrated in the lymphonodes which was able to be examined.Our case is thinkable a reticulum cell sarcoma that arose primarily from spinal extradural space and right psoas major muscle apart from lymphonodes.

LOCAL ANESTHETIC DRUGS

Local anesthetics, injected into the spinal extradural space, can be recovered from the spinal cord and brain. Transport from the extradural space into the neuraxis is independent of an active circulation. Distribution is greatest in the periphery of the cord and is most intense near the site of injection. The drugs probably diffuse into the subperineural spaces of the mixed nerves and then pass centripetally along the spinal roots into the cerebrospinal fluid and the cord.

Local anesthetic drugs: penetration from the spinal extradural space into the neuraxis.

Local anesthetics, injected into the spinal extradural space, can be recovered from the spinal cord and brain. Transport from the extradural space into the neuraxis is independent of an active circulation. Distribution is greatest in the periphery of the cord and is most intense near the site of injection. The drugs probably diffuse into the subperineural spaces of the mixed nerves and then pass centripetally along the spinal roots into the cerebrospinal fluid and the cord.

Neoplastic disease of the spinal extradural space; a review of fifty cases.

When the therapy of an illness falls as far short of the ultimate as does the surgical treatment of neoplastic disease, then it is necessary to reconsider frequently the principles upon which it is based and the results which it achieves. These results are twofold, curative and palliative, and, while our efforts are directed toward the former, we realize all too frequently that the best results will sometimes lie in palliation. The disappointment in accepting this lesser goal must not allow us to underestimate its importance or neglect the help that it may give. Probably nowhere should palliation have a greater place than in malignant disease of the spinal extradural space, where a relatively simple surgical procedure might be expected to relieve pain and avert the catastrophies of paraplegia, bedsores, and incontinence. Within these limited aims the results should be good; yet this apparently is not the case. Rowbotham1

Spinal Extradural Hemangioblastoma Roentgenographically Visualized with Diodrast at Operation and Successfully Removed

Extradural hemangioblastomas of the spine appear to be relatively uncommon. Four instances of intraspinal hemangioblastoma were recorded by Elsberg (1) in a series of 253 intraspinal tumors, and but one of these was extradural. So-called hemangiomas of the vertebrae resulting in cord compression are more common. In 1943 Blackford (2) collected 65 such cases from the literature, including one of his own. On the basis of his microscopic description of the tumor, Blackford's case, and probably some of the others as well, were most likely hemangioblastomas, that is, true neoplasms composed of growing angioblasts rather than hemangiomas (angiomas), which are vascular malformations. This distinction has been clearly made by Cushing and Bailey (3), although considerable confusion of terminology still exists with respect to these lesions. It is the purpose of this communication to relate an experience which, so far as is known to the writer, is unique. A pulsating hemangioblastoma arising from the spinal extradural space was encountered. At the time of the first operation the extent and the true nature of the lesion were not apparent, and it was considered inoperable. At a second operation, diodrast was injected into the mass and its extent as well as its main vessels of supply and drainage were clearly portrayed. It was then possible to extirpate the tumor and bring about functional recovery. Case Report History: H. N., a 42-year-old male, entered the Hospital June 15, 1946, complaining of numbness and coldness of the feet as well as weakness of the lower extremities of fifteen years' duration; urgency and frequency of urination with diminution of sexual potency for two years; occasional low back pain with radiation down the entire left lower limb. The symptoms were progressive. Examination: The general physical examination revealed a hard, freely movable mass, unattached to the skin, measuring 3.5 × 5.0 cm., located in the right anterior superior cervical triangle. The mass had first been noticed three years earlier and had increased in size gradually. A similar mass excised from the left cervical region sixteen years previously was diagnosed “tuberculous adenitis” on microscopic examination. The only other abnormal finding on general examination was the presence of hypertension (240/150). Neurological examination revealed the following abnormal findings: moderate weakness of both lower limbs, greater on the left; very active knee and ankle jerks with bilateral ankle clonus, absence of cremasteric reflexes, and bilateral extensor plantar responses; impairment in appreciation of pin-prick, hot and cold objects, and cotton-wool below the level of the groin on both sides, with a slight degree of sacral sparing of sensation; absence of appreciation of position sense of the great toes and vibration at the ankles.

SPINAL EXTRADURAL CYST

THE INTEREST in noninflammatory and non-neoplastic cysts of the spinal extradural space was initiated by the report of Elsberg, Dyke and Brewer1in 1934. They described 4 cases of such a cyst encountered among 250 tumors of the spinal cord and evolved a clinical and roentgenologic syndrome which has proved to be diagnostic of the condition. They described the combination of signs and symptoms as follows: The individual is an adolescent with the history of symptoms of a progressive spastic paraplegia. Pain is absent or is not a prominent symptom. The objective disturbances of sensibility are slight and their upper level is in the mid-thoracic dermatome. The manometric tests demonstrate a subarachnoid block with the characteristic spinal fluid changes of cord compression. Measurements on anteroposterior x-ray films show that the interpedicular spaces of three or more vertebrae are enlarged. The pedicles of the affected vertebrae, especially those of the