Urgent Laminectomy Research Articles

PATH-42. DIAGNOSIS AND PROGNOSTICATION OF AN ATYPICAL ADULT PRESENTATION OF DIFFUSE LEPTOMENINGEAL GLIONEURONAL TUMOR (DLGNT) BY METHYLATION PROFILING

Abstract BACKGROUND Diffuse leptomeningeal glioneuronal tumors (DLGNT) are rare central nervous system tumors first described in the 2016 WHO classification. A paucity of data exists on this tumor. This case describes an adult presentation of DLGNT, a classically pediatric tumor, and highlights the importance of genetic and epigenetic analyses in neuro-oncologic diagnoses. CASE: A 22-year-old male presented with shoulder paresthesias and back pain, progressing to bilateral leg weakness. Spine MRI demonstrated an enhancing intramedullary T8 lesion, prompting urgent laminectomy and resection. Frozen section suggested a glial neoplasm. Four-month follow-up MRI spine showed leptomeningeal dissemination at the C-spine and caudal thecal sac. CSF analysis revealed 110 mg/dL protein, 2 cells/mcl, and negative cytology. NCI methylation profiling demonstrated 1p deletion and KIAA1549:BRAF fusion, consistent with DLGNT, subtype 1, with MAPK pathway activation; Ki-67 index was 30%. Treatment with binimetinib was initiated. After 1 month of therapy, the patient is tolerating treatment and strength is improving. DISCUSSION This case describes a rare presentation of a rare tumor. DLGNT, subtype 1, has a median age of diagnosis of 5 years and an indolent course. We describe an adult patient with molecular features consistent with DLGNT subtype 1, but a high proliferative index suggesting a more aggressive growth potential. In this case, methylation profiling aided in diagnosing the tumor type and guided treatment. The KIAA1549:BRAF fusion is an activating mutation in the MAPK pathway, and binimetinib was selected as a MEK inhibitor with high CNS penetration. To our knowledge, this is the first case of an adult-onset DLGNT treated with binimetinib. Based on our single patient experience, we would advocate for methylation profiling for rare CNS tumor entities.

Brown sequard syndrome as a manifestation of acute spontaneous spinal haematoma: A diagnostic challenge

Brown-Sequard Syndrome (BSS) is a neurological disorder caused by hemisection lesion of the spinal cord. BSS causes can be dichotomized in traumatic and atraumatic, and they can include vascular causes, as ischemia or haemorrhage. We describe the case of a 52-year-old woman presenting with limbs paraesthesia and right leg hyposthenia, associated with cervical acute nontraumatic pain (C6-C7 level). Neurological consultant was requested with a suspicious of vertebral artery dissection: clinical examination revealed right leg flaccid weakness, loss of pain and temperature sensation in left hemisoma, hypopallesthesia of right limbs and T1-T2 sensory level. Those symptoms were suggestive of a Brown Sequard Syndrome. MRI showed an epidural haematoma compressing spinal cord, associated with abnormal signal to C6-C7 and D1 level of spinal cord. Urgent laminectomy and evacuation were performed. Neurological symptoms improved avoiding permanent paraplegia

Spontaneous Spinal Epidural Hematoma Causing Paraparesis in a Patient of Mitral Valve Replacement with Anticoagulant Treatment – A Decision Dilemma

Summary and Background: Spontaneous spinal epidural hematoma (SSEH) is a known occurrence in patients on anticoagulant therapy. There is an increased risk of developing hematoma after the spine surgery if anticoagulation therapy is reinstated. Purpose of Study: The purpose of the study was to find out solution related with perioperative anticoagulant therapy in high-risk cases if patient redevelops hematoma and paraplegia due to continuation of anticoagulant therapy. Case Report: A 30-year-old male presented to us with history of progressive paraparesis. He had history of mitral valve replacement twice followed by cerebrovascular stroke and on regular oral anticoagulant therapy. Magnetic resonance imaging revealed SSEH from C6-T1 level with cord compression. Initial decision was taken to conservatively treat as his coagulation parameters were altered and he was on high-risk for developing thromboembolism related complications if anticoagulant medicines were stopped. However, urgent laminectomy and evacuation of SSEH had to be performed due to rapid worsening of neurology. Postoperatively, patient had significant neurological recovery and anticoagulant therapy reinstated after 12 h of surgery. Patient developed acute paraplegia within 2 hours of anticoagulant therapy due to post-operative hematoma, which was drained out by opening the wound bedside. He regained neurological recovery within 5 min. Anticoagulation therapy was withheld for next 36 hours and reinstated with low-dose intravenous heparin followed by low-molecular weight heparin without any complications. His coagulation parameters and 2-D echo were followed up daily to check cardiac conditions. Patient improved clinically and became self-ambulatory. Conclusion: Post-operative hematoma after spine surgery should be kept in mind in patients who are on anticoagulant treatment. Reinstating anticoagulation treatment in such high-risk patients should be done with lot of caution and initially with low-dose heparin followed by regular anticoagulation therapy. Close observation on neurological status is must to avoid permanent neurological injury. Keywords: Spontaneous spinal epidural hematoma, Anticoagulat treatment, Decision dilemma

Spontaneous Spinal Epidural Hematoma due to Anticoagulant Therapy: A Case Report and Literature Review

Aims: We report a case of spontaneous spinal epidural hematoma (SSEH) that occurred in a patient on life-long warfarin following liver transplant due to decompensated liver failure secondary to primary Budd-Chiari syndrome. Patients and Methods: Our patient presented with acute central back pain with bilateral lower limb paralysis and incontinence with neurological level of T8 American Spinal Injury Association Impairment Scale (AIS) A. There were no history of fever, trauma or straining. MRI revealed a hyper-intense lesion at level of T8 till T10 and patient underwent an urgent laminectomy which revealed an epidural hematoma at that level. Result: Post-operatively, patient gradually improved with final neurology level at level of T9 AIS D prior to discharge. Conclusion: A prompt diagnosis and intervention are needed in cases of SSEH to achieve a favourable outcome.

Acute medullar compression secondary to a septic arthritis of a thoracic facet joint: a case report and review of literature.

Septic arthritis of a facet joint (SAFJ) is a rare entity and frequently underdiagnosed. It is most frequently localised in the lumbar segment. A 48-year-old woman presented at our emergency room with a chief complaint of lumbar pain and perineal hypoesthesia. An urgent lumbar Magnetic Resonance Imaging (MRI) was performed showing no signs of compressive pathology. Intravenous painkillers were administered improving her clinical symptoms, so she was discharged from the emergency department to be followed at our out-patient clinic. After 12 h, the patient presented again referring an acute loss of strength in her lower limbs and paresthesias at a T10 sensitive level. Due to the severity of the symptoms, we performed an urgent dorsal MRI that showed a septic arthritis of the left T8-T9 facet joint and an epidural abscess causing a medullar compression. Blood cultures were performed before surgical treatment. An urgent laminectomy of T8 and debridement of the abscess were performed. Intraoperative microbiology and blood cultures were positive for Streptococcus constellatus. After surgery, the patient presented a progressive improvement of her symptomatology. Physicians should have in mind and rule out this clinical entity to avoid severe consequences that a misdiagnosed SAFJ could develop.

An Unusual Case of Dorsally Sequestrated Disk Mimicking Tumor with Cauda Equina Syndrome

A 44-year-old male presented with acute onset retention of urine and low back pain. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated an extradural mass extending from the lower border of the L3 vertebra to upper border of L5 vertebra. Axial imaging showed the posterolaterally located mass lesion on left side, producing significant compression and displacement of thecal sac and exiting nerve root. Following contrast administration, there was a peripheral ring enhancement. Diagnosis of extradural mass lesion was made. In view of urinary retention, urgent laminectomy was performed. The massive sequestrated lumbar disk was found on an exploration that was excised completely. This resulted in prompt relief of backache. Bladder took 2 weeks for complete recovery. Here, an unusual case of sequestrated dorsally placed lumbar disk mimicking tumor is presented.

Spontaneous Spinal Epidural Hematoma Causing Paraplegia: A Case Report

A spontaneous spinal epidural hematoma without any identified etiology is a very rare entity. We report here a 44 years old woman admitted within our department for 04 days of severe back pain complicated rapidly of bilateral lower-limbs weakness and urinary retention. Neurological examination found a complete paraplegia (0/5 stergh), with incomplete sensory deficit below the T-10 level, bowel and bladder dysfunction, decreased deep and superficial reflex. MRI with different sequences showed a large epidural mass lesion with slightly high signal intensity on T1-weighted images and heterogeneous low signal intensity on T2-weighted images from T11 to L1 suggesting an epidural hematoma. She underwent an urgent total laminectomy from T11 to L1 following by a complete removal of a large dark and compact epidural hematoma compressing the spinal cord. Operatively, there’s no sign suggesting an AVM. Postoperative course was uneventful and she was discharged ten days after surgery with complete recovery.

Cervical intraspinal extradural primitive neuroectodermal tumour in an adult

Abstract Intraspinal extradural primitive neuroectodermal tumours (PNET) represent a rare entity that almost always carry a poor prognosis. A recent literature research revealed only four cases reported in adults. The tumours have mainly thoracic and lumbar location. We report the only case with cervical location and with the longest survival. Urgent laminectomy was performed resulting in a rapid pain relief for the patient. The patient was followed up with craniospinal irradiation and several cycles of chemotherapy. The patient died due to dissemination of the disease 31 months after the diagnosis. Intraspinal PNET tumours have a rapidly progressive course, and there is no current consensus on the optimal therapeutic approach.

Rapidly progressive paraplegia and pleural empyema: how does that correlate?

A 74-year-old man presented with progressive dyspnea after a 10-days latency following a thoracic trauma. CT imaging showed multiple rib fracture and an empyema that was primarily treated by a chest tube. In the course of the hospital stay, a rapidly progressive paraplegia developed and the MR imaging revealed a peridural abscess caused by a pleural empyema. Due to trauma-related barrier damage and the initial delay of the operative therapy a usually less invasive pathogen (streptococcus intermedius) could affect the peridural space. The successful therapy consisted of urgent laminectomy and a subsequent video-assisted thoracoscopy supported by systemic antibiotic therapy.

Challenges to Treatment of Leukemia in HIV-positive Children

We describe the challenges to treatment of leukemia in three cases of human immunodeficiency virus (HIV)-infected children with multiple infections and complications. Two of the three patients had acute myeloid leukemia and the other one acute lymphoblastic leukemia. Two of the patients were known with HIV infection; the third was diagnosed on admission. All patients received antiretroviral therapy with standard doses of lamivudine, stavudine and efavirenz or lopinavir/retonavir. All three were diagnosed with Mycobacterium tuberculosis on one or more occasions: pulmonary or miliary involvement or tuberculous meningitis. One patient developed spinal paraplegia and needed an urgent laminectomy. Later he recovered almost completely. The interaction between antiretroviral and antituberculosis treatments combined with chemotherapy, antibiotics and supportive care is not known. Despite the severity and the complexity of several associated diseases, the outcome of the patients was rewarding and encouraging.

Quiste sinovial lumbar como causa de síndrome de cauda equina. Presentación de un caso y revisión de la literatura

We report the case of a 77-year-old woman who was admitted to our hospital with cauda equina syndrome. An urgent magnetic resonance imaging scan showed lumbar spinal canal compression at L4-L5 and L5-S1. An urgent laminectomy was performed and cystic lesions were extracted. On pathological examination, the lesions were identified as synovial cysts. The patient required rehabilitation and achieved good functional recovery, although sensory deficit remains in the sacral segments.

Giant thoracic schwannoma presenting with abrupt onset of abdominal pain: a case report

IntroductionGiant intradural extramedullary schwannomas of the thoracic spine are not common. Schwannomas, that is, tumors derived from neoplastic Schwann cells, and neurofibromas represent the most common intradural extramedullary spinal lesions. We report the case of a patient with a giant thoracic schwannoma presenting unusually with acute abdominal pain and with delayed neurological impairment.Case presentationA 26-year-old Hispanic man with no previous medical problems presented with acute periumbilical pain. After extensive work-up including an exploratory laparotomy for appendectomy, magnetic resonance imaging scans of the lumbar and thoracic spine revealed a giant intradural extramedullary thoracic schwannoma within the spinal canal posterior to the T9, T10, and T11 vertebral bodies. Magnetic resonance imaging signal prolongation was noted in the spinal cord both rostral and caudal to the schwannoma. The patient underwent an urgent laminectomy from T8 to L1. After sacrificing the T10 root, the tumor was removed en bloc. Postoperatively, the patient improved significantly gaining antigravity strength in both lower extremities.ConclusionThe T10 dermatome is represented by the umbilical region. This referred pain may represent a mechanism by which a giant thoracic schwannoma may present as acute abdominal pain. Acute, intense abdominal pain with delayed neurologic deficit is a rare presentation of a thoracic schwannoma but should be considered as a possible cause of abdominal pain presenting without clear etiology. Although these lesions may be delayed in their diagnosis, early diagnosis and treatment may lead to an improved clinical outcome.

Recovery from paraplegia after the treatment of spinal dural arteriovenous fistula: case report and review of the literature

Spinal dural arteriovenous fistula (SDAVF) is a rare and enigmatic disease. Functional outcome is particularly uncertain for the small group of patients that are unable to stand at the time of diagnosis (grade 5 gait disturbance on the Aminoff-Logue scale, ALS). The objective of this study is to examine the final functional outcome of patients with SDAVF in grade 5 gait ALS before treatment. We conducted a PubMed search using the keyword "spinal dural arteriovenous fistula." A review of the clinical series and single well-detailed case reports of SDAVF gathered 106 patients with grade 5 gait ALS on the initial examination. Additionally, we report the case of a 56-year-old man presenting acute paraplegia and urinary retention on admission who had complained of sporadic motor and sphincter disturbances for 1 year. Spine T2-weighted MR imaging showed a central hyperintensity within the spinal cord, and the angiography demonstrated a T-11 SDAVF. Interruption of the fistula was performed through an urgent one-level laminectomy. Grade 5 gait ALS was present in 25% of the patients with SDAVF included in the clinical series. Latest follow-up showed that gait disturbance improved in 73% of patients after treatment, although less than 6% became grade 1 gait ALS. Micturition disturbances improved in 39%. Exploration of our patient showed improvement to grade 1 gait ALS 1 year after the surgical treatment. Interruption of SDAVF in paraplegic patients may improve the final functional gait outcome in some cases. No complete recovery (grade 0 gait ALS) was achieved after treatment. Micturition disturbances had a worse prognosis than motor deficits.

Spinal subdural hematoma following tissue plasminogen activator treatment for acute ischemic stroke

A 49-year-old woman with an acute ischemic stroke was treated by the intravenous administration of tissue plasminogen activator within 2 h of symptom onset. She complained of severe upper thoracic back pain the following day. Progressive paraparesis was detected on the third admission day. Spinal MRI demonstrated an acute anterior subdural hematoma from the C7 to T2 level. An urgent laminectomy was performed. Neurologists must be aware of the possibility that neck or back pain after thrombolysis for ischemic stroke may be the first presenting symptom of spinal hematoma.

Staphylococcus aureus meningitis secondary to occult spinal extradural abscess

We report a rare case of spinal extradural abscess presenting as Staphylococcus aureus meningitis in a previously well child. After initial improvement with intravenous antibiotics the patient clinically deteriorated in a non-specific manner. Magnetic resonance imaging (MRI) scan of the spine revealed an occult spinal extradural abscess and urgent neurosurgical laminectomy led to full recovery. No evidence of an underlying spinal abnormality or immunodeficiency was demonstrated on investigation. A high index of suspicion is required in these cases due to the frequent absence in children of classic symptoms of spinal extradural abscess. we advise an urgent MRI of the head and spine in such unexplained cases of Staphylococcus aureus meningitis, to allow early diagnosis and management of occult underlying pathology. Such an approach will minimise the risk of potentially catastrophic neurological sequelae.

Acute Spontaneous Spinal Subdural Hematoma Presenting as Paraplegia

Case report. To report an unusual case of spontaneous spinal subdural hematoma and to review relevant literature and discuss the etiology, pathogenesis, clinical features, imaging, and prognosis. Spontaneous spinal subdural hematoma with no underline pathology is a very rare condition. Only 19 cases have been previously reported. The case of a 44-year-old man is presented. Pubmed (Medline) was used to search publications. Our patient presented with sudden severe low back pain following a minimal effort, with rapid onset of complete paraplegia. MRI revealed an anterior subdural hematoma from T2-T6 with cord compression. An urgent laminectomy was performed. MRI scan, surgery, and CT angiogram did not reveal any underlying pathology to account for the subdural hematoma. The patient demonstrated substantial clinical improvement after 6 weeks of bed rest and intense rehabilitation program. Spinal subdural hematoma (SSDH) is uncommon and can be caused by abnormalities of coagulation, blood dyscrasias, or trauma, underlying neoplasm, and arteriovenous malformation. SSDH is very rare in the absence of these underlying conditions. It occurs most commonly in the thoracic spine and presents with sudden back pain radiating to the arms, legs or trunk, varying degrees of motor, sensory, and autonomic disturbances. On MRI, SSDH is seen as a space-occupying lesion, usually ventrally, contained within the dura matter, and can demonstrate variable T1 and T2 signal depending on the age of the hematoma. The prognosis is variable. The majority of cases in the literature had surgical decompression, although cases that were managed conservatively have been reported to be successful as well. The indications of surgery need to be clarified.

Spinal cord tumour presenting as neck pain

In April 2003, a 48-year-old GP was admitted to the authors' hospital with severe neck pain. He had a 2-week history of progressively worsening neck pain without antecedent trauma or strain. Pain was initially relieved by paracetamol, but progressed to waking him from sleep and became continuous during the day. Physiotherapy and opiates did not alleviate symptoms. Power, sensation and sphincter functions were unaffected. After a further week of unremitting pain, neurosurgical referral was made. A magnetic resonance imaging scan showed an intrinsic spinal cord tumour extending from C3 to C6 level (Figure 1). Urgent laminectomy and resection of tumour was performed. Complete excision was possible as the tumour had not infiltrated into surrounding normal cord. Pathology confirmed intramedullary ependymoma. After a short period in a spinal rehabilitation unit followed by regular outpatient physiotherapy the patient regained full function, resuming work, and was even able to participate in a local relay marathon 2 years later.

Paraplegia due to spinal subdural hematoma as a complication of posterior fossa surgery: Case report and review of the literature

Although blood contamination of cerebrospinal fluid (CSF) after an intracranial operation is possible, development of a symptomatic spinal hematoma after a posterior fossa surgery has never been reported. A 43-year-old woman underwent a posterior fossa tumor removal in the prone position with no intraoperative difficulty. On the second postoperative day, she complained of severe epigastric pain and developed a rapid onset of paraplegia with anesthesia below the thoracic 5 spinal level. The emergency cranial and spinal MRIs revealed a spinal extramedullary hemorrhage spreading to the whole spinal regions, just sparing the cauda equina area. There was a prominent localized hematoma formation surrounding and compressing the spinal cord at the upper thoracic levels, which was evacuated via an urgent laminectomy. The patient showed partial neurological recovery after the decompression. Development of the spinal hematoma was explained by the movement of blood from the tumor bed into the spinal canal under the effect of gravity, during or after the operation. A 30° head elevation might facilitate the accumulation of blood. Localization of the hematoma formation may be caused by the fact that the upper thoracic levels constitute the apex of the kyphosis. We conclusively suggest that a spinal hematoma should be taken into consideration as a rare but potentially severe complication of a posterior fossa surgery. Meticulous hemostasis and isolation of the surgical area from the spinal spaces are essential. Overdrainage of CSF should be abandoned. Postoperatively, patients should be monitored for spinal findings as well as cranial signs.