Unusual Malignant Thoracic Cystic Lesion.

Malignant cystic lesions in the spine are rare. In this report, we present a 65-year-old man who presented with imbalance on walking of 1-week duration with intact motor examination. Magnetic resonance imaging of the thoracic spine showed large expansile, T2-hyperintense mass involving T8 vertebral body, replacing the posterior elements causing cord compression with associated edema. He underwent uneventful T8 corpectomy, placement of expandable interbody cage, and T5-T11 posterolateral fusion using bilateral transpedicular approach. However, he died 5 months later due to progression of moderately differentiated metastatic lung cancer. To our knowledge, this is the first report showing the near-complete replacement of vertebral body and posterior elements with a malignant cystic lesion.

Tenosynovial Giant Cell Tumor of the Cervical Spine: Case Report and Review of the Literature.

Tenosynovial giant cell tumor (TGCT) is a rare entity that is not well described in the neurosurgical literature. We present a case of a 37-year-old woman with a diffuse subtype TGCT of the cervical spine, affecting the left cervical 6-7 facet joint, with co-incidental cervical trauma. Initial management consisted of subtotal resection and cervical stabilization with cervical 6 to 7 laminectomy, and cervical 4 to thoracic 2 posterior instrumented fusion. Gross total resection was achieved at a later date with a plan for postoperative radiation to prevent a recurrence. The patient was lost to follow-up for radiation treatment and returned 2.5 years later with minor symptoms and recurrence at the surgical site.

Symptomatic Lumbar Discal Cyst: A Rare Entity that Can Mimic Other Lumbar Cystic Lesions.

Lumbar discal cyst (LDC) is a rare clinical entity with unclear etiology. Three theories have been proposed to describe the pathogenesis of this condition: (i) a reaction to spinal epidural hematoma; (ii) a pseudomembrane formation that follows the focal annular tear and disc degeneration; and (iii) an inflammatory reaction to the herniated disc fragment. It usually presents with radicular symptoms. Radiographically, LDC can mimic other cystic lesions of the lumbar spine. Imaging nuances such as scalloping of the vertebral body, contrast filling with discography, and MRI signal intensity on different sequences can help to establish a diagnosis of LDC. However, there are no clear guidelines on the best treatment approach. Several treatment options have been prescribed to treat LDC with good outcomes. Here we describe a case of LDC that presented with left-sided radicular symptoms for several months and had not undergone any initial conservative management. The patient was treated successfully with microscopic resection of the cyst with complete resolution of the symptoms.

Traumatic Ventral Cervical Spinal Cord Herniation: A Case Report.

Spinal cord herniation (SCH) is an uncommon traumatic event that should be considered in patients with vertebral fractures who develop an unusual constellation of autonomic and motor deficits. Herein, we describe a case of rapidly deteriorating neurological function following cervical spine fracture including sequelae such as bilateral lower-extremity weakness, loss of upper extremity motor function, and priapism. Decompression of the spinal cord allowed for the identification of the unusual herniation of the spinal cord and prevention of any further worsening of the neurological injury. Hyperflexion of the cervical spine upon traumatic impact provided the impetus for vertebral retropulsion and subsequent incarceration of the spinal cord. This phenomenon should be considered in the setting of acute traumatic injury to the cervical spinal cord. Surgical intervention is likely to allow the preservation of the remaining neurological function.

Sacroiliac Joint Fusion System for High-Grade Spondylolisthesis Using "Reverse Bohlman Technique": A Technical Report and Overview of the Literature.

OBJECTIVE/BACKGROUND: High-grade spondylolisthesis (HGS) is a complex clinical problem that poses significant challenges to the treating physician. Contentious debate has continued regarding the most optimal surgical approach for these patients. A variety of transsacral and transvertebral techniques have been described in reported studies. METHODS AND RESULTS: We present 2 cases of low back pain and radicular symptoms. Our 2 patients were a 35-year-old woman and a 26-year-old white woman. The computed tomography and magnetic resonance imaging scans revealed progressive HGS (grade III) that had not been relieved by conservative measures. Both patients underwent transsacral fixation using the reverse Bohlman technique (RBT) at L5-S1 and L4-L5 anterior lumbar interbody fusion combined with posterolateral fusion. At the 9- and 10-month follow-up visits, the patients reported minimal back pain with no radicular symptoms, and the imaging studies showed satisfactory fusion in both patients. CONCLUSIONS: To the best of our knowledge, this is the first report to demonstrate the utility of the sacroiliac joint fusion cage using RBT in patients with HGS with successful clinical outcome. The RBT is safe, feasible, and effective in carefully selected patients.

Surgical Management of Ruptured Isolated Aneurysm of Artery of Adamkiewicz: Interesting Report and Overview of Literature.

BACKGROUND: Spinal subarachnoid hemorrhage due to rupture of an isolated spinal aneurysm is extremely rare. Patients usually present with symptoms and signs resulting from spinal cord compression. No standard guidelines are available for the treatment of this condition. CASE ILLUSTRATION: In this report we present the case of a 78-year-old Caucasian male who presented with sudden-onset back pain and bilateral lower extremity weakness. Spinal angiogram revealed an isolated aneurysm of the artery of Adamkiewicz. The aneurysm was successfully managed by surgical clipping, and the patient recovered well with rehabilitation. At 46 months' follow-up, the patient was able to ambulate and perform activities of daily living independently. CONCLUSION: Our case is the first description of surgical clipping of a ruptured isolated spinal aneurysm of the artery of Adamkiewicz with a long-term successful outcome and shows that it is a safe and feasible option in carefully selected patients.

Diffuse Nocardial Spinal Subdural Empyema: Diagnostic Dilemma and Treatment Options.

Nocardiosis of the central nervous system and spine, in particular, is a rare infection with significant morbidity and mortality. Treatment is usually with antibiotics and surgical drainage or biopsy. The authors report a case of a 49-year-old man who presented with chronic lower back pain and paraplegia. He was found to have spinal subdural empyema caused by Nocardia farcinica. Laminectomy and sampling of the subdural collection were performed, and the patient was treated with triple intravenous antibiotics (linezolid, amikacin and ciprofloxacin). There was no neurological recovery at follow-up. Spinal nocardiosis should be considered in the differential diagnosis of immunocompromised patients who present with diffuse spinal epidural/subdural or spinal cord abscesses, appropriately unresponsive to antibiotics. Our case provides an insight into the management challenges of this rare disease.

Report of seizure following intraoperative monitoring of transcranial motor evoked potentials.

BACKGROUND: Transcranial motor evoked potentials are used to detect iatrogenic injury to the corticospinal tracts and vascular territory of the anterior spinal artery. Tongue and lip lacerations are the most common complication of this modality. Theoretical complications include cardiac arrhythmia and seizure although there are no published reports of either. CASE REPORT: We report a case of postoperative seizure following motor evoked potential testing in a patient without a seizure history. Although anecdotal reports exist, ours is the first known published report of seizure following transcranial electrical stimulation. CONCLUSION: The intent of this novel report is to encourage the use of anesthetic regimens that raise seizure threshold, decrease stimulation threshold, and increase the specificity of motor evoked potentials. Providers should be prepared to treat intraoperative or perioperative seizure activity when the monitoring protocol includes transcranial motor evoked potentials.

Multi-level corpectomies and reconstruction via a single posterolateral approach.

The surgical treatment of ventral spinal canal compression has traditionally required either an anterior or combined anterior-posterior decompression and stabilization. These types of approaches carry a significant morbidity and may not be appropriate for all patients. We report our experience with multi-level corpectomies and reconstruction performed via a single, posterolateral approach. A retrospective review was performed of six consecutive patients at a single institution who were treated for ventral multi-level spinal cord compression via a single posterolateral approach. All six patients underwent reconstruction and stabilization with an expandable cage and posterior fixation. Five patients had metastatic cancer with spinal cord compression and one patient had osteomyelitis with a ventral epidural abscess and vertebral body collapse. All patients underwent 2-level corpectomies. Pre-operative and post-operative neurologic function and stabilization construct integrity were analyzed. All patients had successful decompression and stabilization and there were no hardware complications. Three peri-operative complications were encountered: post-operative pleural effusion needing thoracostomy drainage, transient leg paresis that resolved at 2months and a post-operative wound infection needing operative debridement. At last follow-up all patients had improvement or stabilization of their neurological function. Long-term follow-up was limited by the progression of metastatic disease and death in all the patients with cancer. This study demonstrates that symptomatic improvement can be achieved in select patients requiring multi-level corpectomies when using a single posterolateral approach with expandable cage reconstruction and posterior stabilization.

Sacral fractures following stand-alone L5-S1 anterior lumbar interbody fusion for isthmic spondylolisthesis.

Recent studies have demonstrated excellent results in treating isthmic spondylolisthesis via an anterior lumbar interbody fusion (ALIF). The authors describe 3 patients with isthmic spondylolisthesis at L5-S1 who experienced sacral fractures after insertion of a unique, stand-alone anterior interbody fixation device. Three consecutive patients at a single institution were treated for Grade I spondylolisthesis at L5-S1 via a standalone ALIF with insertion of a novel biomechanical interbody device. This device is made of polyetheretherketone and has an integrated system for internal fixation into the vertebral bodies. In each patient a bone morphogenetic protein-soaked sponge was placed for the fusion. The indications for treatment in each patient were back and radicular pain that had been unsuccessfully treated with conservative measures. All 3 patients had reduction of their spondylolisthesis and resolution of their unilateral radiculopathies immediately postoperatively. Within 1 month of surgery, all 3 patients had failure of the device and recurrence of their symptoms. In each case the failure was due to fracture of the anterior portion of the S-1 body. Each patient underwent reduction and pedicle screw fixation at L5-S1. In all cases, there was successful reduction in their recurrent spondylolisthesis and resolution of their radiculopathies. Treatment of Grade I isthmic spondylolisthesis at L5-S1 with stand-alone ALIF and fixation can lead to sacral fracture from high stress loads at that level in the spine, and consideration should be made either for supplemental pedicle screw fixation or a completely posterior approach.

Acromegaly caused by a growth hormone-releasing hormone-secreting carcinoid tumor: case report.

OBJECTIVE AND IMPORTANCE: We describe a patient with acromegaly and pituitary hyperplasia secondary to a growth hormone-releasing hormone-secreting gastrointestinal carcinoid tumor. This case report illustrates the importance of including this rare clinical syndrome in the differential diagnosis of acromegaly for patients with suspected or known neuroendocrine tumors. CLINICAL PRESENTATION: A 19-year-old, Asian-American, male patient with a 2-year history of a nonresectable, metastatic, intestinal carcinoid tumor presented with complaints of headaches, arthralgias, sweats, and changing features. The examination revealed a young subject with acromegalic features, without visual field deficits. Magnetic resonance imaging revealed a diffuse sellar mass that extended suprasellarly to compress the optic chiasm. Endocrinological studies demonstrated a growth hormone level of more than 100 ng/ml and an inappropriately elevated growth hormone-releasing hormone level. INTERVENTION: The patient underwent transsphenoidal resection of the pituitary mass for diagnostic and decompressive purposes. The pathological examination revealed pituitary hyperplasia, without evidence of an adenoma. Therapy with long-acting repeatable octreotide (Sandostatin LAR; Novartis AG, Basel, Switzerland) was initiated postoperatively, to further control the acromegaly and carcinoid tumor. The soft-tissue swelling resolved, and the patient remained free of headaches, arthralgias, and sweats at the 6-month follow-up examination. CONCLUSION: Ectopic acromegaly is a rare syndrome that must be recognized by neurosurgeons because its treatment differs from that of classic pituitary acromegaly. We describe a patient for whom this syndrome was documented with magnetic resonance imaging, endocrinological testing, and pathological examinations.