Cervical Paraspinal Chordoma: A Literature Review with a Novel Case Report.

Chordomas are rare malignant neoplasms, accounting for 1-4% of all primary bone tumors. Most spinal chordomas occur in the sacrococcygeal region and the base of the skull; however, 6% of chordomas are observed in the cervical spine. In these cases, the lesion is mainly located in the midline. These tumors slowly grow before becoming symptomatic and encase the surrounding vascular and nerve structures. Patients with advanced chordoma have a poor prognosis due to local recurrence with infiltration and destruction of adjacent bone and tissues. Systemic chemotherapy options have not been fully effective in these tumors, especially for recurrent chordomas. Thus, new combinations of currently available targeted molecular and biological therapies with radiotherapy have been proposed as potential treatment modalities. Here, the present paper describes the case of a 41-year-old male with a C2-C4 chordoma located paravertebrally, who underwent surgical resection with a debulking procedure for a cervical chordoma. Computed tomography angiography revealed a paraspinal mass with bone remodeling and the MRI showed a paravertebral mass penetrating to the spinal canal with a widening of the intervertebral C2-C3 foramen. Initially, the tumor was diagnosed as schwannoma based on its localization and imaging features; however, the histopathology specimen confirmed the diagnosis of chordoma. This case study highlights the effectivity of radical surgical resection as a mainstay treatment for chordomas, discusses neuroimaging, diagnosis, and the use of currently available targeted therapies and forthcoming treatment strategies, as alternative treatment options for chordoma.

Use of O-arm with neuronavigation in percutaneous vertebroplasty reduces the surgeon's exposure to intraoperative radiation.

INTRODUCTION: Percutaneous vertebroplasty is commonly used to treat spinal fractures. The authors compare radiation exposure as potential risk for the surgical team during vertebroplasty guided by O-arm combined with neuronavigation versus vertebroplasty guided by C-arm fluoroscopy. MATERIAL AND METHODS: The clinical material consisted of a group of 29 patients (44 vertebrae) with fractures of the thoracolumbar spine treated with percutaneous vertebroplasty guided by O-arm with neuronavigation. In this new method, the operating room staff leaves the operating room for the duration of the 3D scan of the appropriate spine section using the O-arm. In the next stage, the needle of the vertebroplasty system is introduced using only neuronavigation without the need for a radiological view. Finally, the cement injection was made under O-arm fluoroscopic control. The comparison group consisted of a group of 35 patients (40 vertebrae) treated with the classical method using C-arm fluoroscopy. The two methods were compared in terms of the average dose of emitted ionizing radiation through the device (O-arm vs. C-arm) to which surgeons are exposed during percutaneous vertebroplasty. RESULTS: As a result of vertebroplasty procedures guided by neuronavigation, a statistically significant difference between the values of mean dose of radiation emitted by O-arm and C-arm systems was noted. The O-arm emitted 912 cGy/cm2 vs. 1722 cGy/cm2 emitted by the C-arm during fluoroscopically assisted procedures and 601.28 cGy/cm2 vs. 1506.86 cGy/cm2 per vertebrae. CONCLUSIONS: During vertebroplasty with the O-arm combined with neuronavigation the radiation dose is significantly lower as compared with the C-arm used for fluoroscopic guidance, minimizing the potential risk of radiation exposure to surgeons.

Anatomic Variations of the Lateral Femoral Cutaneous Nerve: Remnants of Atypical Nerve Growth Pathways Revisited by Intraneural Fascicular Dissection and a Proposed Classification.

OBJECTIVE: To trace anatomic variations of the lateral femoral cutaneous nerve (LFCN) in its intrapelvic course. METHODS: Forty cadavers (80 sides) fixed in 10% formalin solution were dissected. The following parameters were recorded: LFCN diameter and variations in its origin and number. The dissection comprised exposure and excision of the lumbar plexus, together with the roots of LFCN, followed by retrograde intraneural fascicular dissection using microsurgical instruments. RESULTS: Several types of LFCN origin from the lumbar plexus were observed. Typically, the LFCN appears as a single trunk arising from dorsal divisions of the ventral rami of the lumbar plexus. The most prevalent origin of the nerve was from the L2 and L3 roots (47 cases; 58.75%). The LFCN took an origin from the L1-L2 level in 12 cases (15%) and from the L2 nerve in 9 cases (11.25%). The main observed variations were the presence of the accessory LFCN (2 cases; 2.5%) and branching of the LFCN from the femoral nerve (6 cases; 7.5%). Communications between the LFCN and the femoral or genitofemoral nerves also were observed occasionally. An atypical course of the LFCN with respect to the anterior psoas was observed in our material in 3 of the 80 sides (3.75% of the examined LFCN specimens). CONCLUSIONS: Considerable variability in the origin and the course of the LFCN was observed, which should be taken into account during clinical assessment of nerve lesions and during surgery via transpsoas approaches to the lumbar spine.

Neurofibromatosis type 2 (NF 2) or schwannomatosis?--Case report study and diagnostic criteria.

INTRODUCTION: Neurofibromatosis type 2 (NF2) and schwannomatosis are entities that may, due to the similarity of clinical symptoms, cause diagnostic difficulties. Incidence rate of both diseases is similar and estimated between 1:25,000 and 1:40,000. The genes associated with the development of the aforementioned disorders are located on chromosome 22 and lay in proxmity. Schwannomatosis is characterized by an incomplete penetrance and the risk of its transmission to the offspring is significantly lower than in the case of NF 2. Schwannomatosis clinical characteristic is similar to the NF2, however vestibular schwannomas are not present. Therefore the imaging studies evaluated by an experienced radiologist play a key role in the diagnostic process. CASE REPORT: Forty two-year-old female hospitalized three times because of the tumors of the spinal canal was admitted to the Department of Neurosurgery and Peripheral Nerve Surgery in 2008 because of the cervical pain syndrome with concomitant headache. She was diagnosed with a schwannomatosis, recently distinguished, the third form of neurofibromatosis. MRI imaging revealed craniocervical junction tumor. Suboccipital craniectomy with concomitant C1-C2 laminectomy was done in order to remove the lesion. After the surgery the patient did not present any deficits in neurological examination and was discharged from hospital in good general condition. CONCLUSIONS: The patient was diagnosed with schwannomatosis, recently established neurofibromatosis entity which may resemble NF2 clinically. In patients after the age of 30, in whom we observe multiple schwannomas without the concomitant hearing impairment, the diagnosis of schwannomatosis is very likely.

Delayed perforation of posterior pharyngeal wall caused by dislodged bioresorbable interbody cage. Case report.

A 48-year-old man was admitted for the management of congenital anomalies: Arnold-Chiari type I malformation combined with odontoid upward migration. He also had degenerative stenosis of the spinal canal by spurs at C2/C3 and C3/C4 levels. Osseous deformities caused ischaemic changes of the brainstem as well as spinal cord compression. Authors used the Biocage - interbody cage covered by bioresorbable layer to fill the surgically created gap after removal of the right part of C3 vertebral body. Twenty-seven months after implantation, the implant was extruded through posterior pharyngeal wall. Authors describe this unusual case and discuss possible causes of Biocage extrusion.

The use of calcium phosphate cement in vertebroplasty of the base of odontoid process.

The authors describe the use of bone cement containing calcium phosphate for vertebroplasty of the cavity in the base of odontoid process. A 23-year-old female patient was operated on by incision in lateral cervical area (anterior open access). After a blunt dissection, the working cannula (Kyphon) was introduced under fluoroscopic guidance through the C2 vertebral body to the cavity in the base of the odontoid process. Intraoperatively, biopsy of the lesion was taken and histo-pathological examination excluded the presence of neoplasm. The cavity, presumably haemangioma, was successfully filled with calcium phosphate bone cement KyphOsTM FS (Ky-phon). The proper filling without paravertebral cement leak was confirmed by postoperative computed tomography (CT). The CT and magnetic resonance imaging performed 9 months after the procedure showed that cement was still present in the cavity. This is the first use of calcium phosphate cement to conduct the vertebroplasty of C2 vertebra.

Retrospective analysis of operative treatment of a series of 100 patients with subdural hematoma.

This retrospective study of medical records, surgical protocols, patient observation cards, and imaging files of 100 patients treated for subdural hematoma analyzed the type of hematoma, patient age and sex, operative technique, neurological status, cause of injury, duration of hospital stay, mortality rate, and the number of and reasons for reoperations to determine the effects on treatment outcomes. The time between the head injury and onset of neurological symptoms was analyzed versus the type of hematoma determined from computed tomography (CT) scans. Acute hematomas accounted for 38% of the cases, with subacute hematomas representing 20%, and chronic ones accounting for 42%. In trauma patients, the mean time interval between the injury and onset of neurological symptoms was 0.38 days for acute hematomas, 13.8 days for subacute hematomas, and 23.75 days for chronic hematomas. Repeat surgery was carried out in 26% of the cases. Improvement was obtained in 44% of cases, deterioration in 20%, and no change in neurological status in 36%. Timing of the operations was between 15:00 and 23:00 in 45%, between 23:00 and 7:00 in 33%, and between 7:00 and 15:00 in 22%. The classification of hematomas based on CT presentation corresponds to the classification based on the time elapsed between injury and onset of symptoms, and appears to be appropriate and useful in everyday practice. No preceding injury was identified in 31.6% of acute hematomas, 50% of subacute hematomas, and 61.9% of chronic hematomas. Analysis of reoperations indicates that trepanation may be superior to craniotomy as primary surgery for subacute and chronic hematomas. Subdural hematoma surgeries take place at all times of the day, with most carried out outside the usual working hours.