Direct intracranial invasion of eccrine spiradenocarcinoma of the scalp: a case report and literature review.

BACKGROUND: Eccrine spiradenocarcinoma (SC), also known as malignant eccrine spiradenoma, is a rare malignant cutaneous adnexal neoplasm arising from long-standing benign eccrine spiradenoma. Malignant skin tumors rarely show direct intracranial invasion. However, once the intracranial structure is infiltrated, curative excision with sufficient margins can become extremely difficult, particularly when the venous sinuses are involved. No effective adjuvant therapies have yet been established. Here, we report an extremely rare case of scalp eccrine SC with direct intracranial invasion, which does not appear to have been reported previously. CASE PRESENTATION: An 81-year-old woman presented with a large swelling on the parietal scalp 12 years after resection of spiradenoma from the same site. The tumor showed intracranial invasion with involvement of the superior sagittal sinus and repeated recurrences after four surgeries with preservation of the sinus. The histopathological diagnosis was eccrine SC. Adjuvant high-precision external beam radiotherapy (EBRT) proved effective after the third surgery, achieving remission of the residual tumor. The patient died 7 years after the first surgery for SC. CONCLUSIONS: Scalp SC with direct intracranial invasion is extremely rare. Radical resection with tumor-free margins is the mainstay of treatment, but the involvement of venous sinuses makes this unfeasible. High-precision EBRT in combination with maximal resection preserving the venous sinuses could be a treatment option for local tumor control.

Comparative Study of Anterior Transvertebral Foraminotomy and Anterior Cervical Discectomy and Fusion for Unilateral Cervical Spondylotic Radiculopathy.

OBJECTIVE: To study the compared surgical and radiographic outcomes of Transvertebral foraminotomy (TVF) with anterior cervical discectomy and fusion (ACDF) in patients with unilateral cervical spondylotic radiculopathy (CSR). METHODS: We performed a retrospective comparative study of 72 consecutive patients with 1- or 2-level CSR treated with ACDF or TVF. 27 patients who underwent TVF (group T) and 45 patients who underwent ACDF (group A) with a minimum 2-year follow-up were enrolled. We evaluated clinical outcomes and radiological assessment. Clinical outcome included Visual analog scale (VAS) scores for axial, arm pain at preoperatively and final follow-up. VAS score for painful swallowing was also evaluated 1 week after surgery. Radiological assessment included C2-7 sagittal Cobb angle (C2-7 CA), range of motion (ROM) of C2-7 CA, the height, angle and ROM of the functional spinal unit (FSU), and tip of the spinous process of the operated segment. We also evaluated the disc height, FSU angle, and ROM of the FSU at the cranial adjacent segment. RESULTS: Both groups had good clinical outcomes. Soft tissue swelling was significantly less prominent in group T than that for group A. VAS scores for painful swallowing is lower in group T without significant difference. The ROM of C2-7 CA, FSU, and spinous processes demonstrated a significant reduction in group A compared with group T.(P < 0.05). Disc height at the cranial adjacent segment was maintained in group T. CONCLUSIONS: TVF is as effective as ACDF for unilateral CSR and preserves whole cervical spine and segmental alignment.

Lateral Lumbar Interbody Fusion within Three-level for Patients with Neurological Symptoms due to Vertebral Fragility Fractures in the Lumbar Spine.

There is a lack of agreement on whether minimally invasive lateral lumbar intervertebral fusion (LLIF) is a suitable treatment option for vertebral fragility fractures (VFFs). Hence, we sought to evaluate the efficacy and safety of LLIF in the management of VFF with neurological deficits in the lumbar spine. Between April 2015 and March 2020, we conducted a retrospective observational study of patients with VFF treated with three-level or less LLIF. The participants had previously received conservative treatment but had not been able to control their neurological symptoms. To assess the outcomes of the LLIF procedures, the patients were followed up for a minimum of 1 year. Clinical and radiological results, which include the timing and location of the bony fusion, were analyzed. The study involved 19 patients with 23 vertebral fracture levels. The residual height of the fractured vertebra was found to be 57.0 ± 12.3% of the height of the adjacent level. The mean Japanese Orthopedic Association score significantly improved postoperatively. Postoperative radiological parameters were significantly maintained at 1 year, and lumbar lordosis was maintained at the last follow-up (45.0 ± 26.7). In total 31 LLIF levels, bone fusion was observed in four levels at 6 months postoperatively, in 16 levels at 1 year, and in 23 levels at the last follow-up. The facet joint had the highest bony fusion location. LLIF within three levels can be safely performed in certain VFF cases with sufficient residual vertebral height.

Radiological Analysis of Minimally Invasive Microscopic Laminectomy for Lumbar Canal Stenosis with a Focus on Multilevel Stenosis and Spondylolisthesis.

OBJECTIVE: We retrospectively compared the radiological and clinical outcomes of two different surgical techniques (lumbar spinous process splitting laminectomy [LSPSL] and unilateral laminotomy for bilateral decompression [ULBD]) to treat lumbar spinal canal stenosis (LCS). METHODS: We performed a retrospective comparative study of 141 consecutive patients with an average age of 70.8 ± 9.4 years who had undergone LSPSL or ULBD for LCS between April 2015 and April 2019. None of the patients had developed remote fractures of the spinous processes using either technique. These cases were divided into 2 groups: group L, 73 patients who had undergone LSPSL from April 2015 to April 2017; and group U, 68 patients who had undergone ULBD from May 2017 to April 2019. The clinical and radiological outcomes and surgical complications at the 1-year postoperative follow-up period were evaluated. RESULTS: We found no significant differences in the operative time between the 2 groups. However, group U had had significantly less blood loss than group L. The facet joints were significantly well preserved in group U. We examined the multilevel and spondylolisthesis cases separately and found that both surgical procedures were equally effective and that the visual analog scale scores for back or leg pain and Japanese Orthopaedic Association scores had significantly improved postoperatively in each group. Group U showed better outcomes in terms of LCS recurrence, with 3 patients in the group L requiring repeat surgery. CONCLUSIONS: We found both ULBD and LSPSL to be safe and effective techniques for LCS, even for patients with spondylolisthesis and multilevel disease. ULBD was superior in terms of recurrence prevention, preservation of the facet joints, and less blood loss.

Preoperative Intracranial Dissemination of Spinal Myxopapillary Ependymoma Attributed to Tumor Hemorrhage.

BACKGROUND: Spinal myxopapillary ependymoma (SME), generally considered a benign entity, can exhibit brain and whole-spine metastases as well as local recurrence after surgery. However, the presence of preoperative retrograde intracranial dissemination at the time of diagnosis is very rare. CASE DESCRIPTION: We report a case of SME in a 22-year-old man who presented with acute exacerbation of chronic back pain shooting down both thighs and weakness in both legs. Magnetic resonance imaging of the brain and whole spine showed an enhancing mass occupying the majority of the spinal canal at the L1-L2 level and multiple foci dissemination, including in the right pons, lateral midbrain, and occipital lobe, and at the C7, Th6, L4, and S2 levels of the spinal canal at the time of diagnosis. On gross total removal of the dominant tumor located at the L1-L2 level, severe intradural arachnoiditis and syrinx filled with xanthochromic cerebrospinal fluid was noted, indicating the presence of previous tumor hemorrhage. Histopathologic analysis of the tumor supported SME diagnosis, and <1% of cells showed Ki-67 expression. We speculated that distant retrograde dissemination could have been attributed to metastatic spread through cerebrospinal fluid caused by tumor hemorrhage, which may explain distant dissemination despite low expression of Ki-67. CONCLUSIONS: Screening of the whole brain and spine at the time of diagnosis is imperative when tumor is detected at any level of the neuraxis. The present case of SME with a preoperative intracranial lesion is the fifth case documented in the medical literature.

Piecemeal resection of aggressive vertebral hemangioma using real-time navigation-guided drilling technique.

Vertebral hemangiomas are the most common benign vertebral tumors and are usually asymptomatic. Aggressive subtypes of the tumor, called aggressive VHs (AVHs), can become symptomatic with extraosseous extensions and require surgical removal. We present a case of AVH in a 36-year-old man presenting with low back pain and right leg pain that persisted for three months. Imaging studies showed a Th12 vertebral tumor that extended into the spinal canal and was squeezing the spinal cord. Computed tomography (CT)-guided biopsy indicated vertebral hemangimoa. Following preoperative arterial embolization, piecemeal gross total resection was attained under navigation guidance. He was left with no neurological deficit and remained well at the 12-month postoperative folow-up. Since AVHs are benign tumor, piecemeal removal of the tumor can be selected. However, disadvantage of the approach include difficulty of making decision how much to remove the front part of the vertebral body close to thoracic descending aorta. Furthermore, when the tumor tissue is too hard to curett, manipulation in tight spaces near the spinal cord carries the risk of damaging it. Navigation-guided drill is highly helpful for real-time monitoring of ongoing tumor resection. It enables safely resection of the tumor especially in the anterior cortical surface of the vertebral body and easily resection even hard tumors. This method results in reducing residual tumor and maintaining safety resection.

Spontaneous Rupture of a Huge Presacral Tarlov Cyst Leading to Dramatic Neurologic Recovery.

BACKGROUND: This manuscript discusses the case of huge presacral Tarlov cysts (TCs) and the substantial neurologic recovery noted in the patient following spontaneous rupture of the most prominent cyst. Perineural or TCs are nerve root cysts, which are usually incidental findings on magnetic resonance imaging (MRI) and are most frequently observed in the sacral spine. Symptomatic lesions are rarely encountered. CASE DESCRIPTION: In this case, a 44-year-old woman presented with anal and vulva pain on the right side, and bladder and bowel dysfunction. MRI of the lumbosacral spine showed multiple huge bilateral TCs located within the presacral space from S1-3. There was a substantially large right-sided S3 cyst that was presumed to be responsible for her symptoms. Surgical intervention was considered; however, her symptoms improved significantly during the waiting period for surgery because of spontaneous rupture of the right-sided S3 cyst, as confirmed on follow-up MRI. On follow-up over a 1-year period, the patient had been very well with no recurrent symptoms. CONCLUSIONS: To our knowledge, this is the first report of spontaneous cyst rupture and resultant neurologic improvement in a case of symptomatic presacral TCs.