Evaluation of surgically treated primary spinal cord tumors in a single Indian institution: A case series study of 178 patients.

Introduction: Primary spinal cord tumors are rare tumors that are usually heterogeneous having variable histopathological subtypes. Rapidly, growing space-occupying lesions in the spinal canal cause severe loss of function. This study aimed to analyze all adult patients diagnosed with primary spinal cord tumors and to describe their location, symptoms, histopathological types, surgical outcome, complications, recurrence in a single institution, and prognostic factors. Materials and Methods: The study was a retrospective study of 178 patients with spinal tumor who underwent surgical intervention at the department of neurosurgery at a tertiary care institute from 2014 to 2021. Patient demographic characteristics, symptoms, radiological features, spinal level of tumor, spinal compartment, preoperative and postoperative McCormick grade, and complications were recorded, and a comparison of outcomes after surgical intervention was done. Results: In our study, 97 patients were males and the rest of the 81 patients were females. The mean age at the time of surgery was 43.5 years. The thoracic region of the spinal canal was the most involved with 67 (37.64%) cases, whereas intradural extramedullary was the most common (65.73%). Schwannoma was the most common histopathological subtype (46.06%). Total excision was achieved in 154 cases. A total of 37 patients were in Grades 4 and 5 of modified McCormick's grade preoperatively. However, postoperatively, there were only 17 patients in this group. Two patients with cervical intramedullary tumor expired in the postoperative period. Conclusion: Early surgical intervention with sound microneurosurgical skills gives good outcomes independent of the type and location of tumor. Better outcomes are seen in extradural tumors, early surgical intervention, tumors better amenable to total resection, and in patients with better preoperative neurological status.

Clival Tuberculosis: A Case Report.

A 39-year-old female presented with complaints of occipital headaches, diplopia, numbness over left half of face and deviation of face to the right. On examination she had hypoesthesia over left half of face, associated with bilateral abductor and left facial palsy. Neuroradiology showed a well-defined lytic lesion involving the clivus and adjacent sphenoid sinus and sella. The patient underwent an endoscopic transnasal decompression of the clival lesion. Intraoperative squash preparation was reported to show tuberculous granulation, which was confirmed on postoperative histology. The patient was advised anti-tubercular therapy. At 12 months follow up neuroradiology showed a near total resolution of the clival lesion. The patient had completely recovered from her cranial nerve deficits. Tuberculous involvement of spheno-clival region is rare and the authors' literature search has yielded only three previous similar case reports. A surgical decompression followed by anti-tubercular therapy is the recommended approach for management of clival tuberculosis. The relevant literature on the subject is presented.

Transthoracic approach for ventrally situated paraspinal extradural hydatid cyst of the dorsal spine.

A 40-year-old female presented with back pain without any neurological deficits. Radiological investigations revealed a ventrally situated paraspinal lesion causing widening of the right D4 neural foramen. She underwent a right posterolateral thoracotomy and excision of the lesion in toto, which was reported as a hydatid cyst on histology. Ventrally situated paraspinal extradural hydatid cysts are rare. A Transthoracic surgical exposure offers a direct approach for complete excision of the lesion, minimizing the chances of rupture and spillage.

Radiologic Evaluation of Basilar Invagination Without Obvious Atlantoaxial Instability (Group B Basilar Invagination): Analysis Based on a Study of 75 Patients.

BACKGROUND: We evaluated the radiologic features of 75 patients with group B basilar invagination who exhibited no evidence of atlantoaxial instability based on the conventional parameter of an abnormal increase in the atlantodental interval. We specifically studied the variability and possible significance of the presence of cerebrospinal fluid (CSF) within and outside the confines of neural tissues. MATERIALS AND METHODS: During the period January 2008-May 2015, we encountered 75 cases with group B basilar invagination. These patients were divided into 4 groups depending on cervical spinal imaging that showed the presence of syringomyelia (group B1), increased CSF volume in the extramedullary space or external syrinx (group B2), the presence of both syringomyelia and external syrinx (group B3), and no abnormality of CSF cavitation in the spinal canal (group B4). RESULTS: Our cohort comprised 39 group B1 cases, 10 group B2 cases, 20 group B3 cases, and 6 group B4 cases. The neck size and posterior fossa height were simultaneously reduced, by 15.89% and 15%, respectively, but the length of the neural structures remained within the normal range. Excessive amounts of CSF were present within or outside the confines of neural structures, including the spinal cord, brainstem, and cerebellum. CONCLUSIONS: In cases of basilar invagination, various musculoskeletal and neural alterations seem to have a common functional role in protecting the craniocervical cord and delaying or stalling neurologic dysfunction.

Is Only Stabilization the Ideal Treatment for Ossified Posterior Longitudinal Ligament? Report of Early Results with a Preliminary Experience in 14 Patients.

BACKGROUND AND OBJECTIVE: Surgical treatment of ossified posterior longitudinal ligament (OPLL) continues to be wrought with confusion, debate, and arguments. We report our experience with an alternative form of treatment that involves only fixation of the involved spinal segments. We report and put on record our remarkably gratifying clinical experience in 13 of 14 patients having OPLL after surgery that involved only facetal fixation and aimed at arthrodesis of involved spinal segments. No direct bone, ligament, or disc resection was done for decompression of the spinal dural tube or root canal. The OPLL was not directly handled during the surgical procedure. The rationale of the proposed treatment is discussed. METHODS: During the period June 2012 to August 2014, 14 patients having OPLL were treated by facetal transarticular screw fixation technique. The Japanese Orthopaedic Association score, visual analogue scale, and Odom's criteria were used as indices to monitor the clinical status. RESULTS: The procedure resulted in firm stabilization and fixation of the spinal segments and provided a ground for arthrodesis. During an average follow-up period of 17 months, there was immediate postoperative and progressive recovery in symptoms in 13 patients. There were no surgery or implant-related mechanical or infective complications. CONCLUSIONS: Instability could be the defining phenomenon in pathogenesis of clinical symptoms related to OPLL. The clinical outcome in our patients suggests that only fixation of the spinal segments can be a simple, safe, and rationale form of treatment for the complex pathology of OPLL.

Bifid Anterior and Posterior Arches of Atlas: Surgical Implication and Analysis of 70 Cases.

BACKGROUND: On reviewing the database of patients with craniovertebral junction anomalies, the authors identified 70 patients with a bifid posterior arch of atlas. OBJECTIVE: To speculate on the pathogenesis of spondyloschisis of both the anterior and posterior arches of atlas, particularly as it relates to atlantoaxial instability. METHODS: Seventy patients with bifid anterior and posterior arches were identified by a retrospective review of the database from 2007 to 2013. RESULTS: The ages of the patients ranged from 14 months to 50 years. The patients were divided into 3 groups. Group 1 (3 patients) had multiple additional spinal bony and neural abnormalities. Group 2 (34 patients) had mobile and partially (5) or completely (29) reducible atlantoaxial dislocation. Group 3 (33 patients) had atlantoaxial instability and related basilar invagination. The os odontoideum was identified in 21 patients, and C2-3 fusion was seen in 24 patients. Two of 3 patients in group 1 were treated conservatively and without any surgery. All patients in groups 2 and 3 were surgically treated. Surgery was done using lateral mass plate/rod and screw fixation techniques. The general observation during surgery included identification of discrete movements of both halves of the atlas, lateral positioning of the facets of atlas in relation to the facets of the axis and occipital condyle and closer approximation of the occipital bone, atlas, and axis resulting in "crumpling" of bone and neural elements. CONCLUSION: Understanding of the pathogenesis and mechanical alterations in cases with a bifid arch of atlas can assist in evaluating the clinical implications and in conduct of surgery.

Pan ventricular neurocytoma.

Central neurocytomas are intraventricular benign neoplasms located within the lateral ventricle adjacent to foramen of Monro. A rare case of a central neurocytoma extending throughout the entire ventricular system at the time of presentation is reported. The clinical course of this tumor in a 25-year-old male and its management are presented with relevant review of the literature.

Congenital meningocoele presenting in an adult.

A 53-year-old male patient presented with low back pain radiating to both lower limbs for 2 years and urinary incontinence for 2 months. He had swelled over his lower back since birth. The neurological examination revealed a decreased perianal sensation. Local examination of the lumbar swelling showed a brilliantly transilluminant, cystic midline swelling in the lumbar area with underlying spina bifida. Magnetic resonance imaging revealed a low-lying conus at L3 level associated with spina bifida at L5 and a meningocoele sac. The patient underwent excision of the meningocoele and detethering of cord by extirpation of hypertrophied filum terminale. The patient had an immediate relief of his symptoms. At 3 month follow-up the lumbar wound had healed well, and there was a significant improvement in the perianal hypoesthesia. The adult presentation of a congenital meningocoele and spinal dysraphism is rare, especially in the fifth decade. The possible causes of this delayed presentation are analyzed, and the relevant literature on the subject is presented.

Hemangiopericytoma of the cervical spine.

A 28-year-old male presented with neck pain and dysesthesias in the right upper limb. On examination, he had a firm, well-defined midline posterior cervical mass discernible on palpation at the mid-cervical level. He had no neurological deficit. Neuroradiology revealed a variegated enhancing cervical mass is arising from C3 lamina. The mass extended into the right extradural space eroding the C3 lamina and posteriorly into the intermuscular plane. The tumor was excised totally. Histopathology of the tumor showed features of hemangiopericytoma (HPC). The patient underwent postoperative radiotherapy. Primary osseous spinal HPC are rare malignant extra-axial tumors that tend to recur and metastasize. Only two cases of primary osseous HPC have been reported earlier to involve the cervical spine. The clinical presentation and management of the present case with a review of the literature is presented.

Tethered cord due to caudal lipomeningocele associated with a lumbar dural arteriovenous fistula.

A 29-year-old man presented with progressive paraparesis associated with sensory impairment in both lower limbs for the past 2 years. He was experiencing the sensation of incomplete urinary evacuation. The patient had undergone an earlier operation for a lumbar lipomeningocele at birth. Magnetic resonance images of the lumbosacral spine showed a low-lying conus medullaris adherent to a caudal lipoma. There was a leash of abnormal vascular channels in the adjacent subarachnoid space. The patient underwent spinal angiography that revealed a dural arteriovenous fistula (AVF) principally fed by the left fourth lumbar (L-4) radicular branch. At surgery the cord was detethered by disconnection of the sacral lipoma. The dural fistula was obliterated by occlusion of the L-4 radicular feeder close to the nidus of the fistula. Postoperatively, the patient experienced an immediate relief of sensation of tightness in both lower limbs. There was a gradual improvement of power and sensation at the 6-month follow-up examination. According to the authors' literature search, the present case is a unique report of a rare association of spinal cord tethering due to a caudal lipoma associated with a lumbar dural AVF. The present report discusses the etiopathology, presentation, and management of this case.

Traumatic cervical epidural hematoma in an infant.

An 8-month-old male infant had presented with a history of a fall from the crib a fortnight ago. He had developed progressive weakness of both lower limbs. On examination, the infant had spastic paraplegia. Magnetic resonance (MR) imaging of the cervical spine showed an epidural hematoma extending from the fourth cervical (C4) to the first dorsal (D1) vertebral level with cord compression. The patient had no bleeding disorder on investigation. He underwent cervical laminoplasty at C6 and C7 levels. The epidural hematoma was evacuated. The cervical cord started pulsating immediately. Postoperatively, the patient's paraplegia improved dramatically in 48 hours. According to the author's literature search, only seven cases of post-traumatic epidural hematoma have been reported in pediatric patients, and our patient is the youngest. The present case report discusses the etiopathology, presentation, and management of this rare case.

Intramedullary conus metastasis from carcinoma lung.

A 46-year-old male presented with progressive paraparesis and sensory impairment in both lower limbs since 2 months. He had urinary and bowel incontinence. On examination he had flaccid paraplegia with a sensory level at 11(th) dorsal vertebral level. Magnetic resonance imaging (MRI) scans of the lumbosacral spine showed an enhancing intramedullary lesion in the conus. The patient underwent excision of the conus mass. Histopathology confirmed the tumor to represent a poorly differentiated metastatic carcinoma from an unknown primary. A positron emission tomography-computed tomography (PET-CT) scan of the whole body revealed hypermetabolic activity in the hilum of the right lung confirmed to be a lung carcinoma on a CT-guided biopsy. The patient was undergoing chemoradiation at 1 month follow-up. The author's literature search has yielded only four other case reports of conus metastasis of which only one is in English literature. The present case report and review of literature are presented.

Giant cerebral cavernous hemangiomas: a report of two cases and review of the literature.

Giant cerebral cavernous malformations (GCM) are rare vascular anomalies. They occur predominantly as solitary lesions in the supratentorial compartment. They are usually not associated with any other vascular malformations. Clinical Presentation GCM are common in the second decade, affecting females predominantly, and occur without familial association. They are all symptomatic due to their giant size and location. The GCM mimic neoplastic lesions because of their size and need to be considered in the differential diagnosis. A complete surgical extirpation is the treatment of choice. Use of intraoperative neuronavigation, diffusion tensor imaging (DTI) of fiber tracts and electrophysiological monitoring assist in safe and total excision of the lesions. A complete surgical excision of GCM is possible without significant surgical morbidity and results in long term cure.

Diabetes insipidus associated with a thickened pituitary stalk in a case of Langerhans Cell Histiocytosis.

Diabetes insipidus (DI) associated with a thickened pituitary stalk is a diagnostic challenge in the pediatric population. Langerhans Cell Histiocytosis (LCH) is a rare cause of this entity. A 4-year-old male child presented with central DI of 1-year duration, associated with a thickened pituitary stalk. The etiology for the same remained elusive as the patient had no other manifestation to suggest LCH. A year later, the patient developed a left frontal scalp swelling. Neuroradiology demonstrated multiple punched out osteolytic lesions in both the frontal bones. The infundibulum was thickened and showed post-contrast enhancement. Histology and immunohistochemistry (IHC) of the biopsy specimen confirmed LCH. The child was administered chemotherapy according to LCH protocol, which resulted in 33% reduction in the size of the skull lesions. The DI was controlled with medical management. The present case highlights the need for serial follow-up and magnetic resonance (MR) imaging that led to a diagnosis of LCH. The clinical presentation and management of central DI and a thickened pituitary stalk is presented and the relevant literature is discussed.

Multicompartmental cerebrospinal fluid dissemination of cerebellar pilocytic astrocytoma at presentation.

A 26-year-old male presented with a rare cerebellar pilocytic astrocytoma with multicompartmental subarachnoid metastases. Cerebrospinal fluid dissemination of low grade astrocytoma at presentation is rare in adults. In the present patient, clinical and neuroradiological follow-up at 4 years, without adjuvant treatment, revealed non progression of tumors. The occurrence of benign dormancy, low grade tumor histology and multifocal involvement of the neuraxis is rare. Close clinical observation is the best approach for management of such a patient. The relevant literature is discussed.

Intraparenchymal temporal neurenteric cyst.

A 41-year-old male presented with a rare temporal intraparenchymal neurenteric cyst. A definitive preoperative diagnosis was not possible based upon the neuroradiological features. A complete excision of the cyst was achieved. Histopathology confirmed the diagnosis of a neurenteric cyst, an endodermally derived lesion of the central nervous system.

Intracanalicular epidermoid cyst. A case report.

We describe the presentation and management of a rare case of an epidermoid cyst located within canal of the left internal acoustic meatus, lying entirely within the petrous part of the temporal bone. The patient underwent surgery by an extended middle fossa approach and a total excision of a cyst containing cheesy, pearly white, avascular material was achieved. Neuroradiology provides a diagnosis with reasonable accuracy and an appropriate surgical approach can be planned for the excision of the tumour.

Craniofrontonasal dysplasia associated with Chiari malformation.

Craniofrontonasal dysplasia (CFND) is a rare developmental anomaly associated with an X-linked inheritance. It is predominantly expressed in females. A Chiari malformation (CM) has not been reported in such patients earlier. The authors report on a family with 3 female members who have marked and generalized CFND. The generalized bone dysplasia/hypertrophy resulted in reduction in the posterior cranial fossa volume in all 3 patients, and in a CM associated with syringomyelia in 2 of them. One of the 2 affected family members who had a CM and syringomyelia was symptomatic and was treated by foramen magnum decompression surgery. The 3 family members had remarkable similarity in their external facial features and in their radiologically revealed morphological features. A review of the relevant literature, genetic abnormalities, and pattern of inheritance is presented.

Circumferential craniocervical extradural tuberculous granulations.

A 49-year-old female presented with a 7-month history of progressive quadriparesis. Investigations revealed a circumferential lesion involving the cervicomedullary junction and the upper cervical cord. The firm extradural granulomatous lesion was partially resected. Histological examination revealed that the lesion comprised tuberculous granulation tissue, which resolved on anti-tuberculous drug treatment. We were unable to find a similar report of extradural tuberculous granuloma in our literature search.