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1.
Neurol India ; 69(5): 1354-1355, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34747811

RESUMO

The use of intraoperative neurophysiological monitoring is a helpful tool during surgeries of conus medullaris tumors and helps in reducing the risk of post-operative functional compromise like paraparesis, sensory deficits, or urological dysfunctions. External anal sphincter (EAS) motor evoked potential (MEP) monitoring is usually done for monitoring sacral nerve roots and to prevent post-operative neurological deficits. Here we describe a case where unilateral motor cortical stimulation aided us to differentiate the laterality of TcMEP responses in EAS.


Assuntos
Potencial Evocado Motor , Neoplasias da Medula Espinal , Canal Anal/diagnóstico por imagem , Canal Anal/cirurgia , Humanos , Neoplasias da Medula Espinal/diagnóstico por imagem , Neoplasias da Medula Espinal/cirurgia , Raízes Nervosas Espinhais
2.
Spinal Cord Ser Cases ; 7(1): 97, 2021 11 05.
Artigo em Inglês | MEDLINE | ID: mdl-34741004

RESUMO

INTRODUCTION: Gliofibroma is a rare tumor that develops in the brain and spinal cord. Due to the rarity of its nature, its pathophysiology and appropriate treatment remain elusive. We report a case of intramedullary spinal cord gliofibroma that was surgically treated multiple times. This report is of great significance because this is the first case of recurrence of this tumor. CASE PRESENTATION: A 32-year-old woman complained of gait disturbance and was referred to our institution. At the age of 13 years, she was diagnosed with intramedullary gliofibroma and underwent gross total resection (GTR) in another hospital. Based on imaging findings, tumor recurrence was suspected at the level of cervical spinal cord, and surgery was performed. However, the resection volume was limited to 50% because the boundary between the tumor and spinal cord tissue was unclear and intraoperative neuromonitoring alerted paralysis. At 1 year postoperatively, the second surgery was performed to try to resect the residual tumor, but subtotal resection was achieved at most. At 2 years after the final surgery, no tumor recurrence was observed, and neurologic function was maintained to gait with cane. DISCUSSION: Although complete resection is desirable for this rare tumor at the initial surgery, there is a possibility to recur even after GTR with long-term follow-up. During surgical treatment for tumor recurrence, fair adhesion to the spinal cord is expected, and reoperation and/or adjuvant therapy might be considered in the future if the tumor regrows and triggers neurological deterioration.


Assuntos
Astrocitoma , Neoplasias da Medula Espinal , Adolescente , Adulto , Astrocitoma/cirurgia , Feminino , Humanos , Procedimentos Neurocirúrgicos , Neoplasias da Medula Espinal/diagnóstico por imagem , Neoplasias da Medula Espinal/cirurgia , Resultado do Tratamento
3.
BMJ Case Rep ; 14(11)2021 Nov 09.
Artigo em Inglês | MEDLINE | ID: mdl-34753734

RESUMO

Sacral spinal cord ependymoma is an uncommon pathology. Most of the reported cases are consistent with a myxopapillary ependymoma histopathologic subtype. Non-myxopapillary ependymomas rarely occur in the sacral region. Most lesions are intradural; however, rare extradural cases can occur. We present the case of a 46-year-old female patient diagnosed with a grade II sacral extradural ependymoma, emphasising the importance of an interdepartmental case approach for diagnosis and management. Even though grade II ependymomas are considered low grade, the potential for recurrence and metastatic disease has been reported. There are no treatment guidelines for these rare tumours besides gross total resection.


Assuntos
Ependimoma , Neoplasias da Medula Espinal , Ependimoma/diagnóstico por imagem , Ependimoma/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Região Sacrococcígea , Sacro/diagnóstico por imagem , Neoplasias da Medula Espinal/diagnóstico por imagem , Neoplasias da Medula Espinal/cirurgia
4.
Pediatr Neurosurg ; 56(6): 563-568, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34518487

RESUMO

BACKGROUND AND IMPORTANCE: Diffuse leptomeningeal glioneuronal tumor (DLGNT) represents a provisional entity in the 2016 World Health Organization classification of tumors; it is characterized by a widespread leptomeningeal growth and oligodendroglial-like cytology. To this day, 4 pediatric patients have been reported to present with an isolated spinal cord tumor in the absence of leptomeningeal dissemination. Gross total resection (GTR) was achieved in only 1 patient. We present the clinical and technical nuances of this unique type of tumor, as well as the second reported case of GTR in a patient with DLGNT. CLINICAL PRESENTATION: A 4-year-old boy presented to the emergency department after an episode of flaccid paralysis of bilateral lower extremities. MRI showed an intramedullary spinal cord tumor centered at T8. The patient was taken to the operative room, where a laminectomy and tumor resection were performed; cystic and solid tumor components were identified. Pathology report was consistent with DLGNT. After achieving GTR, patient is free of recurrence after a 15-month follow-up. CONCLUSION: No standard treatment for DLGNT has been identified. Current literature report surgery and chemotherapy with variable success rates. DLGNT presenting as an isolated intramedullary tumor is an uncommon condition which progression appears to be halted when treated promptly. Identifying solid and cystic components of this tumor is crucial for achieving GTR.


Assuntos
Neoplasias Encefálicas , Neoplasias Meníngeas , Neoplasias da Medula Espinal , Criança , Pré-Escolar , Humanos , Masculino , Neoplasias Meníngeas/diagnóstico por imagem , Neoplasias Meníngeas/cirurgia , Recidiva Local de Neoplasia , Neoplasias da Medula Espinal/diagnóstico por imagem , Neoplasias da Medula Espinal/cirurgia
6.
J Clin Neurosci ; 91: 396-401, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34373058

RESUMO

Primary spine tumors are rare neoplasms that affect about 0.62 per 100,000 individuals in the US. Intramedullary spinal cord tumors (IMSCTs) are the rarest of all primary tumors involving the spine and can cause pain, imbalance, urinary dysfunction and neurological deficits. These types of tumors oftentimes necessitate surgical treatment, yet there is a lack of data on hospital length of stay and complication rates following treatment. Given that treatment candidacy, quality of life, and outcomes are tied so closely to potential for prolonged length of stay and postoperative complications, it is important to better understand the factors that increase the risk of these outcomes in patients with IMSCTs. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried for all patients undergoing surgery for treatment of intramedullary spinal cord tumors between 2005 and 2017. Univariate and multivariate analysis were performed to assess patient risk factors influencing prolonged length of stay and post-op complications. RESULTS: A total of 638 patients were included in the analysis. Pre-operative American Society of Anesthesiology (ASA) physical status classification of 3 and above (OR 1.89; p = 0.0005), dependent functional status (OR 2.76; p = 0.0035) and transfer from facilities other than home (OR 8.12; p <0.0001) were independent predictors of prolonged length of stay (>5 days). The most commonly reported complications were pneumonia (5.7%), urinary tract infection (9.4%), septic shock (3.8%), superficial incisional infection (5.7%), organ or space infection (5.7%), pulmonary embolism (11.3%), DVT requiring therapy (15.1%) and wound dehiscence (5.7%). CONCLUSION: Our study demonstrated the significant influence of clinical variables on prolonged hospitalization of IMSCT patients. This should be factored into clinical and surgical decision making and when counseling patients of their expected outcomes.


Assuntos
Qualidade de Vida , Neoplasias da Medula Espinal , Humanos , Tempo de Internação , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Neoplasias da Medula Espinal/epidemiologia , Neoplasias da Medula Espinal/cirurgia , Estados Unidos
7.
J Clin Neurosci ; 90: 171-177, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34275545

RESUMO

Cervical and thoracic or lumbar intramedullary spinal cavernous malformations (ISCMs) may behave differently. We conducted this retrospective study by using data from adult ISCMs to compare their natural histories and explore prognostic factors for improved clinical outcomes. Neurological functions were assessed by using the Modified McCormick Scale (MMCS) and Aminoff-Logue Disability Scale. A total of 111 study-eligible adult patients were included in this study. Patients with cervical ISCMs mostly demonstrated a shorter duration of symptoms (P = 0.026), an acute onset pattern with some recovery (P = 0.026), and a larger lesion size (P = 0.033) than their thoracic or lumbar counterparts. Thoracic or lumbar lesions had a higher proportion of motor symptoms (P = 0.001) and sphincter problems (P = 0.005), and they were usually associated with an aggressive clinical course (P = 0.001, OR = 9.491, 95% CI = 2.555-35.262) in multivariate analysis. There was no difference in age, sex distribution, hemorrhage risk between the cervical and thoracic-lumbar groups. A better preoperative neurological status (P = 0.034, OR = 2.768, 95% CI = 1.081-7.177) and improvement immediately after surgery (P < 0.001, OR = 8.756, 95% CI = 4.837-72.731) were identified as indicators for long-term improvement by multivariate analysis. Cervical lesions had a high proportion for long-term improvement, but it was not a predictor for improvement in multivariate analysis. ISCMs in the thoracic or lumbar location should be considered for surgical removal more aggressively than those in the cervical location. Surgical removal of symptomatic ISCMs can avoid further neurological deterioration and usually result in satisfactory long-term outcomes.


Assuntos
Hemangioma Cavernoso do Sistema Nervoso Central/cirurgia , Neoplasias da Medula Espinal/cirurgia , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
9.
J Stroke Cerebrovasc Dis ; 30(8): 105925, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34153593

RESUMO

Spontaneous non-aneurysmal subarachnoid haemorrhage (naSAH) is an unusual finding that could be burdened by significant mortality and morbidity rates. Rare pathologies and delayed diagnosis could be advocated as responsible of unfavourable outcomes. Herein, we describe an exceedingly rare giant lumbar spinal hemangioblastoma (80 × 23 mm) presenting as an intracranial naSAH. Based on our radiological and clinical findings a pathophysiological hypothesis linking intracranial naSAH to venous hypertension was discussed for the first time even among lumbar spinal tumors. Although rare, unusual causes should be investigated in presence of radiological atypical finding as a prompt evaluation and treatment could be needed.


Assuntos
Hemangioblastoma/complicações , Neoplasias da Medula Espinal/complicações , Hemorragia Subaracnóidea/etiologia , Idoso , Feminino , Hemangioblastoma/diagnóstico por imagem , Hemangioblastoma/fisiopatologia , Hemangioblastoma/cirurgia , Humanos , Laminectomia , Neoplasias da Medula Espinal/diagnóstico por imagem , Neoplasias da Medula Espinal/fisiopatologia , Neoplasias da Medula Espinal/cirurgia , Fusão Vertebral , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/fisiopatologia , Resultado do Tratamento
10.
Zh Vopr Neirokhir Im N N Burdenko ; 85(3): 104-113, 2021.
Artigo em Russo | MEDLINE | ID: mdl-34156212

RESUMO

Cavernous malformations (CMs) of central nervous system are vascular malformations usually localized in the brain and rarely in the spinal cord. To date, these malformations are well studied. However, some problems of the management of this pathology are still unresolved. This is due to rare localization of intramedullary CMs in the spinal cord and difficult treatment of spinal pathology per se. To date, about 1000 cases of spinal CM are described in the literature. This review is devoted to natural course of disease and postoperative outcomes. These data allow getting a complete picture of modern concepts of the treatment of spinal CMs and formulating the questions requiring further discussion.


Assuntos
Hemangioma Cavernoso do Sistema Nervoso Central , Neoplasias da Medula Espinal , Encéfalo , Hemangioma Cavernoso do Sistema Nervoso Central/diagnóstico por imagem , Hemangioma Cavernoso do Sistema Nervoso Central/cirurgia , Humanos , Imageamento por Ressonância Magnética , Período Pós-Operatório , Medula Espinal , Neoplasias da Medula Espinal/diagnóstico por imagem , Neoplasias da Medula Espinal/cirurgia
11.
J Clin Neurosci ; 89: 68-70, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34119297

RESUMO

Spinal teratoma with associated neuroendocrine tumour (NET) is a rare entity. To date there have been only three such cases reported in the literature. Information available to clinicians regarding clinical presentation, behaviour of this tumour over time, management options and follow-up, are as a consequence very limited. We present a case of a 37-year-old woman who was found to have an incidental lumbar spine teratoma with NET after presenting with a one-week history of acute lower back pain and radiculopathy. Magnetic resonance imaging (MRI) of the lumbosacral spine demonstrated an acute disc prolapse at the L4/5 level as well as incidental lesion at the L1/2 level causing effacement of the conus medullaris. Lumbar laminectomy with gross total resection of the intradural extramedullary lesion at the L1/2 level was performed with histopathology confirming the teratoma with NET. The objective of our case is to report our experience with this unique tumour and potential management implications.


Assuntos
Tumores Neuroendócrinos/cirurgia , Neoplasias da Medula Espinal/cirurgia , Teratoma/cirurgia , Adulto , Feminino , Humanos , Laminectomia , Região Lombossacral/diagnóstico por imagem , Região Lombossacral/cirurgia , Imageamento por Ressonância Magnética , Tumores Neuroendócrinos/complicações , Tumores Neuroendócrinos/diagnóstico , Neoplasias da Medula Espinal/complicações , Neoplasias da Medula Espinal/diagnóstico , Teratoma/complicações , Teratoma/diagnóstico
12.
World Neurosurg ; 152: 84-94, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34087464

RESUMO

BACKGROUND: Hemangioblastomas are benign vascular neoplasms of the central nervous system that may occur sporadically or in association with Von Hippel-Lindau disease. A minority of these lesions can occur in the spine, mostly as intramedullary masses. The authors present a rare case of primary sporadic spinal hemangioblastoma occurring as an intradural extramedullary (IDEM) lesion. Diagnostic workup and surgical management of the patient are described. METHODS: A systematic MEDLINE search was conducted using the keywords "hemangioblastoma" and "intradural extramedullary," "extramedullary," or "cauda equina." Clinicopathological characteristics and outcomes of the present case were reviewed and compared with those in the literature. RESULTS: A 72-year-old man was found to have an IDEM lesion in his cervical spine after presenting with neck and shoulder pain. Gross total resection was successfully performed with sacrifice of an involved dorsal nerve rootlet. Screening for Von Hippel-Lindau was negative. Thirty-three additional patients with sporadic IDEM hemangioblastomas are reported in the literature. There was a slight male preponderance (54%) with a median age of 52 years. Patients presented with pain (54%), radiculopathy (33%), or myelopathy (32%). The majority of lesions were located in the lumbosacral spine (56%). All patients underwent maximal safe resection with stable or improved clinical status. CONCLUSION: Primary IDEM hemangioblastomas are a rare entity. Differential diagnosis includes other IDEM lesions, such as schwannomas, meningiomas, or some vascular malformations. Resection of these sporadic tumors can be safely performed and result in improvement of neurologic deficits associated with mass effect from the tumor with low likelihood of recurrence.


Assuntos
Hemangioblastoma/patologia , Neoplasias da Medula Espinal/patologia , Idoso , Hemangioblastoma/cirurgia , Humanos , Masculino , Neoplasias da Medula Espinal/cirurgia
13.
Neurol Med Chir (Tokyo) ; 61(8): 484-491, 2021 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-34078828

RESUMO

The current study aimed to evaluate the relationship between preoperative neuroradiological findings and intraoperative bulbocavernosus reflex (BCR) amplitude in patients with intradural extramedullary tumors. A total of 24 patients with lesions below the 12th thoracic vertebra were included in the analysis. Objective and subjective urinary symptoms were investigated using data obtained from medical records and the core lower urethral symptom score (CLSS) questionnaire. The lesion compression rate was evaluated with MRI. In the epiconus-to-conus medullaris (Epi-CM) group, BCR amplitude changes were found to be correlated with the compression rate (p <0.05). The preoperative CLSS of the group with a BCR amplitude of <50% was worse than that of the group with ≥50% (p <0.01). The group did not experience symptom improvement 6 months postoperatively based on the CLSS. The preoperative CLSS of the group with compression rate of ≥80% on imaging was worse than that of the group with <80% (p <0.05). In the group with preoperative compression rate of ≥80%, CLSS at 1 month and 6 months postoperatively was improved as compared to preoperative CLSS (p <0.01, p <0.05). Hence, BCR amplitude changes are associated with the degree of lesion compression on preoperative images and pre- and postoperative urinary symptoms. Patients with intradural extramedullary Epi-CM lesions with strong compression are likely to present with low BCR amplitude and worsened postoperative symptoms. It is considered that the risk of postoperative urinary symptoms increases even with careful surgical manipulation under these conditions.


Assuntos
Neoplasias da Medula Espinal , Humanos , Imageamento por Ressonância Magnética , Reflexo , Estudos Retrospectivos , Neoplasias da Medula Espinal/diagnóstico por imagem , Neoplasias da Medula Espinal/cirurgia
14.
World Neurosurg ; 153: 139, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34146736

RESUMO

Surgical removal of lateral or ventrolateral spinal intramedullary gliomas remains a challenge. For lateral or ventrolateral tumors, the dorsal root entry zone (DREZ) myelotomy (equivalent to dorsolateral sulcus approach) and the posterior midline myelotomy would require dissection of the posterolateral tract or posterior column tracts and cause neurologic dysfunction. In Video 1, we introduce a novel approach in which myelotomy was performed anterior to DREZ. The spinal cord was entered between the DREZ and dorsal spinocerebellar tracts, and the surgical path was posterior to the lateral corticospinal tract. Thus no important spinal cord tracts were damaged. The patients with intramedullary glioma depicted in this video had no new neurologic dysfunction postoperatively. This approach has also been reported in treating intramedullary cavernous malformations.1 Compared with the DREZ approach, myelotomy anterior to the DREZ has 2 advantages. First, the blood vessels anterior to DREZ are always sparser than the posterolateral sulcus. Second, the injury of the somatosensory tract and posterior horn of the spinal cord caused by the dorsolateral sulcus approach can be avoided. Special technique details for this approach are as follows: 1) Myelotomy anterior to DREZ can be optional for selective cases of lateral or ventrolateral intramedullary tumor. 2) It is difficult for cervical intramedullary tumors because the cervical dorsal roots always cover the area of the anterior DREZ. 3) It is useful for a multisegment tumor to cut the dentate ligament. 4) Hemilaminectomy can be used in selective cases for this approach.


Assuntos
Glioma/cirurgia , Procedimentos Neurocirúrgicos/métodos , Neoplasias da Medula Espinal/cirurgia , Humanos , Raízes Nervosas Espinhais
15.
World Neurosurg ; 153: e250-e258, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34175485

RESUMO

BACKGROUND: Despite potential advantages, broad carbon dioxide (CO2) laser diffusion in neurosurgery was historically prevented by several operative limitations. Nonetheless, in recent decades, significant improvements, in particular the development of surgical scanners, have made CO2 laser surgery easier and reproducible. The aim of this study was to report our preliminary experience with the SmartXide2 CO2 laser system. METHODS: The SmartXide2 laser system is a CO2 laser with a radiofrequency-excited laser source, a surgical scanner, and a high-precision micromanipulator, which are connected to the surgical microscope. Ten different brain and spinal tumors were treated to evaluate the laser system potential in different neurosurgical scenarios. Four illustrative cases were presented. RESULTS: The CO2 laser was used together with the traditional instruments in every step of the procedures, from the initial pial incision (intra-axial tumors) or early debulking (extra-axial lesions), to progressive tumor removal, and, lastly, for surgical cavity hemostasis. No injury to the surrounding neurovascular structures was observed. Postoperative neuroimaging confirmed complete tumor removal and showed a marked reduction of preoperative surrounding edema without signs of cerebral/medullary contusions. CONCLUSIONS: In selected cases, the SmartXide2 CO2 laser system could be a helpful, reliable, and safe surgical instrument to treat different cerebral and spinal lesions. It addresses some of the limitations of laser systems and is able to cut/ablate and coagulate the tissue simultaneously, with minimal lateral thermal spread, preserving the surrounding eloquent neurovascular structures. Moreover, having no consumable accessories, it is also cost-effective.


Assuntos
Neoplasias Encefálicas/cirurgia , Glioma/cirurgia , Terapia a Laser/instrumentação , Lasers de Gás/uso terapêutico , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Neuroma Acústico/cirurgia , Procedimentos Neurocirúrgicos/instrumentação , Neoplasias da Medula Espinal/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Encefálicas/secundário , Feminino , Humanos , Terapia a Laser/métodos , Masculino , Metastasectomia , Microcirurgia/instrumentação , Microcirurgia/métodos , Pessoa de Meia-Idade , Neurilemoma/cirurgia , Procedimentos Neurocirúrgicos/métodos
16.
J Clin Neurosci ; 93: 260-261, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34120790

RESUMO

The surgical outcomes which evaluated in studies depend on preoperative condition, demographic data of patients, surgical approaches or treatment and local factors. Author argues that the neurological deterioration rate 4,2% which is reported in our study is marvelous and he exemplifies the other studies in literature. Neurosurgeons know that the clinical studies in literature do not compare only their results. Authors compare and evaluate studies with preoperative demographic data, surgical approach, local factors or others between their results. Therefore this detail explains paralogism of the author. The neurological deterioration rate is reported as smaller or similar in our study to the contrary of others due to all the preoperative demographical data were evaluated with others. We suppose the author alludes that the neurological deterioration rate is marvelous since he does not compare all of the demographical data in these clinical studies.


Assuntos
Neoplasias da Medula Espinal , Humanos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos , Procedimentos Neurocirúrgicos , Estudos Retrospectivos , Neoplasias da Medula Espinal/diagnóstico por imagem , Neoplasias da Medula Espinal/cirurgia , Resultado do Tratamento
17.
Spinal Cord Ser Cases ; 7(1): 52, 2021 06 24.
Artigo em Inglês | MEDLINE | ID: mdl-34168112

RESUMO

INTRODUCTION: Subependymomas are slow growing WHO grade 1 tumours, typically attached to the ventricular wall of the fourth or lateral ventricles. Spinal subependymomas are rarer still and experience of their biological characteristics remains limited. CASE PRESENTATION: A 29-year-old lady presented with chronic attacks of itchy dysaesthesia involving the left hand, neck and trunk, and associated with ipsilateral leg spasms. Recent symptomatic change involved occasional limping and left sided facial numbness but no pain. MRI showed an intradural mass surrounding most of the cervical spinal cord, which appeared scalloped extrinsically, rather than diffusely expanded, by a seemingly extramedullary lesion. At operation, the cord appeared expanded, with no clear margin or distinction between tumour and cord tissue; and the tumour was found to be intramedullary with an exophytic component, rather than extramedullary. Moderate reduction of the left abductor pollicis brevis evoked potential led to a pause in surgery. There was transient hand weakness postoperatively with full recovery, and no radiological change in the tumour morphology for a further 6 years. DISCUSSION: An intramedullary tumour such as a spinal cord subependymoma can be mistaken radiologically for an extramedullary tumour, such as an epidermoid. If a subependymoma is suspected, given its indolent course and long-term survival, caution in the extent of surgical resection is advisable in order to avoid surgical morbidity.


Assuntos
Medula Cervical , Glioma Subependimal , Neoplasias da Medula Espinal , Adulto , Feminino , Glioma Subependimal/diagnóstico , Glioma Subependimal/cirurgia , Humanos , Parestesia , Neoplasias da Medula Espinal/diagnóstico por imagem , Neoplasias da Medula Espinal/cirurgia , Tronco , Extremidade Superior
18.
Neurosurg Focus ; 50(5): E19, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33932926

RESUMO

OBJECTIVE: Ventrally situated thoracic intradural extramedullary tumors are surgically challenging and difficult to access, and they may be complicated by extensive adhesions and calcifications. Selecting an approach for adequate ventral access is key to complete resection and optimization of outcomes. The authors present a case series of patients who underwent resection of ventral thoracic intradural extramedullary tumors and discuss indications and considerations for this technique. Additionally, they describe the use of a posterolateral transpedicular approach for resection of ventral thoracic intradural extramedullary tumors compared with other techniques, and they summarize the literature supporting its application. METHODS: From May 2017 to August 2020, 5 patients with ventral thoracic intradural extramedullary tumors underwent resection at one of the two academic institutions. RESULTS: Patient ages ranged from 47 to 75 (mean 63.4) years. All tumors were diagnosed as meningiomas or schwannomas by histological examination. Three of the 5 patients had evidence of partial or extensive tumor calcification. Four of the 5 patients underwent an initial posterolateral transpedicular approach for resection, with positive radiographic and clinical outcomes from surgery. One patient initially underwent an unsuccessful traditional direct posterior approach and required additional resection 2 years later after interval disease progression. There were no postoperative wound infections, CSF leaks, or other complications related to the transpedicular approach. CONCLUSIONS: Posterolateral transpedicular tumor resection is a safe technique for the treatment of complex ventrally situated thoracic intradural extramedullary tumors compared with the direct posterior approach. Anecdotally, this approach appears to be particularly beneficial in patients with calcified tumors.


Assuntos
Neoplasias Meníngeas , Meningioma , Neurilemoma , Neoplasias da Medula Espinal , Neoplasias Torácicas , Idoso , Humanos , Neoplasias Meníngeas/diagnóstico por imagem , Neoplasias Meníngeas/cirurgia , Meningioma/diagnóstico por imagem , Meningioma/cirurgia , Pessoa de Meia-Idade , Neoplasias da Medula Espinal/diagnóstico por imagem , Neoplasias da Medula Espinal/cirurgia
19.
Neurosurg Focus ; 50(5): E21, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33932929

RESUMO

OBJECTIVE: The use of intraoperative neuromonitoring (IONM) has become an imperative adjunct to the resection of intramedullary spinal cord tumors (IMSCTs). While the diagnostic utility of IONM during the immediate postoperative period has been previously studied, its long-term diagnostic accuracy has seldom been thoroughly assessed. The aim of this study was to evaluate long-term variations in the diagnostic accuracy of transcranial motor evoked potentials (tcMEPs), somatosensory evoked potentials (SSEPs), and D-wave recordings during IMSCT excision. METHODS: The authors performed a retrospective evaluation of imaging studies, patient charts, operative reports, and IONM recordings of patients who were operated on for gross-total or subtotal resection of IMSCTs at a single institution between 2012 and 2018. Variations in the specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) for postoperative functional outcome (McCormick Scale) were analyzed at postoperative day 1 (POD1), 6 weeks postoperatively (PO-6 weeks), and at the latest follow-up. RESULTS: Overall, 28 patients were included. The mean length of follow-up was 19 ± 23.4 months. Persistent motor attenuations occurred in 71.4% of the cohort. MEP was the most sensitive modality (78.6%, 87.5%, and 85.7% sensitivity at POD1, PO-6 weeks, and last follow-up, respectively). The specificity of the D-wave was the most consistent over time (100%, 83.35%, and 90% specificity at the aforementioned time points). The PPV of motor recordings decreased over time (58% vs 33% and 100% vs 0 for tcMEP and D-wave at POD1 and last follow-up, respectively), while their NPV consistently increased (67% vs 89% and 70% vs 100% for tcMEP and D-wave at POD1 and last follow-up, respectively). CONCLUSIONS: The diagnostic accuracy of IONM in the resection of IMSCTs varies during the postoperative period. The decrease in the PPV of motor recordings over time suggests that this method is more predictive of short-term rather than long-term neurological deficits. The increasing NPV of motor recordings indicates a higher diagnostic accuracy in the identification of patients who preserve neurological function, albeit with an increased proportion of false-negative alarms for the immediate postoperative period. These variations should be considered in the surgical decision-making process when weighing the risk of resection-associated neurological injury against the implications of incomplete tumor resection.


Assuntos
Monitorização Neurofisiológica Intraoperatória , Neoplasias da Medula Espinal , Potencial Evocado Motor , Potenciais Somatossensoriais Evocados , Humanos , Procedimentos Neurocirúrgicos , Estudos Retrospectivos , Neoplasias da Medula Espinal/diagnóstico , Neoplasias da Medula Espinal/cirurgia
20.
Neurosurg Focus ; 50(5): E22, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33932931

RESUMO

OBJECTIVE: Tumorous lesions of the spinal cord, as well as some vascular lesions like cavernous hemangiomas, demand careful consideration as to the indication and approach for surgery. As these lesions are rare in any departmental series, refinement of treatment strategies evolves over long periods. In this context, the authors evaluated a series of 500 intramedullary lesions for approach, technique, outcome, complications, and follow-up. METHODS: Five hundred intramedullary lesions in 460 patients were treated with a continuously evolving departmental strategy between 1985 and 2020. No lesions of the cauda equina or filum terminale were included. The focus of the evaluation was on the adaptation of exposure, resective methodology, sequelae, imaging, and rate of recurrence. Thirty-seven patients were children at the time of diagnosis. RESULTS: Among the 348 neoplastic lesions, the largest subtype was ependymoma (n = 192, 55.2%), followed by astrocytoma (n = 89, 25.6%). As a trend, metastases (n = 21) have become more frequent and more apparent only in the past 15 years. Reoperations for recurrent or progressive cases or referrals after incomplete resection were performed in 56 cases, mostly for progressive diffuse or pilocytic astrocytomas. Among the vascular lesions, 68 (54.8%) were hemangioblastomas, followed by 56 (45.2%) cavernous hemangiomas. All intramedullary tumors were approached through a midline myelotomy, refining an en bloc resection technique for endophytic tumors to increase the rate of radical resection. Cavernous hemangiomas reaching the surface and hemangioblastomas were approached directly. Complete removal was possible in 77.2% of endophytic tumors but in only 41.7% of diffuse tumors. All WHO grade II diffuse astrocytomas, WHO grade III tumors, and glioblastoma progressed despite treatment according to standard regimens. Vascular lesions were regularly removed completely, with only 1 recurrence of a large hemorrhagic thoracic cavernous hemangioma. The major sequelae were sensory deficits and neuropathic pain. Stabilizing instrumentation was placed in 5 cases of spinal deformity, mostly when more than 4 levels were affected, and in the pediatric population. CONCLUSIONS: In a large series of intramedullary surgeries, refinement of treatment strategies related to exposure, implementation of intraoperative adjuncts such as ultrasound, intraoperative neuromonitoring, resective strategies, and reconstruction were evaluated. The authors found that for almost any defined, endophytic medullary lesion, a safe and complete removal can be offered.


Assuntos
Astrocitoma , Ependimoma , Neoplasias da Medula Espinal , Criança , Ependimoma/cirurgia , Humanos , Recidiva Local de Neoplasia/cirurgia , Neoplasias da Medula Espinal/diagnóstico por imagem , Neoplasias da Medula Espinal/cirurgia
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