Osteochondrolipoma of the foot treated by surgical excision: a case report and literature review.

BACKGROUND: Osteochondromas, classified as a new benign subtype of lipomas and characterised by chondroid and osseous differentiation, are rare lesions that have been infrequently reported in previous literature. The maxillofacial region was reported as the most frequent localization, with infrequent occurrence in the lower limb. This paper represents the first documented case report of osteochondrolipoma in the foot. CASE PRESENTATION: A 51-year-old male patient presented with a chief complaint of right foot pain at the plantar aspect, accompanied by the observation of swelling between the first and the second metatarsal shafts. His complaint of pain and swelling started 10 and 4 years prior, respectively. Since their onset, both symptoms have progressed in nature. Imaging revealved a large mass exhibiting a nonhomogenous composition of fibrous tissue and bony structures. Surgical intervention through total excision was indicated. CONCLUSION: Osteochodrolipoma is a benign lesion that can affect the foot leading to decreased functionality of the foot due to the pain and swelling. Surgical excision is the recommended approach for this lesion, providing both symptomatic relief and confirmation of the diagnosis through histopathological examination.

Bizarre parosteal osteochondromatous proliferation in the distal ulna where the lesion is continuous with the medullary cavity: a case report.

BACKGROUND: Bizarre parosteal osteochondromatous proliferation (BPOP) is a rare benign bone tumor, it is also called "Nora's lesion". The lesion is characterized by heterotopic ossification of the normal bone cortex or parosteal bone. The etiology of BPOP is unclear and may be related to trauma. In most BPOPs, the lesion is not connected to the medullary cavity. Here we report an atypical case, characterized by reversed features compared to the typical BPOP, which demonstrated continuity of the lesion with the cavity. CASE PRESENTATION: An 11-year-old female child had a slow-growing mass on her right wrist for 8 months with forearm rotation dysfunction. Plain X-rays showed an irregular calcified mass on the right distal ulna, and computed tomography (CT) showed a pedunculated mass resembling a mushroom protruding into the soft tissue at the distal ulna. The medulla of this lesion is continuous with the medulla of the ulna. A surgical resection of the lesion, together with a portion of the ulnar bone cortex below the tumor was performed, and the final pathology confirmed BPOP. After the surgery, the child's forearm rotation function improved significantly, and there was no sign of a recurrence at 1-year follow-up. CONCLUSION: It is scarce for BPOP lesions to communicate with the medullary cavity. However, under-recognition of these rare cases may result in misdiagnosis or inappropriate treatment thereby increasing the risk of recurrence. Therefore, special cases where BPOP lesions are continuous with the medulla are even more important to be studied to understand better and master these lesions. Although BPOP is a benign tumor with no evidence of malignant transformation, the recurrence rate of surgical resection is high. We considered the possibility of this particular disease prior to surgery and performed a surgical resection with adequate safety margins. Regular postoperative follow-up is of utmost importance, without a doubt.

Bizarre parosteal osteocondromatous proliferation (BPOP) of the acromion with soft tissue recurrence.

Bizarre parosteal osteochondromatous proliferation (BPOP) is a benign but rare periosteal-originating chondrogenic tumor. It commonly arises from the hands and feet. It is slow-growing and often presents as a painless lump. On imaging, the mass is well-marginated and almost always remains contiguous with the cortical bone. Histologically, the lesion is composed of a disorganized admixture of fibrous tissue, bone, and cartilage with bizarre features. Treatment is surgical and local recurrence is common contiguous with bone. This case report demonstrates an uncommon acromial BPOP with the first reported recurrence not contiguous with the underlying cortex.

The Role of Routine Pathologic Assessment After Pediatric Osteochondroma Excision.

BACKGROUND: Osteochondromas are benign osseous lesions often excised for pain, growth abnormalities, and aesthetic concerns. While characteristic clinical and radiographic features leave little diagnostic ambiguity in most cases of osteochondroma, pathologic analysis to confirm the diagnosis and screen for malignancy is routinely performed following surgical excision. The purpose of this study was to determine the clinical and economic value of routine pathologic analysis after osteochondroma excision in a pediatric population. METHODS: A retrospective review of clinical records from 2 pediatric orthopaedic hospitals (St. Louis Children's Hospital and Shriner's Hospital for Children, St. Louis) identified 426 osteochondroma lesions surgically resected from 201 patients. Patients with solitary and multiple lesions were included. Clinical, radiographic, and surgical data were recorded for each resection surgery. Pathologic reports were evaluated. Costs incurred for routine pathologic assessment was also noted. RESULTS: Totally, 132 patients were treated with surgical resection of a solitary osteochondroma lesion, while an additional 291 lesions were resected from 69 patients with multiple lesions. Average age at the time of surgical resection was 13.0 years (2.1 to 17.9). The most common anatomic locations of excised lesions included the distal femur (110, 25.8%), proximal tibia/fibula (95, 22.3%), and distal radius/ulna (58, 13.6%). All resected specimens were sent for pathologic analysis. The average size of the resected lesions was 19.9 mm 3 (0.02 to 385.0 mm 3 ). In all cases, the histologic diagnosis confirmed benign osteochondroma. The total charges of pathologic analysis including processing and interpretation fees was ∼$755.00 for each lesion assessed, for a total cohort charge of $321,630. CONCLUSION: We propose that in most cases of pediatric osteochondroma excision procedures, postoperative histologic analysis is not strictly indicated as it rarely, if ever, alters diagnosis or management. We suggest using a "gross only" analysis in these cases. However, we do believe that with preoperative diagnostic ambiguity, or if patients present with concerning features such as rapidly expansile lesions or cortical destruction, have axial skeleton or pelvic involvement, or enlarged cartilaginous caps, full histologic evaluation of the excised lesions will continue to be prudent. LEVEL OF EVIDENCE: Level IV-case series.

BPOP in early childhood following resection of osteochondroma: report of a case.

The diagnosis of an osteochondroma in the short bones of the extremities is atypical and the presentation in infancy is unusual. A 3-month-old female presented for evaluation of radial deviation of the right index finger present since birth. Radiographs showed a broad-based osseous outgrowth with the usual features of an osteochondroma arising from the base of middle phalanx. Initial corrective surgery at 22 months was followed by recurrence of the lesion. Another resection at 4 years confirmed a final diagnosis of BPOP (bizarre parosteal osteochondromatous proliferation). The subsequent pathologic diagnosis of BPOP appears to support the hypotheses concerning the etiology of BPOP as possibly arising from repeated trauma to the metaphysis.

Benign Brain and Spinal Tumors Originating from Bone or Cartilage.

Benign osseocartilaginous tumors of the spine are overall uncommon, representing between 1 and 13% of all primary bone tumors and less than 10% of all spinal tumors. Tumors in this category include osteoblastic lesions such as the related osteoid osteoma and osteoblastoma, and cartilage-forming lesions including osteochondroma, chondroma, and chondroblastoma. Aneurysmal bone cysts, giant cell tumors of bone, and eosinophilic granulomas also comprise benign tumors of the spine arising from bone. There is significant heterogeneity in the epidemiology, molecular biology, imaging features, and optimal treatment of these lesions. For example, osteoid osteoma is characterized by high expression of the cyclooxygenase enzymes, making it amenable to treatment with anti-inflammatory drugs initially, whereas other lesions such as osteoblastoma may require intralesional curettage or en bloc resection sooner. Generally, en bloc resection is preferred when possible to minimize risk of recurrence. Further, some tumors may arise in the setting of syndromic conditions, such as multiple chondromas arising in Ollier disease or Maffucci syndrome, or as part of genetic disorders, such as osteochondromas in the context of hereditary multiple exostosis. These lesions may present with local pain, cause neurological compromise or be discovered incidentally on routine imaging. The Enneking classification and Weinstein-Boriani-Biagini system are routinely used to classify lesions and assist in surgical planning. More novel techniques such as radiofrequency ablation and laser photocoagulation have been applied for the treatment of osteoid osteoma and may have utility in the treatment of other lesion types. A multidisciplinary approach is critical in the management of benign lesions of the spine, and both chemotherapeutic and surgical approaches are routinely used.

Neuromonitoring for Proximal Fibular Osteochondroma Excision.

BACKGROUND: The peroneal nerve is at risk when excising tumors in the proximal fibula. The rate of nerve injuries during proximal fibular tumor resection varies from 3% to 20%. Our goal was to report our experience with resection of osteochondromas in the proximal fibula and describe the technique and utility of neuromonitoring during excision of proximal fibular osteochondromas (PFO). METHODS: Patients with a diagnosis of symptomatic PFO who had undergone excision at one institution from 1994 to 2018 were included. An institutional review board-approved retrospective review was performed. Intraoperative neuromonitoring was provided from 2006 on by a single group utilizing a multimodality protocol. RESULTS: This study contains 29 patients who had excision of osteochondromas in the proximal fibula. Of these 29 consecutively monitored patients, there were 34 involved extremities. Intraoperative neuromonitoring alerts occurred in 10/29 (34.5%) procedures, which included 3 electromyography (EMG) (30%), 2 motor-evoked potential (20%), 1 somatosensory-evoked potential (10%), and 4 alerts with a combination of EMG/motor-evoked potential/somatosensory-evoked potential changes (40%). The interventions that were taken resulted in resolution of the neuromonitoring changes in all procedures. Postoperatively, we noted 2 (6.9%) new mild sensory deficits, which resolved during follow up. There were 3 patients in whom pre-existing sensory-motor deficits improved but not completely after surgery, 1 motor weakness, and 2 with residual paresthesia. In those initially presenting with paresis, there was improvement in 8 of the 8 extremities by the last follow-up visit. Pain as a symptom was resolved in all cases. There were no iatrogenic foot drop injuries. The average follow up was 32.2 months. CONCLUSIONS: Neuromonitoring during PFO excision demonstrated a high number of alerts, all of which resolved following timely corrective action. The use of neuromonitoring may help decrease the risk of iatrogenic postoperative neurological deficits following fibular osteochondroma surgery. LEVEL OF EVIDENCE: Level IV.

Surgical Guides and Prebent Titanium Improve the Planning for the Treatment of Dentofacial Deformities Secondary to Condylar Osteochondroma.

PURPOSE: To investigate current Computer-Aided Design and Computer-Aided Manufacturing (CAD/CAM) technologies applied in the treatment of dentofacial deformities secondary to condylar osteochondroma and introduce a modified method with additional pre-bent titanium miniplates to improve the accuracy of operation. METHODS: Literature review about the application of CAD/CAM in the treatment of condylar osteochondroma and secondary dentofacial deformities was conducted. And 8 patients with condylar osteochondroma and secondary dentofacial deformities were treated by the CAD/CAM cutting and drilling surgical guides as well as pre-bent titanium miniplates. Pre- and post-operative 3D-cephalometric measurement were recorded and the difference between virtual simulation and postoperative modeling images was measured. Follow-up and radiographic examinations were performed. RESULTS: A total of 17 studies (including 216 patients) about the application of CAD/CAM in the treatment of dentofacial deformities secondary to condylar osteochondroma have been reported since 2010, including the 8 present patients. In our study, all patients were satisfied with the surgical outcome, without obvious relapse or evidence of temporomandibular joint disorder or other complications during follow-up; all patients avoided condylar reconstruction and sagittal split of ramus osteotomy on the ipsilateral mandible side. Comparison between simulated plans and actual postoperative outcomes showed surgical simulation plan was accurately transferred to the actual surgery. CONCLUSIONS: The application of CAD/CAM cutting and drilling guides as well as pre-bent titanium plates could achieve more accurate and favorable outcomes, improving the clinical planning and surgical execution for patients with condylar osteochondroma and secondary dentofacial deformities.

Simultaneous Management of Condylar Osteochondroma and Secondary Malformation With a New Intraoral Approach.

PURPOSE: The present study aimed to investigate the clinical efficacy of simultaneous management of condylar osteochondroma and its secondary dentofacial deformities using an intraoral surgical approach. METHODS: Six patients with condylar osteochondroma were treated with intraoral vertical ramus osteotomies and condylar resection. The free rising branch was used for reconstructing the temporomandibular joint. The simultaneous orthognathic surgery and plastic surgery were performed sequentially to correct the secondary dentofacial deformities. The indexes of aesthetic symmetry, occlusion relationship, temporomandibular joint function, condylar height, and volume change were assessed in the subsequential follow up. RESULTS: The mean follow up period was 31 months. All patients had no tumor recurrence. The ipsilateral joint function, occlusal relationship, and facial symmetry were satisfied. The ipsilateral condylar reconstruction had no obvious bone resorption and the ramus height was maintained well. Postoperative assessment showed the preoperative design was accurately fulfilled. CONCLUSIONS: The simultaneous condylar osteochondroma resection and temporomandibular joint reconstruction using intraoral approach avoids extraoral scars and correct facial asymmetry without compromising the long-term joint function and occlusal relationship.

Bizarre Parosteal Osteochondromatous Proliferation (Nora's Lesion) of Mandible With Recurrence: Case Report and Review of Literature.

Bizarre parosteal osteochondromatous proliferation (BPOP) is a rare benign lesion exhibiting radiographic and histologic features that can be mistaken for malignancy. Most cases have been reported in the small tubular bones of the hands and feet, but involvement of the skull and jaws is extremely rare. Here, we present a case of BPOP involving the mandible in a 23-year-old male that, after initial excision, recurred within 18 months. To the best of our knowledge, this is only the third published case of BPOP arising in the mandible.

Bizarre Parosteal Osteochondromatous Proliferation (Nora Lesion) in Pediatric Phalanges.

Bizarre parosteal osteochondromatous proliferation, or Nora tumor, is an uncommon lesion affecting the tubular bones of the hands and feet. Normally arising from the cortical surface and periosteum of these bones, these lesions histologically consist of a hypercellular cartilaginous cap covering a bony stalk that is surrounded by ossified areas and spindle cell stroma. The differential diagnosis includes conditions involving the periosteum such as chondrosarcoma, parosteal osteosarcoma, osteochondroma, turret exostosis, and florid reactive periostitis. The only effective treatment is wide surgical excision; nevertheless, local recurrence rates are extremely high and may necessitate revision surgery. In the present study, we report 3 cases of Nora lesion located in the hand in pediatric patients. The diagnosis in these cases was challenging owing to their presenting symptoms and radiographic findings. The diagnosis was made based on characteristic findings noted on the radiographic images and was confirmed by histological examination following excision.

Peroneal Nerve Function Before and Following Surgical Excision of a Proximal Fibular Osteochondroma.

BACKGROUND: Osteochondromas occur most commonly in the distal femur, proximal tibia, and humerus. There are no large studies reviewing the outcome of treatment for patients with an osteochondroma involving the proximal fibula. The purpose of this study is to specifically understand the manifestations of a proximal fibular osteochondroma (PFO) on the preoperative peroneal nerve function, and how surgical management of the osteochondroma affects function immediately postoperatively and at long-term follow-up. METHODS: This is an institutional review board-approved retrospective review of a consecutive series of patients with a PFO treated operatively at a single institution. The medical record was carefully reviewed to identify demographic data, clinical data especially the status of the peroneal function at various time points. RESULTS: There were 25 patients with 31 affected extremities who underwent surgical excision of the PFO at an average age of 12.4 years (range, 3.0 to 17.9 y). There were 16 males and 9 females. The underlying diagnosis was isolated PFO in 2 (8%) patients and multiple hereditary exostosis in 23 (92%) patients. Preoperatively, 9 (29%) had a foot drop and 22 (71%) did not. Those with a preoperative foot drop underwent surgery at a younger age (9.1 vs. 13.8 y) (P<0.004) and postoperatively 5 (55.5%) had complete resolution, 3 (33.3%) had improvement, and 1 (11.1%) persisted requiring an ankle foot orthosis. Of the 22 who were normal preoperatively, 5 (22.7%) developed an immediate postoperative foot drop, 3 (60%) completely resolved, 1 (20%) improved, and 1 (20%) persisted and was found to have a transected nerve at exploration. In total, 23 of the 25 (92%) patients who had a PFO excision, had a normal or near-normal peroneal nerve function including those who had poor function preoperatively. CONCLUSIONS: Patients with a PFO have a preoperative peroneal nerve dysfunction 30% of the time and 23% of those who were normal preoperatively have postoperative dysfunction. Fortunately, nearly all patients have a complete recovery following excision of the osteochondroma. LEVEL OF EVIDENCE: Level IV.

Simultaneous Condylar Reconstruction by Free Ramus Osteotomy Graft After Complete Condylectomy for Osteochondroma.

ABSTRACT: Mandibular condyle osteochondromas cause morphologic and functional disturbances. Multiple options exist for reconstructing the condylar segment following complete condylectomy. In this series, we describe 3 cases of mandibular condyle osteochondroma treated with complete condylectomy, orthognathic surgery, and a novel free ramus osteotomy graft. This is the first report to reconstruct the temporomandibular joint using a free ramus graft. Through this single-staged approach we were able to avoid recurrence, preserve function, and restore facial balance without a separate donor site or an alloplastic implant.

Arthroscopic removal of a solitary osteochondroma interfering with the podotrochlear apparatus in a foal.

OBJECTIVE: To report the diagnostics, surgical treatment, and outcome of a juvenile foal with solitary osteochondroma (SO) interfering with the podotrochlear apparatus. STUDY DESIGN: Case report ANIMAL: One 36-day-old Arabian colt. METHODS: Clinical, radiographic, ultrasonographic, computed tomographic, and histopathologic examinations were required to characterize and treat an SO located at the palmar aspect of the diaphysis of the second phalanx of the left forelimb. This SO caused severe distal interphalangeal joint (DIPJ) inflammation, marked interference with the podotrochlear apparatus, and associated lameness. RESULTS: Despite the small size of the foal's foot, complete resection of the SO was possible via palmar DIPJ arthroscopy by using motorized equipment. Full resolution of the lameness was achieved within 3 months of surgery. CONCLUSION: Atypical SO located on the palmar aspect of the second phalanx can cause marked nonseptic inflammation of the DIPJ and interference with the podotrochlear apparatus and should be considered among the differential diagnoses for severe lameness in juvenile foals. Arthroscopic resection of the SO led to an excellent outcome.

Osteochondroma : the local effects and the management.

Osteochondroma is a common benign bone tumour, presenting as a single or multiple lesions, pedunculated or sessile type, mainly in 1st-2nd decades and mostly in males. The presented case series, studied the local effect of (osteochondroma) at the end of long bones with best line of treatment (RQ). Eighteen patients with osteochondromas, with an age range of 9- 45 years, mean age 19.6 ± 11.147 years, were seen from October 2016 to November 2018. There were 8 cases with painful lesion due to (mechanical interaction) or (pressure on near by neurovascular bundle), or from (inflamed bursa). Four cases were asymptomatic, 3 cases had Growth disturbances of the fellow bone, 3 cases presented with neurological symptoms and one case had vascular complications. Osteochondromas may present with different types of local effects on its surrounding tissues. Surgical excision is the best line of treatment.

Bilateral Proximal Tibiofibular Synostosis Caused by Osteochondroma in a 21-Year-Old Highly Active Male-First in Literature.

Background and Objectives: Up until now, only one case of unilateral proximal tibiofibular synostosis caused by osteochondroma has been reported. This report is the first well-documented bilateral case of proximal tibiofibular synostosis caused by an osteochondroma. Case Report: A 21-year-old, highly active male patient with bilateral proximal tibiofibular synostosis caused by an osteochondroma suffering from persistent knee pain is presented. As conservative methods had failed, the patient was treated by bilateral open resection of the connecting bone. Histopathological findings confirmed the preoperative diagnosis. The patient returned to sports three weeks after surgery and continued soccer training six weeks after surgery. Discussion: The case report presents the successful treatment of a bilateral proximal tibiofibular synostosis caused by an osteochondroma by bilateral open resection of the connecting bone.

Trevor's disease of the distal radioulnar joint in two children with achondroplasia.

Two children with achondroplasia who developed an abnormal bony outgrowth at the distal radioulnar joint (DRUJ), indistinguishable from an osteochondroma on histology, but the radiographic appearance, location, and asymmetry suggested the rare diagnosis of dysplasia epiphysealis hemimelica (DEH or "Trevor's disease"). One child experienced symptomatic relief with surgical excision and one was observed clinically due to lack of significant symptoms. These are the first presented cases of DEH in achondroplasia, both affecting the DRUJ. Due to the infrequency of DEH, more research is needed to better understand the potential connection to achondroplasia. For management, we suggest shared surgical decision making based on symptoms.

Stability of Orthognathic Surgery in the Treatment of Condylar Osteochondroma Combined With Jaw Deformity by CT Measurements.

PURPOSE: We evaluated the stability of orthognathic surgery in the treatment of unilateral condylar osteochondroma combined with jaw deformity. PATIENTS AND METHODS: Patients with unilateral condylar osteochondroma and jaw deviation deformity who had undergone surgery at the Ninth People's Hospital of Shanghai Jiaotong University School of Medicine from July 2014 to March 2017 were enrolled. The operation included a low condylectomy and both Le Fort I osteotomy and bilateral mandibular sagittal split osteotomies. ProPlan CMF, version 1.4, software (Materialise, Leuven, Belgium) was used to reconstruct and measure the preoperative, immediately postoperative, and follow-up (>6 months) maxillofacial computed tomography images. The position of the jaw and contralateral condyle and remodeling of the affected side were compared during follow-up. RESULTS: Eight patients were included in the present study. The canting of the maxilla was significantly decreased postoperatively, and the contralateral condyle had rotated inward. The position of the maxillary and contralateral condyles was stable during follow-up, and the posterior aspect of the affected condyle demonstrated significant resorption. CONCLUSIONS: The results of single-stage surgery combined with orthognathic surgery and condylar osteochondroma resection were stable, and the affected condyle stump had adaptively reconstructed.

Atypical osteochondroma of the hamate that presented clinically as carpal tunnel syndrome: report of an extremely rare case and literature review.

BACKGROUND: Osteochondroma is a benign tumor that occurs mainly at the metaphysis of long bones and seldom arises from carpal bones. We describe an extremely rare case of osteochondroma of the hamate without a typical cartilaginous cap and with a spiky bony protrusion in an elderly patient. CASE PRESENTATION: A 78-year-old right-handed female housekeeper had a multilobed osteochondroma of the hamate, which caused carpal tunnel syndrome and irritation of the flexor tendons. Radiological examinations showed a morphological abnormality of the hamate comprising a spiky bony protrusion into the carpal tunnel and a free body proximal to the pisiform. Open carpal tunnel release and resection of the spiky bony protrusion on the hook of the hamate were performed. The flexor digitorum profundus tendons of the ring and little fingers displayed synovitis and partial laceration in the carpal tunnel. Histological examination also showed atypical findings: only a few regions of cartilaginous tissue were seen in the spiky bony protrusion, whereas the free body proximal to the pisiform contained thick cartilaginous tissue such as a cartilaginous cap typical of osteochondroma. We speculated that the bony protrusion to the carpal tunnel had been eroded by mechanical irritation caused by gliding of the flexor tendon and had resulted in the protruding spiky shape with less cartilaginous tissue. The fractured cartilaginous cap had moved into the cavity within the carpal tunnel proximal to the pisiform and had become a large free body. CONCLUSIONS: Osteochondroma of the carpal bone may take various shapes because the carpal bone is surrounded by neighboring bones and tight ligaments, which can restrict tumor growth. This type of tumor is likely to present with various symptoms because of the close proximity of important structures including nerves, tendons, and joints. The diagnosis of osteochondroma of the carpal bone may be difficult because of its rarity and atypical radiological and histological findings, such as the lack of a round cartilaginous cap. We suggest that surgeons should have a detailed understanding of this condition and should make a definitive diagnosis based on the overall findings.

Tarsal tunnel syndrome secondary to osteochondroma of the calcaneus: a case report.

BACKGROUND: Tarsal tunnel syndrome is an entrapment neuropathy that can be provoked by either intrinsic or extrinsic factors that compresses the posterior tibial nerve beneath the flexor retinaculum. Osteochondroma, the most common benign bone tumor, seldom occur in foot or ankle. This is a rare case of tarsal tunnel syndrome secondary to osteochondroma of the sustentaculum tali successfully treated with open surgical excision. CASE PRESENTATION: A 15-year-old male presented with the main complaint of burning pain and paresthesia on the medial plantar aspect of the forefoot to the middle foot region. Hard mass-like lesion was palpated on the posteroinferior aspect of the medial malleolus. On the radiological examination, 2.5 × 1 cm sized bony protuberance was found below the sustentaculum tali. Surgical decompression of the posterior tibial nerve was performed by complete excision of the bony mass connected to the sustentaculum tali. The excised mass was diagnosed to be osteochondroma on the histologic examination. After surgery, the pain was relieved immediately and hypoesthesia disappeared 3 months postoperatively. Physical examination and radiographic examination at 2-year follow up revealed that tarsal tunnel was completely decompressed without any evidence of complication or recurrence. CONCLUSIONS: As for tarsal tunnel syndrome secondary to the identifiable space occupying structure with a distinct neurologic symptom, we suggest complete surgical excision of the causative structure in an effort to effectively relieve symptoms and prevent recurrence.