Syringomyelia associated with cervical spondylosis: A rare condition

Spinal spondylosis is an extremely common condition that has only rarely been described as a cause of syringomyelia. We describe a case of syringomyelia associated with cervical spondylosis admitted at our division and treated by our institute. It is the case of a 66-yearold woman. At our observation she was affected by moderate-severe spastic tetraparesis. T2-weighted magnetic resonance imaging(MRI) showed an hyperintense signal within spinal cord from C3 to T1 with a more sharply defined process in the inferior cervical spinal cord. At the same level bulging discs, facets and ligamenta flava hypertrophy determined a compression towards subarachnoid space and spinal cord. Spinal cord compression was more evident in hyperextension rather than flexion. A 4-level laminectomy and subsequent posterior stabilization with intra-articular screws was executed. At 3-mo follow up there was a regression of tetraparesis but motor deficits of the lower limbs residuated. At the same follow up postoperative MRI was executed. It suggested enlargement of the syrinx. Perhaps hyperintensity within spinal cord appeared "bounded" from C3 to C7 with clearer margins. At the level of surgical decompression, subarachnoid space and spinal cord enlargement were also evident. A review of the literature was executed using Pub Med database. The objective of the research was to find an etiopathological theory able to relate syringomyelia with cervical spondylosis. Only 6 articles have been found. At the origin of syringomyelia the mechanisms of compression and instability are proposed. Perhaps other studies assert the importance of subarachnoid space regard cerebrospinal fluid(CSF) dynamic. We postulate that cervical spine instability may be the cause of multiple microtrauma towards spinal cord and consequently may damage spinal cord parenchyma generating myelomalacia and consequently syrinx. Otherwise the hemorrhage within spinal cord central canal can cause an obstruction of CSF outflow, finally generating the syrinx. On the other hand in cervical spondylosis the stenotic elements can affect subarachnoid space. These elements rubbing towards spinal cord during movements of the neck can generate arachnoiditis, subarachnoid hemorrhages and arachnoid adhesions. Analyzing the literature these "complications" of cervical spondylosis are described at the origin of syringomyelia. So surgical decompression, enlarging medullary canal prevents rubbings and contacts between the bone-ligament structures of the spine towards spinal cord and subarachnoid space therefore syringomyelia. Perhaps stabilization is also necessary to prevent instability of the cervical spine at the base of central cord syndrome or syringomyelia. Finally although patients affected by central cord syndrome are usually managed conservatively we advocate, also for them, surgical treatment in cases affected by advanced state of the symptoms and MRI.

360° fusion for realignment of high grade cervical kyphosis by one step surgery: Case report

Surgical treatment for cervical kyphotic deformity is still controversial. Circumferential approach has been well described in the literature but long terms outcomes are not well reported. Important to decide the correct treatment option is the preoperative radiological exams to value the type of deformity(flexible or fixed). We report the case of a 67-year-old woman affected by a severe cervical kyphotic deformity who underwent combined anterior/posterior surgical approach, getting a good reduction of the deformity and an optimal stability in a long term follow up.

Trans-sacral screw fixation in the treatment of high dyplastic developmental spondylolisthesis

We describe the case of a 67-year-old woman with L5-S1 ontogenetic spondylolisthesis treated with pedicle fixation associated with interbody arthrodesis performed with S1-L5 trans-sacral screwing according to the technique of Bartolozzi. The procedure was followed by a wide decompressive laminectomy. The patient had a progressive improvement of the symptoms which gradually disappeared in 12 mo. The radiograph at 6 and 12 mo showed complete fusion system. The choice of treatment in L5-S1 ontogenetic spondylolithesis is related to a correct clinical and diagnostic planning(X-ray, computer tomography magnetic resonance imaging, Measurement). In particular, the severity index and the square of unstable zone, and the standard measurements already described in the literature, are important to understand and to plane the correct surgical strategy, that require, in most of the times, fusion and interbody artrodesis.

First description of cervical intradural thymoma metastasis

Thymoma and thymic carcinoma are rare epithelial tumors, which originate from the thymus gland. According to the World Health Organization there are "organotypic"(types A, AB, B1, B2, and B3) and "non-organotypic"(thymic carcinomas) thymomas. Type B3 thymomas are aggressive tumors, which can metastasize. Due to the rarity of these lesions, only 7 cases of extradural metastasis are described in the literature. We report the first and unique case of a man with cervical intradural B3 thymoma metastasis. A 46-year-old man underwent thymoma surgical removal. The year after the procedure he was treated for a parietal pleura metastasis. In 2006 he underwent cervical-dorsal extradural metastasis removal and C5-Th1 stabilization. Seven years after he came to our observation complaining left cervicobrachialgia and a reduction of strength of the left arm. He underwent a cervical spine magnetic resonance imaging, which showed a new lesion at the C5-C7 level. The patient underwent a surgery for the intradural B3 thymoma metastasis. Neurological symptoms improved although the removal was subtotal. He went through postoperative radiation therapy with further mass reduction. Spinal metastases are extremely rare. To date, only 7 cases of spinal extradural metastasis have been described in the literature. This is the first case of spinal intradural metastasis. Early individuation of these tumors and surgical treatment improve neurological outcome in patients with spinal cord compression. A multimodal treatment including neoadjuvant chemotherapy, surgery and postoperative radiation therapy seems to improve survival in patients with metastatic thymoma.

Giant xanthogranuloma of the pelvis with S1 origin: Complete removal with only posterior approach, technical note

Xanthogranulomas(XG) are benign proliferative disorder of histiocytes, a non-Langerhans cell histiocytosis. Whose etiology is unknown. The nature of these lesions is controversial and could be either reactive or neoplastic;the presence of monoclonal cells does, however, favor the second hypothesis. Xanthogranuloma is frequently found in young adults and children(under 20 years old), mainly in the skin. In about 5%-10% of all Juvenile XG(JXG) cases xanthogranuloma are extracutaneous. Within this group, the site most frequently involved is the eye. Other involved organs are heart, liver, adrenals, oropharynx, lung, spleen, central nervous system and subcutaneous tissue, although involvement of the spine is uncommon. Isolated lesions involving the sacral region are extremely rare. To date, this is the first reported case of a giant JXG arising from S1 with extension into the pelvic region in an adult spine.

Post traumatic dural sinus thrombosis following epidural hematoma: Literature review and case report

Dural sinus thrombosis following a head trauma is a rare condition,described in literature along with the lack of consensus regarding diagnosis and management.We present a case of a fifty-year-old man with a head injury and combined supratentorial-subtentorial epidural hematoma who was treated conservatively through the administration of low molecular weight heparin.The diagnosis and management of this condition are discussed based on a literature review.The early diagnosis may prevent potentially treatable poor outcomes.

Anterior Surgery in Multilevel Stenosis of the Lower Cervical Spine: Technical Indications and Personal Experience. 12 Years Follow-Up

Objective: cervical spondylotic myelopathy is a progressive degenerative cervical spine disease. During later stages of segmental degeneration, kyphosis of the cervical spine can occur and further compromise the spinal cord and nerve roots. Optimal surgical approach remains controversial. The choice to perform an anterior, posterior or combined approach depends on: sagittal alignment, number of involved levels, main compression localization, and clinical status. The anterior approach is recommended when compression involves primarily anterior horn of spinal cord. Methods: between January 2001 and December 2005, 121 patients (42 F, 79 M, mean age 62 years) were operated for cervical spondylosis (98 myelopathy, 23 radiculopathy). Anterior surgical approach was performed in 81 patients. 63 patients were operated performing multilevel discectomy and fusion (ACDF) and 18 patients performing corpectomy and fusion and anterior plating (ACCF). Preoperative documentation collected consisted of cervical X-ray (static-dynamic), cervical spine TC, cervical MRI. Clinical documentation permitted us to obtained clinical status of each patient based on JOA, NDI and VAS. A Clinical and radiological follow-up was performed at 1 month, 3 months, 1 year, 6 years, 12 years. Results: the fusion rate was calculated based on the static and dynamic X-ray (flexion and extension position), only a little percentage of patients underwent CT scan. There were no significant differences between ACDF and ACCF in clinical outcome at 6 years evaluated by VAS and NDI. The rate of fusion at 6 years for 2 levels ACCF (92%) was higher than that for 2 levels ACDF (86%) but is not statistically significative. Conclusion: classifying degenerative disease and biomechanics feature, preoperatively in necessary to guide the surgeon to choose the best anterior approach for cervical spondylosis.