Metastatic Spinal Tumors: Diagnostic Methods, Management and Prognosis at the Yaounde Central Hospital and Yaounde General Hospital

Introduction: Metastatic spinal tumors (MST) refer to secondary involvement of the vertebral column by hematogenously-disseminated metastatic cells. They could affect either the bony structures or the spinal cords. Mechanical instability and neurologic deficits resulting from spinal cord compression are the most common manifestations. Surgical intervention remains the most effective treatment for about 20% of patients who present with spinal cord compression. The prognosis is relatively poor. This work has as objectives to describe: the diagnostic tools, the different modalities of management and the prognostic elements of spine metastasis. Methodology: We conducted an ambispective cross-sectional descriptive study;with retrospective data collection from January 2015 to December 2021 and prospective collection from January to April 2022 in the “Neurosurgery” unit of the Yaounde Central Hospital and the “Oncology and Neurosurgery” units of Yaounde General Hospital. Result: We included 101 patients. The M/F sex ratio was 1.66. The average age of the participants was 56.44 years (±14.19 SD) with a median of 58 years. Metastatic spinal tumors were discovered in 61.39% of patients with a previously known primary tumor and 21.78% of patients had newly discovered tumors. The neurologic examination revealed a vertebral syndrome in 79.21% of cases, radicular syndrome in 60.40% and sub-lesional syndrome in 59.89%. Sensory disorders accounted for 39.60% and sphincter disorders accounted for 34.65%. According to the degree of severity, the lesions were classified as Frankel E (37.62%) followed by Frankel D (21.78%). Metastatic lesions were mostly found at the thoracic vertebrae (68.25%) and lumbar vertebrae (22.22%). The most represented primary tumors were: prostate tumors (41.58%) and breast tumors (23.76%);followed by malignant hemopathies (15.84%). Computed-tomography scan (CT-scan) was the most frequent diagnostic imaging technique used (71.28%). Analgesic treatment mostly involved level II analgesia (64.36%). High dose steroid therapy (greater than 80mg/24h) was used in more than half of the patients. Radiation therapy was performed in 24.75% of the patients, chemotherapy in 55.44% and specific surgical interventions performed in 20.79%. The most frequent surgical indication was complete motor deficit according to the Frankel classification (47.21%). One patient in four (23.76%) experienced improvement in functional prognosis with increased muscle strength after a period of 2 weeks to 5 months of treatment. About 1 in 10 patients (8.8%) rather had worsening of their neurologic status. We observed that there was a correlation between spine surgery and improvement in muscle strength (P-value less than 0.05). Patients (12) who had better recovery or preserved gait were those with partial compression (P-value = 0.0143). Four out of five patients (81.18%) of our series had an estimated survival of less than one year according to the Tokuhashi score. Conclusion: MSTs are frequent in our context. Most patients sought consultation late after the first symptoms appeared (principally back pain). The clinical examination revealed a high proportion of patients with spinal cord compression syndrome. Medical treatment was first-line for the management of pain and most patients who underwent surgical treatment had complete neurologic deficits. The functional prognosis was found to be improved by surgery and the vital prognosis depended on the Tokuhashi score, with better accuracy when the prediction is more than 12 months.

Association Between Constipation and a Reduction in Lower Limb Muscle Strength in Preoperative Patients with Thoracic Spinal Tumors

Objective To investigate the clinical symptoms experienced by patients with thoracic spinal tumors and verify the associated symptoms that are predictive of a decline in muscle strength in the lower limbs.Methods A single-center,retrospective cross-sectional study was conducted on in-patients diagnosed with epidural thoracic spinal tumors between January 2011 and May 2021.The study involved a review of electronic medical records and radiographs and the collection of clinical data.The differences in clinical manifestations between patients with constipation and those without constipation were analyzed.Binary logistic regression analyses were performed to identify risk factors associated with a decline in muscle strength in the lower limbs.Results A total of 227 patients were enrolled,including 131 patients with constipation and 96 without constipation.The constipation group had a significantly higher proportion of patients who experienced difficulty walking or paralysis compared to those without constipation prior to surgery(83.2%vs.17.7%,χ~2=99.035,P 0.001).Constipation(OR=9.522,95%CI:4.150±21.849,P 0.001)and urinary retention(OR=14.490,95%CI:4.543±46.213,P 0.001)were independent risk factors for muscle strength decline in the lower limbs.Conclusions The study observed that patients with thoracic spinal tumors who experienced constipation symptoms had a higher incidence of lower limb weakness.Moreover,the analysis revealed that constipation and urinary retention were independent risk factors associated with a preoperative decline in muscle strength of lower limbs.

Differential study of DCE-MRI parameters in spinal metastatic tumors, brucellar spondylitis and spinal tuberculosis

Objective： In the present study, spinal metastatic tumors, brucellar spondylitis and spinal tuberculosis werequantitatively analyzed using dynamic contrast-enhanced magnetic resonance imaging （DCE-MRI） to assess thevalue of DCE-MRI in the differential diagnosis of these diseases.Methods： Patients with brucellar spondylitis, spinal tuberculosis or a spinal metastatic tumor （30 cases of each）received conventional MRI and DCE-MRI examination. The volume transfer constant （Ktrans）, rate constant （Kep）,extravascular extracellular volume fraction （Ve） and plasma volume fraction （Vp） of the diseased vertebral bodieswere measured on the perfusion parameter map, and the differences in these parameters between the patients werecompared.Results： For pathological vertebrae in cases of spinal metastatic tumor, brucellar spondylitis and spinaltuberculosis, respectively, the Ktrans values （median ＋ quartile pitch） were 0.989±0.014, 0.720±0.011 and0.317±0.005 min-1; the Kep values were 2.898±0.055, 1.327±0.017 and 0.748±0.006 min-1; the Ve values were0.339±0.008, 0.542±0.013 and 0.428±0.018; the Vp values were 0.048±0.008, 0.035±0.004 and 0.028±0.009; thecorresponding H values were 50.25 （for Ktrans）, 52.47 （for Kep）, 48.33 （for Ve） and 46.56 （for Vp）, and all differenceswere statistically significant （two-sided P〈0.05）.Conclusions： The quantitative analysis of DCE-MRI has a certain value in the differential diagnosis of spinalmetastatic tumor, brucellar spondylitis and spinal tuberculosis.

Bone cement enhanced pedicle screw fixation combined with vertebroplasty for elderly patients with malignant spinal tumors

Background Older patients with malignant spinal tumors are difficult to treat because they have many co-morbidities including osteoporosis. The purpose of this research is to discuss the technique and clinical outcome of bone cement enhanced pedicle screw fixation combined with vertebroplasty （the Sandwich Procedure） for elderly patients with severe osteoporosis and malignant spinal tumors. Methods This study includes 28 consecutive elderly patients with malignant thoracic or lumbar spinal tumors. There were nine patients with myelomas, and 19 patients with metastatic bone tumors. The Sandwich Procedure began with curettage of the tumor and a vertebroplasty with bone cement （polymethyl methacrylate, PMMA）, followed by PMMA enhanced pedicle screw fixation. Patients were evaluated with the visual analogue scale （VAS）, oswestry disability index （ODI）, American Spinal Cord Injury Association （ASIA） neurological function classification, and the radiographic degree of kyphosis （Cobb angle）. Data were analyzed using paired t-test to compare the pre- and post-operative values. The complications, local recurrences, and the survival status were also recorded. Results There was no operative mortality, and the mean operative time was 210 minutes （range 150-250 minutes）. The average blood loss was 1550 ml （range 650-3300 ml）. The average amount of cement for vertebroplasty was 3.6 ml （range 3-5 ml）. The VAS, ODI, and ASIA scores were significantly improved after surgery （P 〈0.05）. However, we found no differences between the pre and post-operative Cobb angles. The shortest survival time was 3 months, and we found no evidence of local recurrence in this group of patients. Conclusion The Sandwich Procedure is a safe operation and provides symptomatic relief in these difficult patients, permitting further treatment with chemotherapy or radiotherapy.

Three-dimensional Fluoroscopy-based Navigation for the Pedicle Screw Placement in Patients with Primary Invasive Spinal Tumors

Background：Although pedicle screw placement （PSP） is a well-established technique for spine surgery,the treatment of patients with primary invasive spinal tumor （PIST） has high surgical risks secondary to destroyed pedicles.Intraoperative three-dimensional fluoroscopy-based navigation （ITFN） system permits safe and accurate instrumentation of the spine with the advantage of obtaining intraoperative real-time three-dimensional images and automatic registration.The aim of this study is to evaluate the feasibility and accuracy of PSP using ITFN system for patients afflicted with PIST in the thoracic spine.Methods：Fifty-one patients diagnosed with PISTs were retrospectively analyzed,and 157 pedicles screws were implanted in 23 patients using the free-hand technique （free-hand group） and 197 pedicle screws were implanted in 28 patients using the ITFN system （ITFN group）.Modified classification of Gertzbein and Robbins was used to evaluate the accuracy of PSP,and McCormick classification was applied for assessment of neurological function.Demographic data and factors affecting accuracy of screw insertion were compared using independent t-test while comparison of accuracy of screw insertion between the two groups was analyzed with Chi-square test.Results：Of 51 patients,39 demonstrated improved neurological status and the other 12 patients reported that symptoms remained the same.In the free-hand group,145 screws （92.4%） were Grade Ⅰ,9 screws （5.7%） were Grade Ⅱ,and 3 screws （1.9%） were Grade Ⅲ.In the ITFN group,192 screws （97.4%） were Grade Ⅰ,5 screws （2.6%） were Grade Ⅱ,and no Grade Ⅲ screw was detected.Statistical analysis showed that the accuracies of pedicle screws in the two groups are significantly different （χ^2 =4.981,P =0.026）.Conclusions：The treatments of PISTs include total tumor resection and reconstruction of spine stability.The ITFN system provides a high accuracy of pedicle screw placement.

Strategies of surgical treatment of the spinal metastatic tumors

Objective To study the clinical features, surgical treatments and the prognosis of the 103 patients with the metastatic tumors in the spine. Methods From Jan. 1996 to Dec. 2001,103 cases were treated by operation in our department, there were 62 males and 41 females, aging from 33 to 79 years old (average,59 years). The lesions were located at cervical spines in 34 cases, thoracic spines in 39,lumbar spines in 25 and sacrum in 5. The patients underwnet anterior, prosterior,combined or staged antero-posterior operations based on the location of lesions in the spine. Most of the patients were adopted vertebral reconstruction and internal fixation depending on the conditions. Preoperative clinical evaluation included of general conditions,X-ray films,CT scan.MRI and ECT in odrer to decide the endurance of the patient to the surgical treatment. The operation was only considered when the patient could have the expected survival time more than 6 months. Operative indications, surgical methods and prognosis

Prognostic factors and its predictive value in patients with metastatic spinal cancer

BACKGROUND The spine is the most common location of metastatic diseases.Treating a metastatic spinal tumor depends on many factors,including patients’overall health and life expectancy.The present study was conducted to investigate prognostic factors and clinical outcomes in patients with vertebral metastases.AIM To investigate prognostic factors and their predictive value in patients with metastatic spinal cancer.METHODS A retrospective analysis of 109 patients with metastatic spinal cancer was conducted between January 2015 and September 2017.The prognoses and survival were analyzed,and the effects of factors such as clinical features,treatment methods,primary lesions and affected spinal segments on the prognosis of patients with metastatic spinal cancer were discussed.The prognostic value of Frankel spinal cord injury functional classification scale,metastatic spinal cord compression(MSCC),spinal instability neoplastic score(SINS)and the revised Tokuhashi score for prediction of prognosis was explored in patients with metastatic spinal tumors.RESULTS Age,comorbidity of metastasis from elsewhere,treatment methods,the number of spinal tumors,patient’s attitude toward tumors and Karnofsky performance scale score have an effect on the prognosis of patients(all P<0.05).With respect to classification of spinal cord injury,before operation,the proportion of grade B and grade C was higher in the group of patients who died than in the group of patients who survived,and that of grade D and grade E was lower in the group of patients who died than in the group of patients who survived(all P<0.05).At 1 mo after operation,the proportion of grade A,B and C was higher in the group of patients who died than in the group of patients who survived,and that of grade E was lower in patients in the group of patients who died than in the group of patients who survived(all P<0.05).MSCC occurred in four(14.3%)patients in the survival group and 17(21.0%)patients in the death group(P<0.05).All patients suffered from intractable pain,dysfunction in spinal cord and even paralysis.The proportion of SINS score of 1 to 6 points was lower in the death group than in the survival group,and the proportion of SINS score of 7 to 12 points was higher in the death group than in the survival group(all P<0.05).The proportion of revised Tokuhashi score of 0 to 8 points and 9 to 11 points were higher in the death group than in the survival group,and the proportion of revised Tokuhashi score of 12 to 15 points was lower in the death group than in the survival group(all P<0.05).Frankel spinal cord injury functional classification scale,MSCC,SINS and revised Tokuhashi score were important factors influencing the surgical treatment of patients with metastatic spinal cancer(all P<0.05).CONCLUSION Frankel spinal cord injury functional classification scale,MSCC,SINS and revised Tokuhashi score were helpful in predicting the prognosis of patients with metastatic spinal cancer.

Spinal giant cell-rich osteosarcoma-diagnostic dilemma and treatment strategy:A case report

BACKGROUND Giant cell-rich osteosarcoma(GCRO) is a rare histological variant of osteosarcoma. Spinal GCROs are extremely rare, with challenging diagnosis and management. Herein, we present a case of spinal GCRO at T2, which was not diagnosed in initial biopsy but after T2 corpectomy. We detailed the clinical course, management strategy, and outcome after a 4-year follow-up.CASE SUMMARY A 17-year-old female patient presented with back pain followed by ascending paresthesia. Spinal computed tomography(CT) and magnetic resonance imaging(MRI) revealed a collapsed T2 vertebra with an enhancing osteolytic mass. CTguided biopsy showed inconclusive morphology. Pathology from T2 corpectomy revealed GCRO. The patient subsequently received neoadjuvant chemotherapy followed by salvage operation of T2 costotransversectomy with grossly-total resection adjuvant chemoradiation. Upon treatment completion, she had complete GCRO remission. The 4-year follow-up spinal MRI showed no tumor recurrence.CONCLUSION Spinal GCRO poses unique challenges in obtaining sufficient tissue diagnosis and complete surgical removal. However, long-term local control of spinal GCRO is possible following complete resection and adjuvant chemoradiation.

THE DIAGNOSIS OF MAGNETIC RESONANCE IMAGING FOR SPINAL CAVERNOUS ANGIOMAS

Objective To assess the characteristics of magnetic resonance imaging for spinal cavernous angiomas.Methods The examinations of plain scan and contrast enhanced scan of magnetic resonance were performed in three patients with spinal cavernous angiomas.Results The focus of two cases was located in thorax segment of the spinal cord and one in lower cervical segment.All focuses were single and the shape of spinal cord was normal or slightly thick. MRI characteristic of spinal cavernous angiomas was just like popcorn or mulberry with a jumbled gobbet signal. Low and short T 2 signal appeared around the focus. In all cases, there were no obvious contrast enhanced signal in 2 cases and one case with moderate contrast enhanced signal. The diameter of hemorrhage was smaller than that of the spinal cord.Conclusion MRI has higher sensitivity and specificity in the diagnosis of spinal cavernous angioma.

Concurrent chemotherapy and reduced - dose cranial spinal irradiation followed by conformal posterior fossa tumor bed boost for average - risk medulloblastoma: efficacy and patterns of failure

PURPOSE:To review the efficacy and patterns of failure in average-risk medulloblastoma patients treated withconcurrent chemotherapy and reduced-dose cranial spinal irradiation and a conformal tumor bed boost.METH-ODS AND MATERIALS:Thirty-three patients with average risk(defined as<==1.5 cm(2)of residual tumorafter resection,age>3 years,and no involvement of the cerebrospinal fluid or spine)medulloblastoma werediagnosed at our institution between January 1994 and December 2001.They were enrolled in an institutional

Arachnoiditis Ossificans Mimicking Spinal Intradural Extramedullary Tumor: A Case Report and Review of the Literature

Arachnoiditis ossificans is an intradural extramedullary lesion resulting from an unusual chronic meningeal inflammatory process and it is thought to be the sequela of end-stage adhesive arachnoiditis secondary to surgery, trauma, arachnoid hemorrhage, meningeal irritation, myelography (particularly oil-based contrast agents), and spinal anesthesia. The spinal arachnoiditis ossificans may be silent or cause a variety of symptoms depending on its location and uncommonly happen to cause spinal cord compression. Very little attention has been paid to the management and outcome of this rare condition in the neurosurgical reem. We report the case of a 45 years old man admitted with L1 - L2 arachnoiditis ossificans revealed by polyradiculopathy on incomplete cauda equina syndrome mimicking spinal canal tumors. The patient underwent surgery and we performed the laminectomy of L1 - L2, total resection of the lesion, followed by a complete remission of the hemiparesis after three months of kinesitherapy nursing.

Hyperalgesic Lumbosciatica Symptomatic of a Spinal Schwannoma: A Case Report

Introduction: Spinal schwannomas also known as neurinomas are often benign slow growing lesion that may develop from Schwann cells of the spinal roots, it is a nerve sheath tumor. The authors reported a case of a patient presenting a hyperalgesic lumbosciatica symptomatic of a spinal schwannoma. Observation: A 36-year-old female patient, with a history of asthma under treatment was admitted to our department because of one year lasting of an intermittent fashion bilateral L5 hyperalgesic lumbosciatica. The initial examination has shown back muscles contractures and a segmental deficit of the right lower limb in L5 and S1, but no genital or sphincter disorders were noted. The lumbosacral CT scan was without particularity but the magnetic resonance imaging (MRI) revealed an intradural, extra medullary lesion at the level of L1-L2. A monobloc resection of the lesion was done. The follow-up is good. Pathology concluded in schwannoma WHO grade I classification. Conclusion: Lumbar neurinoma that grows slowly is most often manifested by a radiculalgia often hyperalgesic and disabling. MRI is the examination of choice to make the diagnosis and complete removal is possible.

The Magnetic Resonance Image and Pathology of Spinal Cord Cavernous Hemangioma

Objective To investigate the characteristics of magnetic resonance image (MRI) of spinal cord cavernous hemangioma. Methods Six cases of spinal cord cavernous heman-gioma diagnosed by MRI and confirmed by pathology were reviewed. The characteristics of MRI were analyzed and correlated with pathological characteristics of spinal cord cavernous hemangioma. Results In 4 cases, the tumors were located in thoracic segment of the spinal cord and 2 in cervical cord. All lesions were solitary and the spinal cords were normal or a little thicker. The MRI showed that the images of focus were ball-like popcorn or mulberry with mixed signal,with short T2 signal around the focus. Under microscope, the hemangioma was composed of highly expanded blood sinusoids and its wall was thin and consisted of flat epithelial cells. There were some red blood cells in the cavity of the sinusoid and a little fibrous tissue in the diazoma between blood sinusoids. And also some fresh and old hemorrhages could be seen in the specimen. Conclusion MRI has high sensitivity and specificity in the diagnosis of spinal cavernous hemangioma.

Diagnosis and treatment of spinal primitive neuroectodermal tumor

Objective To sum up the clinical experience in diagnosis and treatment of spinal primitive neuroectodermal tumor(PNET). Methods Thirteen patients with spinal PNET were included in the study from 1999 to 2009.There were 8 males and 5

The role of intraoperative neurophysiological monitoring in intramedullary spinal cord tumor surgery

Intramedullary tumors are a class of central nervous system tumors with an incidence of 2 to 4%.As they are located very deep and frequently cause postoperative neurological complications,surgical resection is difficult.In recent years,many surgeons have performed electrophysiological monitoring to effectively reduce the occurrence of post-operative neurological complications.Modern electrophysiological monitoring technology has advanced considerably,leading to the development of many monitoring methods,such as SSEPs,MEPs,DCM,and EMG,to monitor intramedullary tumors.However,electrophysiological monitoring in tumor resection is still being studied.In this article,we discussed the different monitoring methods and their role in monitoring intramedullary tumors by reviewing previous studies.Intratumorally tumors need to be monitored for a summary of the condition of the patient.Only by using various monitoring methods flexibly and through clear communication between surgeons and neurophysiological experts can good decisions be made during surgery and positive surgical results be achieved.

Total Spondylectomy of C2 and Circumferential Reconstruction via Combined Anterior and Posterior Approach to Cervical Spine for Axis Tumor Surgery

As a result of the complex anatomy in upper cervical spine, the operative treatment of axis neoplasms is always complicated. Although the procedure for the second cervical vertebra （C2） surgery had been described previously in diverse approaches and reconstruction forms, each has its own limita- tions and restrictions that usually result in less satisfactory conclusions. The purpose of this study was to evaluate the operation efficacy for axis tumors by using a combined anterior （retropharyngeal） cervical and posterior approach in achieving total resection of C2 and circumferential reconstruction. Eight con- secutive C2 tumor patients with mean age of 47.6 years in our institute sequentially underwent vertebra resection and fixation through aforementioned approach from Jan. 2006 to Dec. 2010. No surgical mor- tality or severe morbidity occurred in our group. In terms of complications, 2 cases developed transient difficulty in swallowing liquids （one of them experienced dysphonia） and 1 developed cerebrospinal fluid leakage （CSFL） that was resolved later. During a mean follow-up period of 31.9 months, the visual analogue scale （VAS） and Japanese orthopedic association （JOA） score revealed that the pain level and neurological function in all patients were improved postoperatively, and there was no evidence of fixa- tion failure and local recurrence. It is concluded that the anterior cervical retropharyngeal approach permits a visible exposure to facilitate the C2 vertebra resection and perform an effective anterior re- construction at the same time. The custom-made mesh cage applied in our cases can be acted as a firm and convenient implant in circumferential fixation.

Leveraging nano-engineered mesenchymal stem cells for intramedullary spinal cord tumor treatment

Intramedullary spinal cord tumor(IMSCT)is comparatively rare malignant tumor in the central nervous system and is very difficult accessible by conventional chemotherapy regimen.Currently,there are very limited researches for IMSCT treatment using nanomedicine.To fill this gap,we originally reported a targeted strategy by leveraging nano-engineered mesenchymal stem cells(MSCs)for synergistic antiIMSCT treatment.In this study,two mode drugs paclitaxel(PTX)and metformin(MET)were co-loaded in maleimide-modified poly(lactic-co-glycolicacid)(PLGA-MAL)nanoparticles,which were further conjugated onto MSCs surface via the thioether bond formed between PLGA-MAL and MSCs without affecting the migration ability of MSCs.Owing to the excellent tumor tropism and penetrability of MSCs and good biodegradability of PLGA,the designed drug delivery platform could accurately target IMSCT sites to exert long-term synergistic antitumor efficacy,exhibiting promising research value for alternative IMSCT management beyond surgery.

Lumbar disc sequestration mimicking a tumor:Report of four cases and a literature review

BACKGROUND Disc herniation refers to the displacement of disc material beyond its anatomical space.Disc sequestration is defined as migration of the herniated disc fragment into the epidural space,completely separating it from the parent disc.The fragment can move in upward,inferior,and lateral directions,which often causes low back pain and discomfort,abnormal sensation,and movement of lower limbs.The free disc fragments detached from the parent disc often mimic spinal tumors.Tumor like lumbar disc herniation can cause clinical symptoms similar to spinal tumors,such as lumbar soreness,pain,numbness and weakness of lower limbs,radiation pain of lower limbs,etc.It is usually necessary to diagnose the disease according to the doctor’s clinical experience,and make preliminary diagnosis and differential diagnosis with the help of magnetic resonance imaging(MRI)and contrast-enhanced MRI.However,pathological examination is the gold standard that distinguishes tumoral from non-tumoral status.We report four cases of disc herniation mimicking a tumor,and all the pathological results were intervertebral disc tissue.CASE SUMMARY The first case was a 71-year-old man with low back pain accompanied by left lower extremity radiating pain for 1 year,with exacerbation over the last 2 wk.After admission,MRI revealed a circular T2-hypointense lesion in the spinal canal of the L4 vertebral segment,with enhancement on contrast-enhanced MRI suggesting neurilemmoma.The second case was a 74-year-old man with pain in both knees associated with movement limitation for 3 years,with exacerbation over the last 3 mo.MRI revealed an oval T2-hyperintense lesion in the spinal canal at the L4–5 level,with obvious peripheral enhancement on contrast-enhanced MRI.Thus,neurilemmoma was suspected.The third case was a 53-year-old man who presented with numbness and weakness of the lumbar spine and right lower extremity for 2 wk.MRI revealed a round T2-hyperintense lesion in the spinal canal at the L4–5 level,with obvious rim enhancement on contrast-enhanced MRI.Thus,a spinal tumor was suspected.The fourth case was a 75-year-old man with right lower extremity pain for 2 wk,with exacerbation over the last week.MRI revealed a round T1-isointense lesion in the spinal canal of the L3 vertebral segment and a T2-hyperintense signal from the lesion.There was no obvious enhancement on contrast-enhanced MRI,so a spinal tumor was suspected.All four patients underwent surgery and recovered to ASIA grade E on postoperative days 5,8,8,and 6,respectively.All patients had an uneventful postoperative course and fully recovered within 3 mo.CONCLUSION Disc herniation mimicking a tumor is a relatively rare clinical entity and can be easily misdiagnosed as a spinal tumor.Examinations and tests should be improved preoperatively.Patients should undergo comprehensive preoperative evaluations,and the lesions should be removed surgically and confirmed by pathological diagnosis.

Plexiform neurofibroma of the cauda equina with follow-up of 10 years:A case report

BACKGROUND Plexiform neurofibromas are extremely rarely found in the region of cauda equina and can pose a significant challenge in the diagnostic and management sense.To our knowledge,only 7 cases of cauda equina neurofibromatosis(CENF)have been reported up-to-date.CASE SUMMARY We describe a case of a 55-year-old man with a 10 years history of progressive lower extremities weakness and bladder dysfunction.Before presenting,patient was misdiagnosed with idiopathic polyneuropathy.Lumbar spine MRI revealed a tortuous tumorous masses in the cauda equina region,extending through the Th12-L4 vertebrae.The patient underwent Th12-L3 Laminectomy with duraplasty.During the operation,the most enlarged electroneurographically silent nerve root was resected,anticipating inadequate decompression if nerve root was spared.The patient’s neurological condition improved post-operatively,but urinary retention became the major complaint.We provide a follow-up period of 10 years.During this time,the patient’s condition progressively worsened despite extensive decompression.The consequent MRI scans showed progressive enlargement of cauda equina roots and increasing lumbar stenosis,predominantly affecting L3-L4 segment.During the follow-up 8 years after the operation,the patient complained of worsening lower extremities sensorimotor function and neurogenic claudication.Subsequent MRI revealed lumbar spine stenosis at the level of L3-L4,requiring further decompression.The patient underwent a second surgery involving L4-L5 Laminectomy with duraplasty and L2-L5 transpedicular fixation.The post-operative period was uneventful.Latest follow-up 18 mo after the second surgery revealed substantial improvement in patient’s well-being.CONCLUSION CENF should be kept in mind during the differential diagnostic work-up for polyneuropathies.Management with an extensive decompression,duraplasty and primary spinal fixation represents a rational approach to achieve a sustained symptomatic improvement and superior overall outcome.

Giant schwannoma of thoracic vertebra: A case report

BACKGROUND It is relatively rare for schwannomas to invade bone,but it is very rare for a large mass to form concurrently in the paravertebral region.Surgical resection is the only effective treatment.Because of the extensive tumor involvement and the many important surrounding structures,the tumor needs to be fully exposed.Most of the tumors are completely removed by posterior combined open-heart surgery to relieve spinal cord compression,restore the stability of the spine and maximize the recovery of nerve and spinal cord function.The main objective of this article is to present a schwannoma that had invaded the T5 and T6 vertebral bodies and formed a large paravertebral mass with simultaneous invasion of the spinal canal and compression of the spinal cord.CASE SUMMARY A 40-year-old female suffered from intermittent chest and back pain for 8 years.Computed tomography and magnetic resonance imaging scans showed a paravertebral tumor of approximately 86 mm×109 mm×116 mm,where the adjacent T5 and T6 vertebral bodies were invaded by the tumor,the right intervertebral foramen was enlarged,and the tumor had invaded the spinal canal to compress the thoracic medulla.The preoperative puncture biopsy diagnosed a benign schwannoma.Complete resection of the tumor was achieved by a two-step operation.In the first step,the thoracic surgeon adopted a lateral approach to separate the thoracic tumor from the lung.In the second step,a spine surgeon performed a posterior midline approach to dissect the tumor from the vertebral junction through removal of the tumor from the posterior side and further resection of the entire T5 and T6 vertebral bodies.The large bone defect was reconstructed with titanium mesh,and the posterior root arch was nail-fixed.Due to the large amount of intraoperative bleeding,we performed tumor angioembolization before surgery to reduce and avoid large intraoperative bleeding.The postoperative diagnosis of benign schwannoma was confirmed by histochemical examination.There was no sign of tumor recurrence or spinal instability during the 2-year follow-up.CONCLUSION Giant schwannoma is uncommon.In this case,a complete surgical resection of a giant thoracic nerve sheath tumor that invaded part of the vertebral body and compressed the spinal cord was safe and effective.