Paraplegia due to intradural cement leakage after vertebroplasty: a case report and literature review

Background Vertebroplasty (VP) is considered an alternative therapy in an osteoporotic compression fracture that failed conservative treatment. However, cement leakage into the intradural space can cause catastrophic complications. To the best of our knowledge, intradural cement leakage following VP has been reported only in 7 cases. We report here a case of intradural cement leakage following VP with a literature review. Case presentation An 84-year-old female with an L1 osteoporotic fracture underwent percutaneous VP at a local hospital. Immediately after the procedure, she complained of weakness, numbness, and pain in both legs, and her back pain aggravated. She was transferred to our hospital. The initial muscle power was grade 2 for the right leg and grade 4 for the left leg. Computed tomography (CT) scan showed intradural cement leakage from T10 to L2. Magnetic resonance imaging showed an intradural mass lesion. Although we performed total laminectomy with durotomy and removed intradural cement completely, the neurological deficit did not completely recover. The muscle power was grade 3 for the right leg and grade 4 for the left leg at the last follow-up. Conlcusions If a neurological deficit is found after VP, a CT scan should be taken to confirm the pattern of cement leakage. In case of intradural cement leakage, surgical decompression should be recommended to improve neurological deficit. To prevent intradural cement leakage during the VP, the needle tip should not perforate the medial wall of the pedicle with appropriate viscosity of cement.

The anterior incisural width as a preoperative indicator for intradural space evaluation: An anatomical investigation

Background: The opticocarotid triangle (OCT) and the carotico-oculomotor triangle (COT) are two anatomical triangles used in accessing the interpeduncular region. Our objective is to evaluate if the anterior incisural width (AIW) is an indicator to predict the intraoperative exposure through both triangles. Methods: Twenty sides of 10 cadaveric heads were dissected and analyzed. The heads were divided into the following: Group A – narrow anterior incisura and Group B – wide anterior incisura – using 26.6 mm as a cutoff distance of the AIW. Subsequently, the area of the COT and the OCT in the transsylvian approach was measured, along with the maximum widths through the two trajectories in modified superior transcavernous approach. Results: The COT in the wide group was shown to have a significantly larger area compared with the COT in the narrow group (38.4 ± 12.64 vs. 58.3 ± 15.72 mm, P < 0.01). No difference between the two groups was reported in terms of the area of the OCT (50.9 ± 19.22 mm vs. 63.5 ± 15.53 mm, P = 0.20), the maximum width of the OCT (6.6 ± 1.89 vs. 6.5 ± 1.38 mm, P = 1.00), or the maximum width of the COT (11.7 ± 2.06 vs. 12.2 ± 2.32 mm, P = 0.50). Clinical cases were included. Conclusion: An AIW <26.6 mm is an unfavorable factor related to a limited COT area in a transsylvian approach for pathologies at the interpeduncular fossa. Preoperative identification and measurement of a narrow AIW can suggest the need to add a transcavernous approach.

Intradural Disc Extrusion in a Dog

Background: Intervertebral disc extrusion is an important cause of spinal cord dysfunction in dogs. Intradural localization of the extruded disc material is rare, and is generally associated with a traumatic event or with recurrence of disc extrusion at a previously affected site. We report the clinical presentation, diagnostic workup, and treatment of a dog with intradural intervertebral disc extrusion not preceded by a traumatic event.Case: A 6-year-old male Dachshund was referred for neurological evaluation due to acute onset of hind-end paralysis preceded by claudication of the left hindlimb. The patient had been receiving conservative treatment to no effect. Neurological examination revealed asymmetric non-ambulatory paraparesis, absence of postural reactions and decreased muscle tone in both hindlimbs, a bilaterally diminished patellar reflex, and a hindlimb withdrawal reflex which was normal on the right and greatly diminished to absent on the left. The lower back was tender to epaxial palpation. Plain radiographs of the lumbar spine in the lateral projection showed calcified material within the spinal canal between the third and fourth lumbar vertebrae. Myelography was suggestively abnormal at the same level, with epidural leakage of contrast at L3-L4. Considering the clinical history, breed, age, neurological signs, and radiographic findings, intervertebral disc disease was suspected despite the inconclusive myelography findings. A dorsolateral lumbar hemilaminectomy was performed. Intraoperatively, the diagnosis was confirmed by visualization of a discolored spinal cord and absence of extradural material. The intradural space was accessed via durotomy. A firm, straw-yellow material was seen compressing the spinal cord and removed. Subsequent histopathological examination confirmed that this material consisted of extruded intervertebral disc contents. Postoperatively, the patient underwent physiotherapy and achieved a satisfactory recovery.Discussion: The most common cause of paraparesis in chondrodystrophic dog breeds is intervertebral disc extrusion. Intradural extrusion of the intervertebral disc is a rare phenomenon, often associated with vigorous exercise that causes laceration of the dura mater, allowing penetration of disc material into the intradural space. Although there were no classic signs of intervertebral disc disease on plain radiography, radiopaque material was visible within the spinal canal, which can occur in cases of calcified intervertebral disc extrusion. Myelography was inconclusive, but the decision was made to operate nevertheless, considering that the patient had not responded to conservative treatment and that surgicaltreatment is the most suitable approach for dogs with non-ambulatory paraparesis or paraplegia secondary to intervertebral disc extrusion. The surgical technique consisted of a hemilaminectomy and durotomy. Our diagnostic suspicion was confirmed intraoperatively, as in most cases of intradural disc extrusion in humans. Intradural disc extrusion is anuncommon phenomenon in dogs, and the diagnosis is usually only established intraoperatively. This unusual variant of intravertebral disc disease should be included in the differential diagnosis of spinal cord dysfunction in chondrodystrophic breeds, even in the absence of a history of trauma or preexisting intervertebral disc disease. Clinical treatment appears ineffective in these cases. Conversely, surgical treatment can yield good outcomes, and even functional recovery.

Imaging and pathological findings of intramedullary inflammatory pseudotumour in a miniature dachshund: a case report

Background Inflammatory pseudotumours (IPTs) are distinctive lesions consisting of myofibroblastic spindle cells and a variety of inflammatory cells. The aetiology of IPTs is unknown. Reports of IPTs in veterinary medicine have been scarse. Moreover, only one case of intradural extramedullary IPT has been previously reported. In this report, we introduce the first known case of canine IPT, which occurred in the parenchyma of the spinal cord. Case presentation A 10-year-old female Miniature Dachshund presented with a 2-month-long history of progressively worsening ataxia and tetraparesis. Neurological examination was consistent with a lesion involving the cervical spinal cord. Magnetic resonance imaging revealed an intradural space-occupying lesion in the region of the fourth cervical vertebra. Dorsal laminectomy and resection of the mass were performed. Histopathological examination revealed the proliferation of immature spindle cells (fibroblasts/myofibroblasts and glial cells) and a highly cellular mixture of neutrophils, macrophages and lymphocytic cells. The mass was located in the parenchyma of the spinal cord and was diagnosed as an IPT occurring in the parenchyma of the spinal cord. No causative pathogen was detected. The dog’s symptoms improved, during the first month after surgery. However, neurological symptoms, such as laboured breathing and dysuria, subsequently worsened and the dog died 42 days after surgery. Conclusions The present study describes a canine case of IPT occurring in the parenchyma of the spinal cord. The diagnosis and determination of the site of the mass was difficult solely based on preoperative imaging in the present case. The outcome of this case was poorer than that observed in cases of canine extramedullary IPT and human intramedullary IPT, in which the patients exhibited recovery. The prognosis after surgical resection cannot be decided from the present case alone. However, patients should be monitored for potential serious complications and recurrence.

Dural and Leptomeningeal Spine Metastases of Breast Cancer

We present a case of a 57-year-old female diagnosed with invasive ductal breast cancer, which was treated and in remission for 12 years. In 2018 she presented a progressive dorsal back pain, which prevented her from performing basic tasks. An MR study was performed and revealed the presence of an extramedullary metastatic sleeve located in the thoracic intradural space. Concomitant multiple small nodular foci were adhering diffusely to the spinal cord, compatible with leptomeningeal metastatic disease. The occurrence of both forms of spread in the spine is uncommon, and its distinction on imaging is of particular importance taking into account the differences in treatment approach and prognosis.

Spinal Canal Involvement in Solitary Infantile Myofibromatosis: Case Report

Infantile myofibromatosis involving the spinal canal is very rare; only 11 cases have been reported so far in the literature. The authors present a case of an 18-month-old male child who presented with the history of dribbling of urine and weakness in bilateral lower limbs since 2 months. MRI of spine revealed single intramedullary intradural space-occupying lesion (SOL) at D1 to D2.The patient underwent laminectomy with excision of SOL with biopsy report suggestive of benign nerve sheath tumor, and immunohistochemistry report revealed desmin negative, smooth muscle actin positive, and S-100 focally positive infantile myofibromatosis. The patient gradually recovered and had a clear stream of urine with improved movements and tone of bilateral lower limbs at the time of discharge.

Intradural Intramedullary Primary Spinal Melanocytoma: A Rare Case Report

Spinal melanocytomas are rare pigmented tumors of the central nervous system commonly affecting females in their fifth decades. It has been reported in various locations with intradural intramedullary being the rarest. Patients can present with varied symptomatology from mild backache to frank myelopathy. Here we report a case of 34-year-old man with no medical comorbidities with vague backache associated with numbness of anterior aspect of right thigh for 1 year aggravated by activities and relieved by rest. His neurologic examination revealed normal power and sensation in both lower limbs except for decreased temperature sensation in right L2 dermatome. MRI of dorsolumbar spine revealed a well-defined lesion that was hyperintense in T1- and hypointense in T2-weighted image at D11–12 region with uniform bright enhancement in gadolinium-enhanced T1 image. The patient underwent laminectomy of D11 and D12, and an en bloc excision was done. Diagnosis of primary intradural intramedullary melanocytoma was made from histopathologic examination. Spinal melanocytomas should be considered as a differential diagnosis for intradural space-occupying lesions. MRI remains the investigation of choice for diagnosis, but histopathologic examination is required to confirm and differentiate from other pigmented tumors and malignant melanomas. Total surgical excision of the tumor remains the standard treatment with radiotherapy reserved for cases of incomplete excision and recurrences.

Discrete or diffuse intramedullary tumor? Contrast-enhanced intraoperative ultrasound in a case of intramedullary cervicothoracic hemangioblastomas mimicking a diffuse infiltrative glioma: technical note and case report

Hemangioblastomas are benign, highly vascularized intramedullary lesions that may also extend into the intradural space. Surgery represents the standard therapy, with the goal of obtaining complete resection even at the risk of neurological morbidity. MRI is the gold standard for diagnosis and assessment of intramedullary tumors. Nevertheless, sometimes MRI may not accurately differentiate between different types of intramedullary tumors, in particular if they are associated with syringes or intra- and peritumoral cysts. This could subsequently affect surgical strategies. Intraoperative ultrasound (ioUS) has become in the last few years a very useful tool for use during neurosurgical procedures. Various ioUS modalities such as B-mode and Doppler have been applied during neurosurgical procedures. On the other hand, the use of contrast-enhanced ultrasound (CEUS) is not yet well defined and standardized in this field. We report a case of a young patient harboring a cervicothoracic intramedullary tumor, for which the preoperative neuroradiologi-cal diagnosis was in favor of a diffuse astrocytoma with nodular components whereas ioUS demonstrated 3 distinct intramedullary nodules. CEUS showed highly vascularized lesions, compatible with hemangioblastomas. These findings, particularly those obtained with CEUS, allowed better definition of the lesions for diagnosis, enhanced understanding of the physiopathological aspects, and permitted the localization of all 3 nodules, thus limiting spinal cord manipulation and allowing complete resection of the lesions, with an uneventful postoperative neurological course. To the best of our knowledge, this is the first report of the use of intraoperative CEUS in a case of intramedullary hemangioblastoma.