OBJECTIVE: Obtaining timely postoperative radiotherapy (RT) following separation surgery is critical to avoid local recurrence of disease yet can be a challenge due to scheduling conflicts, insurance denials, and travel arrangements. In patients undergoing metastatic spine surgery for spinal cord compression, the authors sought to: 1) report the rate of postoperative RT, 2) describe reasons for patients not receiving postoperative RT, and 3) investigate factors that may predict whether a patient receives postoperative RT.
METHODS: A single-center retrospective case series was undertaken of all patients who underwent metastatic spine surgery for extradural disease between January 2010 and January 2021. Inclusion criteria were patients with intermediate or radioresistant tumors with evidence of spinal cord compression who underwent surgery. The primary outcome was the occurrence of RT within 3 months following surgery. Multivariable logistic regression analysis was performed controlling for age, BMI, race, total number of decompressed levels, tumor size, other organ metastasis, and preoperative RT or chemotherapy to predict patients receiving postoperative RT.
UNASSIGNED: Of 239 patients undergoing spine surgery for metastatic disease, 113 (47.3%) received postoperative RT while 126 (52.7%) did not. In the postoperative RT group, 24 (21.2%) received stereotactic body radiation therapy while 89 (78.8%) received conventional external-beam radiation therapy. The most common reasons for patients not receiving postoperative RT included death or transfer to hospice (31.0%), RT not being recommended by radiation oncology (30.2%), and loss to follow-up (23.8%). On critical review with the radiation oncology department, the authors estimated that 101 of 126 (80.2%) patients who did not receive postoperative RT were potential candidates for postoperative RT. Patients who received postoperative RT had more documented inpatient (48.7% vs 32.5%, p < 0.001) and outpatient (100.0% vs 65.1%, p < 0.001) radiation oncology consultations than those who did not. Additionally, patients who received postoperative RT had a higher rate of postoperative chemotherapy (53.1% vs 25.4%, p < 0.001), while patients who did not receive postoperative RT had a higher rate of preoperative RT (7.1% vs 31.0%, p < 0.001). Multivariable analysis confirmed that patients who received preoperative RT had lower odds of undergoing postoperative RT (OR 0.14, 95% CI 0.06-0.34; p < 0.001), and patients who underwent postoperative chemotherapy had higher odds of undergoing postoperative RT (OR 3.83, 95% CI 2.05-7.17; p < 0.001).
CONCLUSIONS: In the current study reflecting real-world care of patients with metastatic spine disease after undergoing separation surgery, 47% of patients did not receive postoperative RT, and 80% of those patients were potential candidates for postoperative RT. Radiation oncology consultation and postoperative chemotherapy were significantly associated with receiving postoperative RT, whereas preoperative RT was significantly associated with not receiving postoperative RT. The lack of timely postoperative RT highlights a potential gap in metastatic spine tumor care and underscores the necessity for prompt radiation oncology consultation and effective planning.

OBJECTIVE: In patients undergoing metastatic spine surgery, we sought to 1) report time to postoperative radiation therapy (RT), 2) describe the predictive factors of time to postoperative RT, and 3) determine if earlier postoperative RT is associated with improved local recurrence (LR) and overall survival (OS).
METHODS: A single-center retrospective cohort study was undertaken of all patients undergoing spine surgery for extradural metastatic disease and receiving RT within 3 months postoperatively between January 2010 and January 2021. Time to postoperative RT was dichotomized at <1 month versus 1-3 months. The primary outcomes were LR, OS, and 1-year survival. Secondary outcomes were wound complication, Karnofsky Performance Status, and modified McCormick Scale (MMS) score. Regression analyses controlled for age, body mass index, tumor size, preoperative RT, preoperative/postoperative chemotherapy, and type of RT.
RESULTS: Of 76 patients undergoing spinal metastasis surgery and receiving postoperative RT within 3 months, 34 (44.7%) received RT within 1 month and 42 (55.2%) within 1-3 months. Patients with larger tumor size (β = -3.58; 95% confidence interval [CI], -6.59 to -0.57; P = 0.021) or new neurologic deficits (β = -16.21; 95% CI, -32.21 to -0.210; P = 0.047) had a shorter time to RT. No significant association was found between time to RT and LR or OS on multivariable logistic/Cox regression. However, patients who received RT between 1 and 3 months had a lower odds of 1-year survival compared with those receiving RT within 1 month (odds ratio, 0.18; 95% CI, 0.04-0.74; P = 0.022). Receiving RT within 1 month versus 1-3 months was not associated with wound complications (7.1% vs. 2.9%; P = 0.556) (odds ratio, 4.40; 95% CI, 0.40-118.0; P = 0.266) or Karnofsky Performance Status/modified McCormick Scale score.
CONCLUSIONS: Spine surgeons, oncologists, and radiation oncologists should make every effort to start RT within 1 month to improve 1-year survival after metastatic spine tumor surgery.

Primary ectopic extradural and extraspinal meningiomas are rare. We present a unique case of this type of meningioma in the brachial plexus. A 25-year-old man consulted us because of neuropathic supraclavicular pain and the appearance of a supraclavicular mass whose volume had increased. Clinical examination found paresis of the deltoid, biceps brachii and brachialis muscles rated as M4 (MRC) and a strong Tinel sign at the supraclavicular fossa, over the palpable mass. There was no sign pointing towards central nervous system involvement or altered general condition. MRI revealed a mass measuring 53 × 24 mm invading the C5-C6 plexus roots and the primary upper trunk, but not the bone or spinal area. This lesion was hyperintense on DWI/ADC, hyperintense on T2 with hypointense spots, and hypointense on T1 with intense heterogeneous gadolinium enhancement. Excisional biopsy was done 6 months after symptoms started. The tumor had developed at the C5 root, which was fibrous and at the C6 root, which was grossly normal. Anatomical pathology confirmed the WHO grade 1 meningioma, meningothelial and psammomatous histological subtypes. At 6 months, a follow-up MRI found no postoperative tumor remnants or recurrence. During the postoperative course, persistent paralysis of the deltoid muscle at 5 months justified a nerve transfer. This is a rare case of ectopic extraspinal and extradural meningioma of the brachial plexus. The diagnosis of an ectopic meningioma must be considered when a patient presents with a brachial plexus tumor causing neurological deficits. The extradural nature is not sufficient to rule out this diagnosis.

BACKGROUND: Chondrosarcoma is an uncommon spinal tumor that can present as an extraskeletal mass. Rarely, these tumors present as dumbbell tumors through the neural foramina, mimicking schwannomas or neurofibromas.
METHODS: A 46-year-old female presented with 2 years of worsening right-arm radiculopathy. Magnetic resonance imaging of the thoracic spine revealed a peripherally enhancing extramedullary mass through the right T1 foramen and compressing the spinal cord. Computed tomography showed the mass to be partially calcified. She underwent C7-T2 laminectomy and C6-T3 posterior instrumented fusion with gross-total resection of an extradural mass. Pathology revealed a grade I chondrosarcoma. Her symptoms improved postoperatively, with some residual right-arm radicular pain.
CONCLUSIONS: Intraspinal extradural dumbbell conventional chondrosarcoma is rare, with only 9 cases, including ours, reported. Patient ages range from 16 to 72 years old, and male sex is more common in these cases. The most common location is the thoracic spine, and our case is the only reported one in the cervicothoracic junction. These tumors often mimic schwannomas on imaging, but chondrosarcoma should remain in the differential diagnosis, because management of these tumors differs. Chondrosarcoma may benefit from more aggressive resection, including en bloc resection, and may require adjuvant radiotherapy.

Spinal teratomas are infrequent lesions in the pediatric population. These lesions can be extradural, intradural or intramedullary. We present a case of an 8-month-old boy that was assessed for underdevelopment of motor milestones. The neurologic examination revealed hyporeflexia, decreased sensation and flaccid paraplegia. MRI of the spine revealed two simultaneous and independent lesions in the extradural and intradural compartment. A laminectomy was performed for the T4-T7 vertebrae with total resection of both lesions. The histopathological analysis confirmed both lesions to be mature cystic teratomas. At the 1-year follow-up, the patient remained with no recovery of neurological function. A debate takes place regarding the etiology of formation of these lesions in the spine. The simultaneous presentation of two independent lesions in this patient could contribute to define the flawed migration of germ cells theory as the etiology for formation of teratomatous lesions in the spine.

The aim of this study was to compare the intra and postoperative analgesic effects of sacrococcygeal epidural levobupivacaine with those of lumbosacral levobupivacaine in feline ovariohysterectomy. Thirty-six cats were premedicated with intramuscular acepromazine (0.05 mg/kg) and meperidine (6 mg/kg). Anesthesia was induced with intravenous propofol and maintained with isoflurane in oxygen. The cats were randomly assigned one of the three treatments receiving 0.33% levobupivacaine (0.3 mL/kg) into the sacrococcygeal (S-C group, n=12) or lumbosacral (L-S group, n=12) epidural space, or the same volume of 0.9% saline solution into one of the epidural approaches (Control group, n=12). Intraoperatively, cardiorespiratory variables, end-tidal isoflurane concentration (FE´ISO), and fentanyl requirements were recorded. Postoperative pain was assessed by the UNESP (Universidade Estadual Paulista)-Botucatu multidimensional composite pain scale and the Glasgow feline composite measure pain scale up to 8 hr post-extubation. Morphine was administered as rescue analgesia. Overall FE´ISO and fentanyl requirements were lower in the L-S and S-C compared to the Control (P=0.002-0.048, respectively). There was no significant difference in the cardiorespiratory variables during anesthesia, postoperative pain and rescue analgesia among groups. The time to standing after anesthesia was prolonged in the L-S and S-C groups than in the Control (P<0.001). Lumbosacral and sacrococcygeal epidural levobupivacaine resulted in similar decreases in isoflurane requirements and intraoperative fentanyl supplementation in the cats, with no postoperative benefits.

BACKGROUND: Spinal dural arteriovenous fistula is the most common spinal vascular malformation. It usually presents with neurological deficits due to venous congestive myelopathy. Sometimes, however, the symptoms are radicular and can imitate those of a disc hernia or synovial cyst.
METHODS: In this illustrated case, a 34-year-old male patient presented with radicular pain due to nerve root compression. In the magnetic resonance imaging (MRI) examination of the spine, a synovial cyst was suspected, so the patient underwent no further examination before surgery. Intraoperatively, the authors were surprised to see a vascular malformation, which was shown to be an extradural arteriovenous fistula according to the histopathological examination.
CONCLUSIONS: In atypical MRI findings of the spine, vascular malformations should be considered. In cases with a spinal dural arteriovenous fistula, the thrombosis risk can be high and lead to a need for prolonged anticoagulation.

Spinal Ewing\'s Sarcoma is a rare tumour predominantly affecting children and adolescents. We describe the case of an 18-year-old male patient who first presented with a primary extradural cervical Ewing\'s sarcoma tumour, and 5 years later had a recurrence with thoracolumbar and lumbosacral intradural extramedullary Ewing\'s sarcoma tumours. Both presentations were successfully treated by surgical resection and adjuvant chemo- and radiotherapy, and he remains disease-free at 12 months follow-up. This is the first reported case of seeding of tumour from an extradural primary Ewing\'s sarcoma to intradural metastases. Total surgical resection of his initial cervical tumour, performed at another centre, was complicated by a dural tear and CSF leak. Thus, we propose that isolated drop metastasis via CSF fistula is the most likely mechanism for tumour spread in this case. Thus, clinicians may wish to counsel patients on the possibility of such spread if a CSF leak is encountered, and potentially increase the frequency of imaging surveillance of the whole spine in this context.

Iatrogenic extradural pneumorrhachis is a rare clinical entity, but anesthesiologists should be aware of this possibility when using the air technique for the identification of epidural space. Although in most published cases extradural pneumorrhachis is asymptomatic, relevant neurological consequences have been described, such as meningeal irritation, radicular pain, unilateral lower extremity weakness, cauda equina syndrome, paraplegia, and tetraplegia.We describe a very extensive extradural pneumorrachis (T9-S1), related to obstetric analgesia, in a patient with severe and atypical perineal pain after forceps-assisted delivery. Our aim is to synthesize and organize the available scientific evidence, analyzing preventive measures and summarizing the most appropriate diagnostic, follow-up and therapeutic techniques for symptomatic conditions, among which high concentrations of inspired oxygen, hyperbaric oxygen therapy and percutaneous or surgical decompression have been described.

Malignant spinal tumors constitute around 22% of all primary spinal tumors. The most common location of metastases to the spinal region is the extradural compartment. The molecular and genetic characterization of these tumors was the basis for the updated WHO classification of CNS tumors in 2016, where many CNS tumors are now diagnosed according to their genetic profile rather than relying solely on the histopathological appearance. Magnetic resonance imaging (MRI) is the current gold standard for the initial evaluation and subsequent follow-up on intradural spinal cord tumors, and the imaging sequences must include T2-weighted images (WI), short time inversion recovery (STIR), and pre- and post-contrast T1-WI in the axial, sagittal, and coronal planes. The clinical presentation is highly variable and depends on the tumor size, growth rate, type, infiltrative, necrotic and hemorrhagic potential as well as the exact location within the spinal compartment. Surgical intervention remains the mainstay of management of symptomatic and radiographically enlarging spinal tumors, where the goal is to achieve maximal safe resection. Tumor recurrences are managed with repeat surgical resection (preferred whenever possible and safe), radiotherapy, chemotherapy, or any combination of these therapies.