The objective of this video was to demonstrate technical nuances of intradural spinal meningioma (ISM) resection through a high-quality surgical video. The authors describe 3 patients with ISM in the cervicomedullary, cervical, and thoracic regions. Patients underwent surgery in the prone position with laminectomy, dorsal durotomy, and then resection of the mass. Case 1 required a suboccipital craniectomy and dissection of the tumor away from the vertebral artery. In case 2, special emphasis is placed on sectioning the dentate ligament with cord rotation. Case 3 highlights meticulous circumferential arachnoid release and the use of ultrasound. Patients saw significant neurological improvement postoperatively. This video provides clear instruction on location-specific technical nuances of ISM removal.

A 60-year-old male with renal cell carcinoma (RCC) presented with back pain, weakness, and bowel and bladder urgency. MRI demonstrated a cauda equina tumor at L2. Following L1-3 laminectomies, intraoperative ultrasound localized the tumor. After dural opening, a vascular tumor was adherent to the cauda equina. Intraoperative nerve stimulation helped to identify the nerve rootlets. Tumor was removed in a piecemeal fashion. Tumor dissection caused periodic spasms in L1-3 distributions. A neuromonitoring checklist was used to recover motor evoked potential signals with elevated mean arterial pressures. Hemostasis was challenging with the vascular tumor. Intraoperative ultrasound confirmed tumor debulking. Pathology confirmed metastatic RCC.

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OBJECTIVE: Spinal schwannomas (SS) and spinal meningiomas (SM) account for most intradural extramedullary (IDEM) tumors. These tumors are usually benign lesions, which generally respond favorably to surgical excision. Few studies up to now tried to determine the long-term outcome after minimally invasive surgery (MIS) with multimodal intraoperative neurophysiological monitoring (IONM) for IDEM tumors. The aim of this study was to present one of the largest case series with special regard to IONM findings and long-term outcome after MIS-keyhole surgery with a tubular retractor system.
METHODS: Between January 2013 and August 2018, 87 patients with IDEM tumors who underwent tumor removal surgery via MIS-keyhole approach under multimodal IONM were retrospectively reviewed. The neurological status was assessed using a modified McCormick grading scale pre- and postoperatively. Multimodal IONM consisted of motor evoked potentials (MEP), somatosensory evoked potentials (SEP), and electromyography (EMG). Both short-term and long-term clinical evaluations as well as patients\' medical files were retrospectively analyzed.
RESULTS: Surgeries were performed for resection of SS in 49 patients and SM in 38 patients. Tumor locations were cervical in 16.1%, thoracic in 48.3%, thoracolumbar in 4.6%, lumbar 31%. Critical IONM changes were detected in 9 operations (10.3%) in which there were 2 SEPs, 5 MEPs, and 2 EMG events. Three IONM changes (2 MEPs, 1 EMG) were turned out to be transient change in nature since they were resolved in a short time when immediate corrective actions were initiated. Six patients with permanent IONM changes (2SEPs, 3MEPs, 1EMG event), all deficits had resolved during hospitalization or on short -term follow-up evaluation. Sensitivity, specificity, and positive and negative predicted values of IONM were 100, 96, 67, and 100%, respectively. Gross total resection rate was 100%, and a stable or improved McCormick grade exhibited in all patients. No tumor recurrence and no spinal instability were found in the long-term follow-up evaluation (mean 5.2 ± 2.9 years postoperatively). Overall, 94% of patients were either satisfied or very satisfied with their operation, and 93% patients reported excellent or good general clinical outcome according to Odom\'s criteria.
CONCLUSIONS: MIS-keyhole surgery with multimodal IONM for IDEM tumors enables a high level of satisfaction and a satisfying long-term clinical and surgical outcome.

BACKGROUND: Primary spinal melanoma is extremely rare, accounting for ∼1% of all primary melanomas. Typically presenting insidiously in the thoracic spinal cord, primary spinal melanomas can have an acute presentation due to their propensity to hemorrhage.
METHODS: Despite its rarity, primary spinal melanoma should be included in the differential diagnosis when a hemorrhagic pattern of T1 and T2 intensities is seen on magnetic resonance imaging. Furthermore, the complete diagnosis is crucial because the prognosis of a primary spinal melanoma is considerably more favorable than that of a primary cutaneous melanoma with metastatic spread.
CONCLUSIONS: Resection is the treatment of choice, with some authors advocating for postoperative chemotherapy, immunotherapy, and/or radiation. We describe a case of acute quadriplegia from hemorrhagic primary spinal melanoma requiring resection.

In this case report, we present a unique cause of coccygodynia due to an intradural lumbar spinal tumour in a patient with multiple filum terminale paragangliomas. We highlight the symptomatology, the clinical course, and the radiological findings. Our review of the literature proved our case to be the first report of an intradural cauda equina tumour presenting with coccygodynia in English literature. Based on the outcome and clinical response to treatment we make a bold hypothesis on the possible anatomical mechanism of his coccygodynia.

Neuropathic pain presents a burdening and impairing condition which may occasionally occur after spinal tumor surgery. While it has been described in peripheral nerve sheath tumors, data on other intradural tumor patients is sparse. We hereby present a large cohort population undergoing different intradural spinal tumor surgery with assessment of early postoperative and follow-up outcomes, focusing on the occurrence of neuropathic pain. We performed a retrospective monocentric study including all patients treated for intradural spinal tumors between 2009 and 2020. We extracted surgical aspects as well as pre- and postoperative clinical courses from the records. Statistical analysis of potential contributing prognostic factors was performed including matched pair analysis. In total, 360 patients were included for analysis. At a median follow-up of 2 years, 26/360 patients complained of a neuropathic pain syndrome (7.2%) requiring continuous medication. Of these patients only 50% complained preoperatively of pain. Tumor entity did not significantly influence the incidence of postoperative neuropathic pain (p = 0.91). Sacrifice of the tumor carrying nerve root and tumor recurrence also did not increase the risk for this condition. Persistent neuropathic pain requiring continuous treatment occurred in 7.2% of patients undergoing intradural spinal surgery in our cohort. This frequently underestimated postoperative adverse event represents a disabling condition leading to a substantial impairment in the quality of life among the affected patients.

UNASSIGNED: Schwannomas of the cauda equina are rare intradural primary spinal tumors. Many of these patients initially present with cauda equina syndromes, and only 2.2% demonstrate clinical recurrence. Gross total excision is the procedure of choice.
UNASSIGNED: A 62-year-old female had undergone resection of a cauda equina schwannoma 5 years previously. She newly presented with cauda equina symptoms attributed to a recurrent schwannoma. Following gross total secondary tumor resection, the patient\'s preoperative deficits fully resolved, and the tumor never recurred.
UNASSIGNED: Secondary gross total excision of schwannomas of the cauda equina is critical to avoid further tumor recurrence.

Extensive multifocal intradural lesions in children present a formidable challenge. This surgical video illustrates our management of a 14-yr=old boy with two intradural mass lesions on magnetic resonance imaging (MRI): one at T2-5 and the other from T12 through the sacral cul-de-sac. In a single procedure, we performed a T2-5 laminectomy and laminoplasty and T12-sacrum laminectomy for tumor resection. For reconstruction, we performed complete laminoplasty at all levels with supplementation at the thoracolumbar junction via T11-L2 posterior spinal fixation and allograft placement for fusion. In this video, we illustrate the microsurgical challenges of intradural tumor resection in both the thoracic cord and amidst the cauda equina. In young patients, prevention of postsurgical spinal deformity is of paramount concern. We discuss considerations for long-segment spinal stabilization in an adolescent and describe our decision-making to perform stabilization at the thoracolumbar junction to supplement laminoplasty while preserving function. The patient and their family consented to the procedure.  Image of the article at 0:51 is from McGirt et al, Short-term progressive spinal deformity following laminoplasty versus laminectomy for resection of intradural spinal tumors: analysis of 239 patients, Neurosurgery, 2010, 66(5), 1005-1012, by permission of the Congress of Neurological Surgeons.

Lumbosacral Tarlov cysts (TCs) have rarely been seen to rupture. Here, we report an unusual presentation of a ruptured TC with intraspinal hemorrhage mimicking carcinomatosis. Pathological diagnosis was obtained using percutaneous biopsy. A conservative approach was utilized and an excellent outcome was achieved. Thus, in cases such as this, a ruptured hemorrhagic TC should be on the differential diagnosis to drive appropriate clinical management decisions.