Concomitant combined degenerative compression of the spinal cord and cauda Equina: A report on three cases

We report on three cases with concomitant combined degenerative compression of the spinal cord and cauda equina which were diagnosed and operated in a single stage. The first case presents left-sided paramedian disc herniations at L1-2 and L4-5 levels, combined with concurrent degenerative spinal stenosis. The second case includes right-sided paramedian disc herniation at Th12-L1 level in combination with severe degenerative lumbar spinal stenosis at L3-4 level. The third case describes advanced degenerative compression at Th7-8 level with concurrent central spinal stenosis at L4-5 level.We have discussed the clinical presentation of concurrent combined symptomatic degenerative compression of the spinal cord and cauda equinа which can deceive the physician and lead to omitted diagnosis of the thoracic compression.In an attempt to avoid misdiagnosis of thoracic degenerative compression, it is necessary to perform thorough neurological examination of the spinal cord motor and sensory functions. In addition, further MRI examination of upper spinal segments is needed, if previous studies of the lumbar spine fail to provide reasonable explanation for the existing neurological symptoms

Myelomeningocele with Associated Anomalies – Case Report and Literature Review

Myelomeningocele is a common defect of the development of the neural tube. It is a complex congenital malformation of the central nervous system (CNS) that can be associated with other concurrent anomalies. We report on a case of lumbar myelomeningocele with concomitant CNS malformations we followed up over a period of 15 years. A concise literature review has also been performed. The current report illustrates that the myelomeningocele is a complex anomaly that is commonly associated with a variety of other CNS malformations such as hydrocephalus and Chiari malformation. It may follow chronic progressive course with exacerbation of clinical symptoms in the long term. Patients that have undergone surgical correction of this spinal defect should be closely monitored over a long period of time because of the possibility of clinical deterioration of the concomitant anomalies such as hydrocephalus, Chiari malformation and siryngomyelia

Clinical Aspects of Spinal Meningiomas: a Review

Spinal meningiomas are found in all age groups, predominantly in women aged over 50 years. The clinical symptoms of this condition may range from mild to significant neurological deficit, varying widely depending on the location, position in relation to the spinal cord, size and histological type of the tumor. Magnetic resonance imaging is the diagnostic tool of choice because it shows the location, size, the axial position of the tumor, and the presence of concomitant conditions such as spinal malformations, edema or syringomyelia.  According to the degree of malignancy, the World Health Organization divides meningiomas into three grades: grade I - benign; grade II – atypical, and grade III - malignant. The goal of the surgery is total resection which is achievable in 82%–98% of cases. Advances in radiosurgery have led to its increased use as primary or adjunct therapy. The current paper aims to review the fundamental clinical as-pects of spinal meningiomas such as their epidemiology, clinical presentation, histological characteristics, diagnostics, and management

Sacral nerve root metastasis in a patient with lung carcinoma resembling neurinoma – a case report and literature review

Intradural extramedullary metastases from systemic neoplasms are very rare, with an incidence ranging from 2% to 5% of all secondary spinal diseases. We present the case of a 53-year-old man diagnosed with lung adenocarcinoma with symptoms of severe back pain and tibial paresis. The magnetic resonance imaging (MRI) revealed an intradural lesion originating from the right S1 nerve root mimicking neurinoma. Total tumor removal was achieved via posterior midline approach. The histological examination was consistent with lung carcinoma metastasis. Due to the rarity of single nodular nerve root metastases, MRI images may be misinterpreted as nerve sheath tumors, such as schwannomas or neurofibromas. We performed a brief literature review outlining the mainstay of diagnosis, therapeutic approach, and the prognosis of these rare lesions

Outcome of Surgical Treatment of Spontaneous Spinal Epidural Abscesses for a 10-year Period

Introduction: Spinal epidural abscess is uncommon but potentially debilitating infection. Delay in early diagnosis may be associated with increased morbidity and mortality despite recent advances in medicine.Aim: To present the clinical course and outcome of treatment of spontaneous spinal epidural abscesses.Materials and methods: Thirty-four patients (20 men and 14 women) with clinical, neuroimaging and/or histological data for spinal epidural abscess were treated at the Clinic of Neurosurgery at St George University Hospital, Plovdiv, Bulgaria, for the period 2009-2018.Results: The average age of patients was 62 years (21-76 years) and the ratio of men to women was 1.4:1. All patients (100%) presented with vertebralgia, 13 patients (38.2%) had additional radiculalgia, and 10 patients (29.4%) presented with sensory or motor deficit. The duration of complaints varied from 4 to 180 days. At hospital admission, only 9 patients (26.4%) had intact neurological status. The most common localization of the spinal epidural abscess was in the lumbar and lumbosacral area (52.9%), concomitant spondylodiscitis was present in 31 patients (91.2%). Twenty-four patients (70.6%) underwent emergency surgery within 24 hours, and the rest had planned surgery. Decompressive interlaminotomy or hemilaminectomy was performed in 9 patients (26.5%). The remaining 25 patients (73.5%) underwent laminectomy, in 15 patients (44.1%) it was combined with posterior pedicle screw fixation. After the treatment, 23 patients (67.6%) had a good outcome, the remaining 11 (32.4%) had a poor outcome, and 3 patients died (8.8%).Conclusion: In patients with spinal epidural abscess, emergency surgery is the treatment method of choice. It allows decompression of neural structures, correction of the spinal deformity, segmental stabilization and rapid mobilization of patients

Sporadic spinal schwannomas and neurofibromas - a review

Tumours arising from the spinal nerve roots are more common in men between the third and fourth decades of life, located mainly in the intradural space of the lumbar region. The clinical symptoms of spinal schwannomas and neurofibromas are similar and depend on the location of the tumour and its relationship to the spinal cord and nerve roots. The pain (radiculalgia and/or vertebralgia) is the earliest symptom, followed by sensory deficit, while motor deficits and sphincter disorders are late symptoms. Magnetic resonance imaging is the diagnostic tool of choice and should be performed when the disease is suspected, as early and accurate diagnosis is essential for treatment outcome. The treatment of these lesions is surgical aiming at total tumour resection that promotes neurological recovery and prevents from recurrences. Subtotal removal also provides favourable outcome but at higher recurrence rates. The aim of this literature review was to study some important characteristics of sporadic spinal schwannomas (SSS) and neurofibromas (SSN), i.e. those notassociated with neurofibromatosis type I and II

Contemporary insight into diffuse axonal injury

Diffuse axonal injury (DAI) is present in approximately 50% of the cases with severe traumatic brain injury. It is one of the leading causes of morbidity and mortality among children and young individuals worldwide. Generally, DAI occurs as a result of high-velocity accidents. Typically, it presents with loss of consciousness for at least 6 hours and neurological deficit dependent on the brain area that is affected by the injury. The final diagnosis is confirmed by neuroimaging studies such as computed tomography and magnetic resonance imaging. According to the injured brain site, DAI is classified into three grades: Grade I–DAI with axonal lesions in the cerebral hemispheres; Grade II–DAI with focal axonal lesions in the corpus callosum; Grade III–DAI with focal or multiple axonal lesions in the brainstem. Each of the three grades is associated with different outcome.Due to the high disability and mortality rate, DAI represents an important medical, personal and social problem. The aim of the current review is to address the unsolved issues connected with the pathogenesis, diagnostics, treatment and outcome of the diffuse axonal injury

Short-term outcome of treatment of elderly patients with epidural hematomas

Introduction: There is substantial literature data dedicated to intracranial epidural hematomas affecting young and middle-aged individuals, but studies focusing on their characteristics in elderly patients are scarce, assuming that old age is a poor prognostic factor. Aim: The aim of the current study was to review the typical features of the etiology, clinical presentation, disease course, and outcome in a series of cases with epidural hematomas in elderly patients. Materials and methods: The etiology, clinical presentation, neuroimaging findings, treatment, and outcome in elderly patients operated for traumatic epidural hematomas were investigated in the Clinic of Neurosurgery at St George University Hospital, Plovdiv between January 2015 and December 2020. The study included patients with isolated traumatic epidural hematoma, as well as those with epidural hematoma in combination with other traumatic intracranial lesions (cerebral contusion, subarachnoid hemorrhage, subdural and intracerebral hematoma). Postoperative epidural hematomas were not included in the study. The neurological status of patients at admission was assessed using the Glasgow Coma Scale. The Glasgow Outcome Scale was used to monitor their condition during the first month after discharge. Results: 121 patients with epidural hematomas underwent surgery during the study period in the Clinic of Neurosurgery at St George University Hospital, Plovdiv. Of these patients, 13 (10.7%) were people aged over 65 years (8 women and 5 men, mean age - 69 years). The most common cause of injury was a fall. Twelve patients (92.3%) had associated craniocerebral lesions and only one had an isolated epidural hematoma. Upon admission, 6 patients (46.2%) were neurologically intact. Ten patients were treated surgically, two – conservatively. Good outcome (GOS=4–5) was achieved in 8 patients (61.5%), poor outcome – in one patient, and four patients (30.8%) died. Conclusions: Good outcome in elderly patients with epidural hematoma can be achieved in two-thirds of the cases, despite the negative influence of the age as a prognostic factor

Intradural Extramedullary Metastasis of the Upper Thoracic Spine – Case Report and Literature Review

We report a case of 46-year-old male operated on for moderately differentiated lung adenocarcinoma. Postoperatively, he underwent six courses of chemotherapy and radiotherapy. He developed progressive severe inferior paraparesis accompanied by excruciating pain between the shoulders two years later. Magnetic resonance imaging revealed metastases in the bodies of T2 and T3 vertebrae with adjacent intradural extramedullary lesion compressing the spinal cord. The patient underwent surgical decompression and vertebral body cement augmentation that lead to pain relief and partial neurological recovery. The histological examination was consistent with metastases from low differentiated pulmonary adenocarcinoma. Surgical resection of intradural extramedullary metastasis improves patient quality of life by reducing pain intensity and neurological deficit