Different endoscopic surgical corridors can be delineated with the endonasal transclival and retrosigmoid approaches to the clival/petroclival area. Some relevant neurovascular structures may limit the extension of the approach and the view via both routes. The combination of the 2 approaches may improve the visualization in this challenging area.
Purpose Spontaneous chronic epidural hematomas are extremely rare and can be extremely challenging to diagnose and differentiate. The clinical findings, computed tomographic scan and magnetic resonance imaging does not always enough to complete differentiate this condition. Our purpose is to report a case of a spontaneous chronic epidural hematoma presenting as an extradural mass leading to compressive radicular symptoms with images of bony scalloping which are sparsely reported in the literature. Methods We describe a 61-year-old woman who was evaluated after 18-month history of pain, disestesias and mild weakness in both lower extremities with significant radicular symptoms on the right side associated to neurogenic claudication. Results CT scans revealed a nodular image of soft tissue density located in the right anterolateral epidural space at the L4-L5 level demonstrating resorption of the bony margins. MRI studies revealed a round mass in the vertebral canal displacing the dural sac and scalloping the posterior wall of the L4 vertebral body. Diagnosis was established between a degenerative cyst versus an atypical neurinoma. Surgical findings demonstrated an isolated well-formed chronic hematoma. Conclusion Spontaneous chronic epidural hematomas are rare, even more when they produce scalloping of bony structures becoming a diagnostic challenge. Therefore they should be always considered as a differential diagnosis in patients with extradural chronic compressions taking into account that also chronic epidural hematomas can cause bone involvement.
The endoscopic endonasal technique is currently used by otolaryngologists for the management of different extradural lesions located below the ethmoidal planum. The cooperation between ENTs and neurosurgeons has recently pushed the use of such approach also in the removal of some intradural lesions, which has promoted the interest for an anatomic study to identify the anatomical landmarks and the dangerous points during the endoscopic approach to this area. In six fresh cadaver heads, unilateral and bilateral measurements between the main landmarks of the approach were performed by means of an endoscopic endonasal approach. A wide exposure of the midline anterior skull base was realized. The maximum of lateral extension was obtained between the two medial orbital walls, at the middle of the cribriform plate (mean distance 25,33 mm), while the mean distance between the anterior and posterior ethmoidal arteries at the level of the lamina papyracea was 16 mm. The endoscopic endonasal route can be considered a minimally invasive technique to approach the ethmoidal planum. It requires adequate anatomical knowledge and endoscopic skill for its realization. Due to the wide window realizable through this corridor, it could be considered in selected cases for the removal of intradural lesions such as meningiomas or estesioneuroblastomas.
Materials and methods: Clinical data and imaging from 90 patients with biopsy-proven spinal metastases, were provided to 83 specialists from 44 hospitals. Spinal levels involved and the Tomita and modified Bauer scores for each case were determined twice by each clinician, with a minimum of 6-week interval. Clinicians were blinded to every evaluation. Kappa statistic was used to assess intra and inter-observer agreement. Subgroup analyses were performed according to clinicians' specialty (medical oncology, neurosurgery, radiology, orthopedic surgery and radiation oncology), years of experience (67, 8-13, P14), and type of hospital (four levels).Results: For metastases identification, intra-observer agreement was ''substantial'' (0.60 < k < 0.80) at sacrum, and ''almost perfect'' (k > 0.80) at the other levels. Inter-observer agreement was ''almost perfect'' at lumbar spine, and ''substantial'' at the other levels. Intra-observer agreement for the Tomita and Bauer scores was almost perfect. Inter-observer agreement was almost perfect for the Tomita score and substantial for the Bauer one. Results were similar across specialties, years of experience and type of hospital. Conclusion: Agreement in the assessment of metastatic spine disease is high. These scoring systems can improve communication among clinicians involved in oncology care.
Background Completely extradural spinal schwannomas have a unique morphology (dumbbell tumors) with an intra- and extraspinal component. When they compromise two contiguous vertebral bodies or have an extraspinal extension >2.5 cm, they are classified as giant spinal schwannomas. The aim of this study is to present our experience in the surgical management of completely extradural giant spinal schwannomas with a minimally invasive approach.
Methods This study is a case series of patients treated at the Neurosurgery Department of the University Clinical and Provincial Hospital of Barcelona, Spain, between January 2016 and December 2019.
Results Fifteen patients met the inclusion criteria, with thoracic and lumbar spines being the most frequent locations. All patients underwent surgical treatment, with a mini-open interlaminar and far-lateral technique. Total gross resection was accomplished in all patients and spine instrumentation was not necessary.
Conclusions Microsurgery is the treatment of choice for spinal schwannomas, and gross total resection with low morbidity must be the surgical goal. Mini-open interlaminar and far-lateral access is a valid surgical option, with low morbidity in experienced hands, and there is no need for spinal instrumentation.
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