Search Results (99)

Background: Cervical dumbbell-shaped neurogenic tumors occurring at two noncontiguous levels are rare, and postoperative cerebrospinal fluid (CSF) collection causing cord compression is an uncommon but serious complication after intradural tumor resection. Case Presentation: A 30-year-old man presented with a 3-month history of progressive gait disturbance. Neurological examination revealed grade 3 paraparesis with upper motor neuron signs. Magnetic resonance imaging (MRI) demonstrated two discrete dumbbell-shaped neurogenic tumors located at the C1-2 and C7-T1 levels. The lesions were simultaneously resected. Complete removal of the C1-2 tumor required total sacrifice of the left C2 nerve root, while the C7-T1 lesion was excised through a T-shaped dural incision. The dura was closed primarily with watertight sutures reinforced with dural sealant, and no CSF leakage was observed during intraoperative Valsalva testing. Two months postoperatively, the patient developed worsening upper back and trapezial pain with severe scapular swelling. MRI revealed a large CSF collection extending from C6 to T5, causing moderate cord compression. Urgent revision surgery was performed. Controlled drainage was attempted to prevent intracranial hypotension, but significant CSF egress occurred. The dural defect was repaired using an autologous muscle plug reinforced with fibrin glue. The patient recovered uneventfully after revision surgery and was discharged without recurrence or complications. Conclusions: This case highlights that delayed, extensive postoperative CSF collection can occur despite apparently watertight primary closure and negative intraoperative Valsalva testing. Clinical vigilance for this complication is essential when patients present with new axial pain or localized swelling following cervical intradural surgery, even in the absence of classic low-pressure headaches. Full article

Lipomyelomeningocele (LMMC) is one of the most common forms of occult spinal dysraphism, with an estimated incidence of 3–6 per 100,000 live births, and microsurgical untethering remains the cornerstone of management for symptomatic and selected at-risk children. The operation is technically demanding: reported rates of long-term symptomatic re-tethering after partial resection still reach 15–25%, and the surgeon must balance adequate untethering against preservation of the placode and lumbosacral nerve roots. In this technical note, we present a stepwise, illustrated description of our institutional 14-step microsurgical technique for pediatric LMMC. Each step is anchored to a defined anatomical landmark, beginning with a midline skin incision planned away from the anal verge and proceeding through subtotal subcutaneous lipoma resection, identification of the dural penetration site, a limited rostral laminectomy over normal anatomy, dural opening with circumferential dissection of lipoma–dura–cord adhesions, exploitation of the arachnoid–dura plane, electrophysiologically guided debulking of the intradural lipoma, stimulation-controlled division of the fatty filum, pia-to-pia reconstruction of the placode with 8-0 monofilament suture, expansile duraplasty with an artificial dural substitute, and reinforced multilayered watertight closure. Technical pearls aimed at minimizing the risks of cord injury, cerebrospinal fluid leak, and postoperative re-tethering are highlighted at each stage, and the role of multimodal intraoperative neurophysiological monitoring is emphasized. This note is intended as a practical, image-anchored operative reference for pediatric neurosurgeons and trainees managing this challenging closed neural tube defect. Full article

Background: Endoscopic spine surgery (ESS) is an established minimally invasive approach for degenerative spinal conditions. Advances in instrumentation and visualization have expanded its application to spinal tumor resection. This review synthesizes reported clinical outcomes and technical considerations of ESS for primary spinal tumors. Methods: PubMed was queried from 2000 to 2025 for studies reporting endoscopic resection of primary spinal tumors. Studies involving metastatic disease or non-resective interventions were excluded. Data were descriptively analyzed given heterogeneity and limited sample size. Results: Eleven patients across seven studies were included (mean age = 50.3 years). Pathologies comprised schwannoma (n = 5), meningioma (n = 3), osteoid osteoma (n = 2), and Ewing sarcoma (n = 1). Seven tumors were intradural extramedullary (63.6%) and four were extradural (36.4%); no intramedullary lesions were included. Of the seven intradural cases, one was performed via uniportal full-endoscopic technique, one via biportal endoscopy, and five via tubular retractor-assisted endoscopy. Across all eleven patients, gross total resection was achieved in 90.9% of cases. Gross total resection was achieved in 100% of cases in which it was the operative intent (10/10); the remaining case was a planned biopsy of recurrent Ewing sarcoma. One transient postoperative lower extremity weakness was reported; no cerebrospinal fluid leaks, reoperations, or perioperative deaths occurred. No recurrences were observed across a mean follow-up of 21.9 months (range 4–48 months), though this duration may be insufficient to assess long-term recurrence for slow-growing tumors such as meningioma and schwannoma. Conclusions: ESS of primary spinal tumors appears feasible and safe in carefully selected cases, particularly for small, well-circumscribed lesions in favorable anatomical locations. Intradural resection introduced distinct technical challenges, including irrigation management and dural closure, which influence platform selection. These findings are limited by small sample size, short follow-up, and likely publication bias. ESS should be considered an emerging minimally invasive option rather than a replacement for established microsurgical approaches. Prospective comparative studies are needed to better define its role in spinal oncology. Full article

Chronic subdural hematoma (CSDH) is traditionally described as a post-traumatic blood collection within the subdural space; however, both its anatomical localization and pathophysiology have been increasingly questioned. Ultrastructural and histopathological evidence demonstrates that no true subdural space exists under physiological conditions and that CSDH originates instead within the dural border cell (DBC) layer, a mechanically fragile and biologically active meningeal interface. Accordingly, chronic “subdural” hematoma may be more accurately interpreted as an intradural border cell lesion. Beyond anatomy, CSDH is a dynamic, self-sustaining disease driven by chronic inflammation, pathological angiogenesis, vascular immaturity, and localized hemostatic dysregulation. Hypoxia-induced HIF-1α/VEGF activation promotes fragile, hyperpermeable neovessels, while local hyperfibrinolysis and kallikrein–kinin activation prevent stable clot formation, driving recurrent microbleeding and plasma exudation. Consequently, hematoma persistence and recurrence represent a biological failure rather than a purely technical surgical shortcoming. This conceptual shift provides a coherent rationale for dural-targeted therapies, including middle meningeal artery embolization and pharmacological modulation of angiogenesis and fibrinolysis. Reframing CSDH as a chronic intradural and biologically active disorder has important implications for terminology, classification, and the development of mechanism-oriented, multidisciplinary management strategies. Full article

Background/Objectives: Cauda equina neuroendocrine tumors (CENETs) are rare neuroendocrine tumors that predominantly arise in the cauda equina and filum terminale region. Due to their nonspecific clinical and radiological features, preoperative diagnosis remains challenging, and available data are limited to small case series. Methods: This retrospective single-center study included nine patients who underwent surgical treatment for histopathologically confirmed CENETs between 2014 and 2025. Clinical presentation, radiological findings, surgical management, histopathological features, and postoperative outcomes were analyzed. Results: The mean age was 51.2 years, with a slight male predominance. Pain was the most common presenting symptom (77.8%), followed by radiculopathy and sensory disturbances. All tumors were intradural and extramedullary, predominantly located in the lumbosacral region. Radiologically, all lesions were isointense on T1-weighted imaging and demonstrated predominantly homogeneous contrast enhancement. Vascular imaging features, including flow voids (55.6%), eccentric vessel sign (66.7%), and tadpole sign (44.4%), were frequently observed. Gross total resection was achieved in all patients, with no neurological deterioration or major complications. Over a mean follow-up period of 59.6 months, no tumor recurrence was detected. Conclusions: Cauda equina neuroendocrine tumors are rare but surgically curable tumors with excellent prognosis. Although preoperative diagnosis remains difficult, recognition of characteristic vascular imaging features may improve diagnostic accuracy. Gross total resection remains the cornerstone of treatment, providing durable disease control with minimal morbidity. Full article

Background and Objectives: We aimed to determine whether preoperative systemic inflammatory markers derived from complete blood count differ between patients with intradural spinal tumors and healthy controls, and whether any such difference varies by pathological subtype or motor deficit status. Materials and Methods: Sixty-four patients who underwent surgery for histopathologically confirmed intradural spinal tumors between 2015 and 2023 were enrolled alongside 64 age- and sex-matched healthy controls. The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), systemic immune-inflammation index (SII), pan-immune-inflammation value (PIV), and red cell distribution width (RDW) were calculated from preoperative complete blood count results. Comparisons were performed at the patient–control level and stratified by pathological diagnosis (meningioma, schwannoma, ependymoma, other) and motor deficit status. Results: NLR (median 2.47 vs. 2.06; p < 0.001), PLR (157.1 vs. 121.0; p < 0.001), SII (706.1 vs. 595.0; p = 0.003), and PIV (404.2 vs. 287.0; p < 0.001) were all significantly elevated in the tumor group, while LMR was significantly lower (3.66 vs. 4.34; p < 0.001). RDW did not differ between groups (p = 0.420). Stratification by pathological subgroup and motor deficit status revealed no significant differences in any marker. Conclusion: Intradural spinal tumors—including the predominantly benign cases that made up most of this cohort—are accompanied by a detectable preoperative shift in systemic inflammatory markers, one that appears independent of tumor histology and neurological presentation. These findings demonstrate a measurable systemic inflammatory response in patients with intradural spinal tumors. However, the absence of differences across pathological subtypes and motor deficit status suggests that these markers reflect a generalized host response rather than tumor-specific characteristics, and their role in clinical decision-making remains to be clarified. Full article

Objective. The aim of this study was to evaluate clinical characteristics, surgical outcomes, and factors influencing postoperative neurological status in patients undergoing resection of intradural spinal tumors, with particular emphasis on the role of preoperative neurological function and intraoperative neuromonitoring (IONM). Methods. We conducted a retrospective analysis of 108 patients who underwent surgical resection of intradural spinal tumors at a single neurosurgical center. Patients were categorized into intradural extramedullary (IDEM) and intramedullary (IM) tumor groups. The primary endpoint was the occurrence of a new or worsened postoperative motor deficit at discharge. Secondary endpoints included postoperative sphincter dysfunction and functional status assessed using the modified McCormick scale at discharge and at 6-month follow-up. Categorical variables were compared using the Chi-square or Fisher’s exact test, and continuous variables using the Mann–Whitney U test. Results. A total of 108 patients were included (61.1% female; mean age 55.7 ± 15.6 years). IDEM tumors accounted for 77 cases, while 31 were intramedullary. There were no significant differences between IDEM and IM tumors in the rate of new or worsened postoperative motor deficits (9.1% vs. 6.7%, p = 1.000), postoperative sphincter dysfunction (2.6% vs. 0%, p = 1.000), or functional outcomes assessed using the modified McCormick scale at discharge (p = 0.85) and at 6 months (p = 0.24). Preoperative motor deficit was strongly associated with postoperative motor dysfunction in the overall cohort (86% vs. 14%, p < 0.001), with an even stronger effect observed in the IM subgroup (90.9% vs. 9.1%, p < 0.001). IONM was used in 34.3% of cases and was significantly associated with tumor location, histopathology, and surgical complexity. However, IONM use was not associated with postoperative motor outcomes (p = 0.645). Conclusions. Postoperative neurological outcomes following intradural spinal tumor resection are comparable between intramedullary and extramedullary lesions. Preoperative motor deficit is the strongest predictor of postoperative neurological status, particularly in intramedullary tumors, underscoring the importance of early surgical intervention. IONM is preferentially used in higher-risk cases and should be interpreted as a marker of surgical complexity rather than an independent determinant of outcomes. Full article

Tethered cord syndrome (TCS) is a disease caused by pathological fixation of the spinal cord, most commonly due to a thickened filum terminale, postoperative adhesions, or congenital dysraphism. Progressive neurological, urological, and orthopedic manifestations result from chronic cord traction and impaired vascular supply. Surgical detethering remains the standard treatment, with the classic intradural sectioning of the filum terminale being the most widely used technique. Recent developments, however, include minimally invasive tubular and endoscopic approaches, spinal column shortening procedures for recurrent or complex cases, and extradural detethering strategies. Each technique aims to reduce cord tension while minimizing postoperative complications, particularly cerebrospinal fluid leakage and retethering. This review summarizes the anatomical background, pathophysiology, and operative strategies for TCS, highlighting current evidence, technical nuances, and limitations of emerging minimally invasive and alternative approaches. Full article

Atypical teratoid rhabdoid tumor (AT/RT) is a rare, highly aggressive embryonal central nervous system malignancy occurring predominately in infants and toddlers. Spinal AT/RT (spAT/RT) cases are even more limited, and as a result, little is known regarding prognostic factors and optimal treatment regimens. Molecularly, AT/RT is divided into three groups: AT/RT-SHH, AT/RT-TYR and AT/RT-MYC. spAT/RT is predominantly of the MYC subtype. Additionally, a third of patients with AT/RT have a germline Rhabdoid Tumor Predisposition Syndrome (RTPS) that increases the likelihood of developing additional rhabdoid tumors, including renal rhabdoid tumors. Due to the rarity of these tumors, there is a lack of consensus on treatment strategies to be employed. This review paper details the published literature on spAT/RT, with particular emphasis on the recent advances in understanding the biology of these aggressive tumors and currently available therapeutic options, and highlights the challenges associated with the management of this extremely rare condition. Full article

Objectives: In this retrospective comparative cohort study, we aimed to compare surgical efficiency, radiographic facet integrity, and postoperative alignment and mobility between unilateral hemilaminectomy (UL) and laminotomy with laminoplasty (LP) for cervical intradural extramedullary (IDEM) tumors. Methods: Thirty-eight patients (UL: 20; LP: 18) were retrospectively reviewed. Operative variables, tumor characteristics, extent of resection, radiographic facet joint violation (graded 1–4), and sagittal alignment parameters, including global and segmental range of motion (ROM), were evaluated at 1 year postoperatively. Propensity score matching was additionally performed to minimize potential baseline imbalance between groups. Results: The UL group had significantly shorter operative time (178.05 ± 61.89 vs. 276.06 ± 121.76 min, p = 0.003) and lower intraoperative blood loss (p < 0.001) than the LP group. Radiographic facet joint violation (Grade ≥ 2) occurred more frequently in the UL group (25.0% vs. 0%, p = 0.048) but was not associated with postoperative sagittal alignment changes or radiographic instability. Global cervical alignment remained in both groups, but the LP group showed a significantly greater reduction in segmental ROM at 1 year (−6.42 ± 8.29° vs. 0.06 ± 7.72°, p = 0.017). These findings were consistent in the propensity score–matched cohort. Conclusions: UL provides favorable operative efficiency and better preservation of segmental cervical mobility than LP, while maintaining comparable clinical and radiographic outcomes. Although radiographic facet joint violation was more frequent in the UL group, postoperative spinal stability was not compromised in this cohort. UL may serve as a safe and motion-preserving alternative in selected patients with cervical IDEM tumors. Full article

Background/Objectives: Spontaneous spinal subdural hematoma (SSSDH) is a rare and severe condition that causes rapid neurological decline. Spontaneous spinal epidural hematoma (SSEH) presents similarly but is more common, and surgical management differs because SSSDH requires an intradural approach. Few studies have assessed the reliability of magnetic resonance imaging (MRI) features used to distinguish SSSDH from SSEH in patients requiring surgery. Methods: We retrospectively reviewed 27 patients who underwent surgical evacuation of spinal hematomas at two institutions (2015–2025). Definitive hematoma location was determined intraoperatively. Four MRI features—shape (crescentic vs. biconvex), location (ventral vs. dorsal), craniocaudal length (<5 vs. ≥5 segments), and spinal region—were independently evaluated by two reviewers. Inter- and intra-rater reliability was assessed using agreement rate and Cohen’s kappa (κ) with 95% confidence intervals (95% CIs). Results: Among 27 cases, three (11.1%) were SSSDH and 24 were SSEH. Hematoma location, length, and spinal region demonstrated perfect inter- and intra-rater agreement (κ = 1.00). For hematoma shape, intra-rater agreement was good (96.2%, κ = 0.84; 95% CI 0.52–1.00), whereas inter-rater agreement was poor to fair (84.6%, κ = 0.26; 95% CI −0.25–0.77). Notably, two of the three SSSDHs demonstrated a biconvex configuration, and 83.3% of SSEHs also exhibited a biconvex morphology. Conclusions: MRI features such as hematoma location, extent, and spinal level were highly reproducible, whereas hematoma shape showed limited reliability. Although ventral hematomas most strongly suggest SSSDH, atypical SSEH presentations occur. When dorsal exposure reveals no epidural hematoma, intradural exploration should be promptly considered. Full article

Background: Postoperative cerebrospinal fluid (CSF) leakage remains a significant complication following endoscopic endonasal skull base surgery (EES), leading to increased morbidity. This study aimed to identify factors and interventions predicting postoperative CSF leaks after EES for intradural skull base tumors and their clinical outcomes. Methods: We retrospectively reviewed data from 542 patients who underwent EES for intradural skull base pathology at the Ottawa Hospital between October 2001 and October 2023. Patient demographics, pre-operative, intraoperative (including reconstruction type), postoperative data, and patient outcomes were collected. Results: A total of 40 patients (7.4%) developed a postoperative CSF leak. The highest rate was in patients with suprasellar lesions (5.9%), followed by anterior cranial fossa lesions (1.1%). Significant predictors included a higher mean Body Mass Index (BMI) (30.4 vs. 26.1, p = 0.001). The use of a nasoseptal flap for reconstruction was associated with a significantly lower incidence of CSF leaks (p = 0.001). Tumor location, approach type, and dural sealants were not independent factors for the development of CSF leaks. Patients with CSF leaks had significantly longer lengths of stay (16.7 vs. 9.21 days, p < 0.001), higher 30-day readmission rates (p < 0.001), and increased postoperative sepsis (p = 0.021) and diabetes insipidus (p < 0.001). Conclusion: This retrospective study shows that higher preoperative BMI is associated with a significant risk of postoperative CSF leaks after EES. Conversely, using a pedicled vascularized flap reduces the risk. Postoperative CSF leaks are linked to increased morbidity, including diabetes insipidus and sepsis, prolonged hospitalization, and higher readmission rates. Full article

Background/Objectives: Tumors of the cerebellopontine angle (CPA) encompass a limited range of histologies, predominantly vestibular schwannomas (VSs), meningiomas, and paragangliomas (PGLs). Their growth region threatens the cranial nerves (V–XII), brainstem, and cerebellum, possibly causing functional deficits. This review aims to synthesize clinical features and multidisciplinary treatment strategies for CPA tumors with brainstem involvement, emphasizing functional preservation alongside tumor control. Methods: A systematic PubMed search identified studies on VSs, CPA meningiomas, and intradural PGLs. Eligibility criteria included studies reporting tumor management and cranial nerve outcomes. Data extraction focused on tumor size, neurological presentation, surgical approach, adjunctive therapies, and postoperative cranial nerve function. Multidisciplinary involvement and rehabilitation strategies were noted. Results: Twenty studies (3311 patients) analyzed large VSs, showing facial nerve dysfunction in 8–53%, trigeminal neuropathy in 20–77%, and cerebellar signs in up to 79%. Microsurgery (MS) achieved variable gross total resection, while stereotactic radiosurgery (SRS) preserved facial nerve function but carried trigeminal and hydrocephalus risks. CPA meningiomas demonstrated cranial nerve displacement patterns critical for surgical planning, with transient deficits common and recovery linked to baseline function. In 388 intradural PGL cases, staged surgery combined with preoperative embolization was standard; functional preservation of lower cranial nerves was often limited. Across all histologies, multidisciplinary management and targeted rehabilitation were essential. Conclusions: Optimal CPA tumor management balances tumor control with functional preservation. VSs benefit from individualized MS or SRS based on size and mass effect. Meningioma surgery prioritizes cranial nerve preservation over radical resection. Intradural PGLs require staged vascular-conscious approaches. Multidisciplinary care and structured rehabilitation are pivotal to improving outcomes and quality of life. Full article

Objective: Intramedullary melanocytomas are extremely rare spinal cord tumors with distinct histopathological and imaging characteristics. This report reviews the literature on this pathology and presents a representative case study, highlighting aspects of diagnosis and management. Methods: A scoping review of PubMed, Web of Science, and Embase databases was conducted to identify reports on intramedullary melanocytomas, focusing on clinical presentation, imaging features, histopathology, treatment, and outcomes. Case reports and case series were included due to the rarity of these tumors. Results: Twelve manuscripts met the inclusion criteria, including 15 patients. In the majority of patients, intramedullary melanocytomas present with progressive myelopathy and pain. Most common MRI findings include hyperintensity on T1-weighted images, iso- to hypointensity on T2-weighted images, and homogeneous contrast enhancement. Intralesional cysts and associated syrinx are common. Gross total resection (GTR) remains the primary treatment, but complete removal is often challenging due to tumor adherence to neural structures. Conclusions: Intramedullary melanocytomas require careful diagnosis and management due to their diagnostic overlap with malignant melanoma and potential for recurrence. While GTR is the mainstay of treatment, long-term surveillance is warranted due to high recurrence rates. Further research is needed to define the natural history of the disease and establish optimal therapeutic strategies. Full article

Intraoperative ultrasound (IOUS) has developed from a rudimentary adjunct into a versatile modality that now plays a crucial role in neurosurgery. Offering real-time, radiation-free and repeatable imaging at the surgical site, it provides distinct advantages over intraoperative magnetic resonance (MRI) and computed tomography (CT) in terms of accessibility, workflow integration and cost. The clinical spectrum of IOUS is broad: in cranial surgery it enhances the extent of resection of gliomas and metastases, supports dissection in meningiomas and enables localization of MRI-negative pituitary adenomas; in spinal surgery, it guides resection of intradural and intramedullary tumors, assists in myelotomy planning and confirms decompression in degenerative conditions such as cervical myelopathy and ossification of the posterior longitudinal ligament. IOUS also offers unique insights into cerebrospinal fluid disorders, including arachnoid webs, cysts, syringomyelia and Chiari malformation, where it visualizes cord compression and CSF flow restoration. In trauma and oncological emergencies, it provides immediate confirmation of decompression, directly influencing surgical decisions. Recent innovations, including contrast-enhanced ultrasound, elastography, three-dimensional navigated systems and experimental integration with artificial intelligence and robotics, are extending its functional scope. Despite heterogeneity of evidence and operator dependence, IOUS is steadily transitioning from an adjunctive tool to a cornerstone of multimodal intraoperative imaging, bridging precision, accessibility and innovation in contemporary neurosurgical practice. Full article