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Compressive vertebral hemangiomas with neurological deficits (CVHND) form a rare, unique subset of lesions comprising of differing clinico-imaging findings, pathologic behavior and treatment, when compared to the commoner and usually incidental intra-osseus vertebral hemangiomas (VH). Though various surgical strategies and a broad array of adjuncts have evolved and changed over the years, there is paucity of comprehensive data from sizeable series of such patients treated surgically with long term follow up. The purpose of this study is to device an optimum management strategy in CVHND based on our surgical experience. The data from electronic medical records of 26 consecutive patients operated in our department from 2009 to 2019 were retrospectively analyzed. There were 11 males and 15 females with a mean age of 34.7 years. Neurological examination revealed paraparesis or paraplegia with myelopathy in all patients with Frankel score of B, C and D in 1 (3.9%), 11 (42.3%) and 14 (53.8%) patients respectively. Sixteen patients (61%) underwent laminectomy and gross total excision of extradural soft tissue component, 7 (27%) laminectomy with posterolateral fusion, three (12%) underwent additional anterior interbody support. The mean follow up was 72.4 months and at last follow-up 24 patients (92%) were Frankel E. Symptomatic recurrence was seen in two patients operated early in the series, they underwent re-surgery, gross total excision with posterolateral fusion, remaining neurologically intact at last follow up. Pre-operative embolization, surgical excision of extradural component and intra-operative vertebroplasty form the mainstay of treatment for CVHND. Instrumented posterolateral fusion with optional anterior interbody support accomplished through the same approach is required only in a minority of cases. The long-term outcome following timely and appropriate treatment is excellent. Anterior or anterolateral approaches for intervertebral support and radical procedures like total en-bloc spondylectomy (TES) are not usually required. [ABSTRACT FROM AUTHOR]

Abstract 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. [ABSTRACT FROM AUTHOR]

Abstract Purpose : Patients with Extradural (EDH) and Acute Subdural Haematomas (ASDH) represent a subgroup of head-injured patients that gain the most from timely treatment. While treatment times for head injury overall improved since the introduction of Major Trauma Centres (MTCs), no data exists describing how the time to treatment of EDH and ASDH has changed. We, therefore, compared the evacuation of ASDH and EDH before and after the implementation of a major trauma network. Methods : Data was collected prospectively between 1 May 2006 to 31 May 2007 and 1 March 2014 to 31 March 2016. The study was carried out at University Hospital Southampton, designated MTC in 2012. Patients over 18 with ASDH or EDH requiring emergency surgery were included. Results : The median time (IQR) for decompression was 4.8h (3.9–6.6) in 2006-7 and 4.4h (3.4–5.9) in 2014–16, p = 0.386. The proportion treated within 4 hours was 32% in 2006–7, and 33% in 2014-16 (p = 1.000). Analysis showed a decrease in time for CT scan (p = 0.01) and acceptance by neurosurgery (p < 0.001). There were increases in time for transferring to hospital (p = 0.005), awaiting operating theatre (p = 0.005), and operative time (p = 0.018). Conclusions : Since the introduction of MTCs, there has been no significant reduction in time to treat this select group of patients despite reductions in time to treatment of most other trauma and head-injured patients. This may be because parts of the pathway have improved, but others haven’t. It is also possible that while previously head injury was poorly served, resources were prioritised to this group so finding further gains is difficult. [ABSTRACT FROM AUTHOR]

Sinonasal undifferentiated carcinoma (SNUC) is a rare and aggressive cancer of the sinonasal tract and is often characterized by intracranial invasion. However, SNUC rarely metastasizes to the spine. In this paper, we present a case of extradural metastasis and invasion of the adjacent spine by SNUC. A 42-year-old man presented to our hospital with two-month history of anosmia and nosebleeds. Imaging studies showed a neoplasm of the ethmoid sinus with extension into the anterior cranial fossa. The patient underwent resection of the carcinoma and began chemoradiotherapy. After completing chemoradiotherapy the patient complained of neck pain radiating down the right arm, and imaging showed an extradural mass at the C5 vertebral level. The patient underwent laminectomy for debulking of this tumor. One month later, the patient complained of recurrent weakness and pain in the right shoulder and arm. Imaging showed an extradural tumor wrapping around the C7 and C8 nerve roots, as well as a separate tumor at C2 adherent to the dura. The extradural tumor at C2 was surgically resected. Further imaging showed multiple new soft tissue masses at the thoracic level. We present a case of SNUC metastasis to the extradural spine representing the second case reported in the literature. Peri-dural metastasis and resulting symptoms should be included in the differential diagnosis and assessment of patients with SNUC. [ABSTRACT FROM AUTHOR]

Purely extradural spinal cavernous malformations (ESCMs) are rare, but the number of cases reported seems to be increasing. A 44-year-old woman presented with progressive cervicothoracic back pain, lower limb paraesthesia and hypertonia. MRI showed a well-circumscribed, convex lesion in the T1-4 extradural space causing cord compression and encroaching into the left T2/3 neural foramen. Selective spinal angiography demonstrated a vascular blush at the T2/T3 level corresponding with the mass. A feeding vessel arising from the base of the T1 spinous process was identified and successfully catheterised, but embolisation was precluded by unfavourable anatomy of the posterior spinal artery. At hemilaminectomy, the lesion was found to be an ESCM. The patient went on to make a full recovery. We reviewed 71 cases of ESCM reported in the last decade. Incidence of ESCM is unclear; the largest case series reported on nine patients, but most published accounts were single case studies. Patients presented with back pain (33%), myelopathy (56%) and/or radiculopathy (39%). Onset of symptoms was usually insidious over months to years, but 30% presented with sudden-onset neurological symptoms, often due to spontaneous haemorrhage. Mean age at diagnosis was 44 (range, 2-74; SD, 19.6) years with a 1:1 sex ratio. Lesions were found at all levels except C1-C2, but a strong predilection for the dorsal thoracic spine (68%) was shown. The lesion extended into an intravertebral foramen in at least 24 cases (34%). MRI is the investigation of choice, and angiography of ESCM has rarely been described. Most (87%) were hypo- to isointense on T1 MRI while hyperintensity on T2 (91%) and avid (89%), usually homogenous gadolinium update was almost universal. Perilesional haemosiderin, characteristic of intracranial and intramedullary cavernous malformation was rarely seen. In many cases, meningioma or nerve sheath tumour was misdiagnosed prior to surgery. All patients underwent total (95%) or subtotal (5%) microsurgical resection with excellent results; all improved (23%) or recovered fully (77%) after surgery. Those who presented acutely did worse; 38% had residual deficits. [ABSTRACT FROM AUTHOR]

Extradural haematomas are a significant consequence of head injuries in children. The aim of this study was to evaluate the demographics, symptoms and signs, management and outcome of patients less than 18 years of age with extradural haematomas in our unit. We also specifically looked at repeat imaging performed, indications for this and its effect on further management. No previous reviews have included this. Fifty-six patients were identified from 01/01/1997 to 01/01/2007 for inclusion in this study. Their imaging was then reviewed as were the case notes. Of the patients studied, 70% were male. The average age was 10 years and 2 months with an average length of stay of one week. The commonest mechanisms of injury were a fall from height and an accident involving a bike. Presenting symptoms were documented in 40% of cases. 32% of patients had associated skull fractures. Six patients had other injuries, including long bone fractures and maxillofacial injuries . Glasgow Coma Scale was generally better on admission than pre-operatively and post-operatively was generally better than prior to surgery. Eight patients had neurological signs on admission, 11 had pre-operatively, and nine had post-operatively. 71% underwent a craniotomy with evacuation of the haematoma. Complications were reported in 16% with no mortality. 66% were seen in a neurosurgical clinic, with 46% seen in a Paediatric Head Injury Clinic after discharge. 66% had further imaging after their initial scan of which 52% had no clinical indication. Eight patients were operated on following re-imaging. Most extradural haematomas in children are caused by falls or vehicle accidents. The majority are treated surgically and do well. Indications for further scanning are often not present and in most, management is unchanged. The follow up of these patients also appears to be suboptimal. [ABSTRACT FROM AUTHOR]

A 17-year-old male with occult cleft palate presented with depressed consciousness due to spontaneous frontal extradural haematoma associated with sinusitis. Craniotomy, evacuation of the haematoma and drainage of the frontal sinuses led to a full recovery. Spontaneous extradural haematomas secondary to craniofacial infections are very rare; this appears to be the first described with a coexisting congenital palatal abnormality. The diagnosis should be considered when signs of infection are present with depressed consciousness as a delay in treatment may result in death. [ABSTRACT FROM AUTHOR]

We report our experience with five lesions exclusively involving the entire cavernous sinus in which an essentially extradural surgical approach was used. There were two cases of cavernous haemangioma, two cases of meningioma and one case of fungal granuloma. The dural cover of the superior orbital fissure, and mandibular and maxillary divisions of the fifth nerve was dissected along with the dura of the lateral wall of the cavernous sinus. The presence of a relatively large intracavernous bulge due to the tumour assisted in this dissection. The contents of the cavernous sinus were exposed from an anterolateral, lateral and inferior approach. Through the corridor available between the splayed out cranial nerves, a radical resection of the tumour was accomplished in each case. The technical advantages of this approach are discussed in light of the anatomy of the dural configuration of the lateral wall of the cavernous sinus. [ABSTRACT FROM AUTHOR]

We present a case report of a 61-year-old gentleman who had a cardiac arrest and was delivered cardiopulmonary resuscitation (CPR) by a bystander. After resuscitation, he regained cardiac output and was breathing spontaneously. CT scan of the head showed spontaneous right frontal extradural aerocele with fracture of the posterior wall of the frontal sinus with no sign of head injury. We discuss the pathophysiology of this unrecognised complication due to CPR. [ABSTRACT FROM AUTHOR]

Haemorrhagic complications of arachnoid cysts have been reported as subdural or intracystic hematoma following trauma. In this paper, we report a patient with arachnoid cyst who developed extradural hematoma after a subtle head injury and presented with very mild symptoms in spite of the huge size of the hematoma. [ABSTRACT FROM AUTHOR]

Spinal haemangiomas are benign vasoproliferative lesions that are typically intra-osseous and generally asymptomatic, although localized pain can be a symptom.1,2 Capillary and cavernous variants have been described.2,3 We describe a rare case of a dumbbell-shaped haemangioma of the thoracic spine with both an intraspinal - extradural and intrathoracic component. [ABSTRACT FROM AUTHOR]

We report a case of spinal angiolipoma, causing paraplegia in a 38-year-old pregnant female. The tumour was excised and the patient made remarkable recovery. The role of pregnancy and its associated hormonal profiles on tumour growth is discussed. [ABSTRACT FROM AUTHOR]