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Background: Extradural arteriovenous fistulas (AVFs) of the cervical spine are extremely rare, and typically manifest as slowly progressive myelopathy caused by mass effect. This is a unique case of extradural AVF of the cervical spine manifesting with purely radicular symptoms and treated endovascularly with coil and liquid embolization. Case Description: A 55-year-old woman presented with neck pain and right upper extremity radiculopathy persisting for 9 months. Imaging studies demonstrated an AVF spanning from C4-C6 with extension into the C5-C6 foramen supplied primarily from the deep cervical branch of the costocervical trunk. The patient underwent successful coil and liquid (Onyx) embolization. Six-week postoperatively, the patient's symptoms completely resolved and magnetic resonance imaging and angiographic imaging confirmed complete obliteration of the fistula. Conclusion: While extradural AVFs typically present with myelopathic symptoms, they may present with solely radicular symptoms and can be successfully treated endovascularly. [ABSTRACT FROM AUTHOR]

Background: Spinal arachnoid cysts (SAC) are typically congenital, spontaneous, traumatic (i.e., including iatrogenic/surgical), or inflammatory in origin. In descending order, they occur in the thoracic, lumbar, and cervical spine, and originate from focal entrapment of the arachnoid membrane. Arachnoid cysts represent 1-2% of all cystic spinal masses/tumors. The majority are extradural arachnoid cysts (EDAC) while 10% of all arachnoid cysts are intradural (IDAC) including subarachnoid, or extra-arachnoidal/subdural. Only rarely are they intramedullary in location. The clinical symptoms/signs of IDAC/EDAC include; intracranial hypotension (i.e., due to continued cerebrospinal fluid drainage), radiculopathy, and/or myelopathy. Methods: Magnetic Resonance Images (MR) and Myelo-Computed Tomography (Myelo-CT) studies classically document the predominant dorsal location of IDAC/EDAC. They also show their extent and severity contributing to root, cord, and/or cauda equina compression. In the cervical/thoracic spine, MR/Myelo-CT studies classically show the "double cord" or "windsock" signs, while the "fake arachnoiditis sign" may be seen in the lumbar spine. The latter sign signals the presence of a circumferential extra-arachnoidal-subdural cyst that centrally "traps" the cauda equina. Note, that this resembles and is often misinterpreted as adhesive archnoiditis. Results: Patients with significant SAC-related neurological deficits typically warrant early surgery. That surgery includes; partial/total resection/fenestration of cyst walls, and occlusion of communicating fistulas with or without accompanying shunts. Conclusion: It is critical to recognize the clinical (i.e., intracranial hypotension, radiculopathy, and/or myelopathy) and radiographic MR/Myelo-CT signs (i.e., "double cord," "windsock signs", or "fake arachnoiditis sign") of IDAC, EDAC, or intramedullary spinal arachnoid cysts to appropriately offer treatment. For those with significant neurological deficits, early surgery (i.e. optimally 0-< 24 hours after the onset of symptoms/signs consisting of laminectomies, partial/total cyst resection/fenestration, and ligation/occlusion of the subarachnoidcyst fistula with or without shunt placement), is essential to avoid significant permanent neurological sequelae. [ABSTRACT FROM AUTHOR]

Background: As part of the 'small round-cell tumor' family, Ewing's sarcoma (ES) is a malignant mesenchymal tumor classified as a primitive neuroectodermal tumor (PNET). Within the PNETs, spinal extraosseous extradural lesions are exceedingly rare. Case Description: A 19-year-old male presented with a one-month history of back pain and paraparesis with loss of urinary control. The MRI revealed an intradural, extramedullary mass at the T3-T4 level. Intraoperatively, the tumor was solely extradural, without evidence of local invasion; it was entirely removed. Due to the high risk of metastasis, the patient was subsequently treated with chemotherapy and radiation. In addition, similar studies on PNETs were reviewed. Conclusion: A 19-year-old male presented with a paraparesis attributed to an extraosseous extradural ES at the T3-T4 level. Following total gross resection, he was successfully managed with chemotherapy and radiation. The patient has been in remission for one month. [ABSTRACT FROM AUTHOR]

Background: Ewing's sarcoma (ES) is a malignant mesenchymal tumor, most often found in the long bones, and usually affecting children and adolescents in the second decade of life. ES of the spine is a clinical rarity. Case Description: A 45-year-old male presented with a 3-month history of lower back pain which acutely worsened in conjunction with urinary retention. The magnetic resonance imaging revealed a mass extending from L5 to S2 with additional extension through the left S2-3 neural foramen. The metastatic workup was negative. At surgery, the lesion was both intradural and extradural. Following complete surgical resection, the patient was later treated with radiation and chemotherapy. Conclusion: Here, we report an adult male who acutely presented with low back pain attributable to primary intradural/extradural sacral ES. [ABSTRACT FROM AUTHOR]

Background: Spinal extradural arachnoid cyst (SEDAC), accounting for approximately 1% of all spinal lesions, rarely causes compressive myelopathy. It is usually found at lower thoracic or upper lumbar levels in males in their forties to sixties. The standard surgical procedures include direct dural repair. Case Description: A 37-year-old male presented with myelopathy attributed to a type I meningeal cyst (SEDAC) that was successfully managed with a laminectomy, cyst excision, and direct dural sleeve repair. Similar cases reported in the literature were also reviewed. Conclusion: SEDACs, although rare, must be considered among the differential diagnoses for compressive myelopathy/neurogenic bladder. [ABSTRACT FROM AUTHOR]

Background: There have been 18 reported cases of primary spinal intradural, extramedullary ependymomas reported in the literature. One of the 18 cases had an extradural component and was benign. Our case is the second spinal intradural, extramedullary ependymoma with an extradural component and the first with its initial presentation as an anaplastic ependymoma. Case Description: A 50-year-old male presented with bilateral upper thigh weakness and thoracic numbness. His exam showed the pin-prick level at T5. Magnetic resonance imaging (MRI) of the thoracic spine showed an enhancing lesion at T5–6 with severe compression of the spinal cord with a dumbbell shape extension of the tumor through the right T5–6 neural foramen. The patient had a laminectomy at T4–T6 with the resection of the tumor. Postoperatively, the patient regained full strength in his lower extremities. Intraoperatively, the tumor was found to be intradural, extramedullary with an extradural component. The tumor was found to be an anaplastic ependymoma. Conclusions: Even though spinal intradural extramedullary ependymomas are very rare, surgeons must be aware that on MRI, they can be mistaken for meningiomas or nerve sheath tumors especially if there is an extradural component. Our case report is the first intradural, extramedullary ependymoma that is anaplastic and has an extradural component. A review of the literature provides little information on the treatment and prognosis for these tumors especially if they are anaplastic. We propose that the treatment, as done in our case, should be complete resection of the tumor with spinal radiotherapy to the tumor level. [ABSTRACT FROM AUTHOR]

Background: Acute bilateral extradural hematoma is a rare presentation of head trauma injury. In sporadic cases, they represent 0.5-10% of all extradural hematomas. However, higher mortality rates have been reported in previous series. Case Description: The authors described the case of a 28-year-old male presenting head injury, comatose, Glasgow Coma Scale of 6, anisocoric pupils without puppilary light reflex. Computed tomography showed asymmetric bilateral epidural hematomas, effacement of the lateral ventricles and sulci, midline shift and a bilateral skull fracture reaching the vertex. Surgical evacuation was performed with simultaneous hematoma drainage. Patient was discharged on the 29th postoperative day with no neurological deficit. Conclusion: The correct approach on bilateral epidural hematomas depends on the volume, moment of diagnosis, and neurological deficit level. Simultaneous drainage of bilateral hematomas has been demonstrated to be an effective technique for it, which soon decreases the intracranial pressure and promotes an efficient resolution to the neurological damage. [ABSTRACT FROM AUTHOR]

Background: Primary extradural tumors of the spine comprise only a small percentage of all spinal tumors. However, given their relative radioresistance and their typical malignant, invasive nature, surgery may be associated with fairly high morbidity and mortality rates. Furthermore, it may be especially difficult to achieve gross total resections with tumor-free margins. Case Descriptions: We present two cases and review the literature regarding the presentation, diagnosis, and evidence-based guidance/treatment of primary extradural spinal tumors. The first patient with an L1 chordoma presented with cauda equina syndrome. Following surgery, the second patient, with a giant cell tumor of the cervicothoracic junction, responded well to the novel drug denosumab, a monoclonal antibody to the RANK ligand. Conclusion: Primary extradural spine tumors pose significant challenges to surgeons as the aim is to achieve satisfactory surgical outcomes with clean tumor margins (e.g, thus avoid recurrence) while minimizing morbidity. Improvements in radiotherapy, chemotherapy, and novel molecular drugs may increase survival rates and improve overall outcomes. [ABSTRACT FROM AUTHOR]