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Intraspinal abscesses (ISAs) are rare lesions that are often neurologically devastating. Current treatment paradigms vary widely including early surgical decompression, drainage, and systemic antibiotics, delayed surgery, and sole medical management. The National Inpatient Sample (NIS) database was queried for cases of ISA from 2003 to 2012. Early and late surgery were defined as occurring before or after 48h of admission. Outcome measures included mortality, incidence of major complications, length of stay (LOS), and inpatient costs. A total of 10,150 patients were included (6281 early surgery, 3167 delayed surgery, 702 medical management). Paralysis, the main comorbidity, was most associated with early surgery (p<0.0001). In multivariate analysis, the rates of postoperative infection and paraplegia were highest with early surgery (p<0.0001), but the incidence of sepsis was higher with delayed surgery (p<0.0001). Early surgery was least associated with in-hospital mortality (p=0.0212), sepsis (p<0.001), and had the shortest LOS (p<0.001). Charges were highest with delayed surgery, and least with medical management (p<0.001). Medical management was associated with lower rates of complications (p<0.001). This is the largest study of patients with ISAs ever performed. Our results suggest that patients with ISAs undergoing surgical management have better outcomes and lower costs when operated on within 48h of admission, emphasizing the importance of accurate and early diagnosis of ISA., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Split cord malformation (SCM) is a rare form of spinal dysraphism in which the spinal cord is divided in the sagittal plane, forming a double neural tube. In addition to being associated with a variety of malformations, SCM may occur with spinal cord tumors, with only exceptional cases involving teratomas. As only eight patients with a teratoma associated with SCM have been reported, their presentation characteristics and treatment are currently unclear. We review the literature of all patients with SCM with concurrent spinal teratoma, discuss the potential dysembryology, and report the first case of SCM with concurrent spinal teratoma in an elderly patient. The mean age of those with concurrent SCM and teratomas was 39.4 years, with 55.6% occurring in females. The lumbar spine was the most frequent location for teratomas (66.7%), with the Type II malformation more commonly occurring with these tumors (75%). The duration of symptoms varied widely, ranging from 1 month to 5 years, with the average duration being nearly 2 years. Back pain (87.5%) and lower extremity weakness (75%) were the most common presenting symptoms. As SCM may be associated with progressive neurological deterioration and teratomas can contain immature or malignant components, surgery should be attempted with the goal of gross total resection. Nonetheless, in patients with a concurrent tumor and spinal dysraphism, spinal teratomas should be considered in the differential diagnosis. Gross total resection of these lesions may be safely achieved even in the presence of SCM using intraoperative electrophysiologic monitoring., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Adult brainstem gliomas (BSG) are uncommon tumors that constitute only 2% of all brain tumors. Due to its rare occurrence in the elderly (60 years and older), there is no literature discussing the natural history, prognosis, and best treatment strategy for malignant BSG in this population to our knowledge. We report seven elderly patients with malignant BSG and propose treatment strategies to manage these aggressive tumors. The median age at onset in this cohort was 65 years, with the majority of patients being male (71.4%) and Caucasian (85.7%). The median duration of symptoms prior to presentation was 0.5 months, with the most common symptoms being facial weakness, blurry vision, headache, and extremity weakness. Tumors were most commonly located in the pons (85.7%), with one tumor being located in the tectal plate. Five of seven (71.4%) patients underwent biopsies, with two patients undergoing partial resections. Following tissue diagnosis, patients received radiation therapy and concurrent temozolomide, followed by additional chemotherapeutics upon progression. Side effects as a result of treatment were seen in three patients and all involved reversible hematological complications such as neutropenia and thrombopenia. The median time to progression was 6.7 months and the median overall survival was 13.5 months. While malignant BSG in elderly patients are aggressive gliomas with an overall poor prognosis, these patients are able to safely undergo aggressive chemoradiotherapy, resulting in improved survival. Resection may be considered for select patients in which the tumor is mostly exophytic, near the brainstem surface, and easily accessible., (Published by Elsevier Ltd.)

Epithelioid sarcoma (ES) is a rare soft-tissue neoplasm which is most commonly found in the extremities of young adult males. ES has a poor prognosis due to its aggressiveness as it frequently recurs locally and can undergo lymphatic metastasis to soft tissue, fascia, bone, lymph nodes, lung, and brain. The most common form is the classic-type (granuloma-like), though a more aggressive subtype known as the proximal- or axial-type has also been described. As ES of the spine is exceedingly rare, with only seven patients being reported in the literature, the outcomes of these patients is unclear. We have reviewed the literature of all existing spinal ES cases to recommend treatment strategies and report the first case of proximal-type ES in the cervical spine. Patients with spinal ES had an average age of 20.7 years, with 71.4% of cases being in males. Metastasis was common and was found in 83.3% of patients, with lung metastasis being found in 60% of these patients. Due to the high rates of local recurrence and distant metastasis, the goal of surgery remains gross total resection of all tumor and involved bony elements if feasible without significant neurological deficits. Ligation of involved nerve roots may be necessary to achieve adequate resection of the tumor mass as nerve sheaths can serve as a pathway for extension. In the cervical spine, resection of these lesions is difficult due to involvement of the vertebral arteries in addition to nerve roots, increasing the surgical risk., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Cerebellar glioblastoma multiforme (GBM) occurs rarely in adults, accounting for 0.4-3.4% of all GBM. Current studies have all involved small patient numbers, limiting the clear identification of prognostic factors. Additionally, while few studies have compared cerebellar GBM to their supratentorial counterparts, there is conflicting data regarding their relative prognosis. To better characterize outcome and identify patient and treatment factors which affect survival, the authors analyzed cases of adult cerebellar GBM from the Surveillance, Epidemiology, and End Results database. A total of 247 adult patients with cerebellar GBM were identified, accounting for 0.67% of all adult GBM. Patients with cerebellar GBM were significantly younger than those with supratentorial tumors (56.6 versus 61.8 years, p < 0.0001), but a larger percentage of patients with supratentorial GBM were Caucasian (91.7% versus 85.0%, p < 0.0001). Overall median survival did not differ between those with cerebellar and supratentorial GBM (7 versus 8 months, p = 0.24), with similar rates of long-term (greater than 2 years) survival (13.4% versus 10.6%, p = 0.21). Multivariate analysis revealed age greater than 40 years (hazard ratio [HR]: 2.20; 95% confidence interval [CI]: 1.47-3.28; p = 0.0001) to be associated with worse patient survival, while the use of radiotherapy (HR: 0.33; 95% CI: 0.24-0.47; p < 0.0001) and surgical resection (HR: 0.66; 95% CI: 0.45-0.96; p = 0.028) were seen to be independent favorable prognostic factors. In conclusion, patients with cerebellar GBM have an overall poor prognosis, with radiotherapy and surgical resection significantly improving survival. As with supratentorial GBM, older age is a poor prognostic factor. The lack of differences between supratentorial and cerebellar GBM with respect to overall survival and prognostic factors suggests these tumors to be biologically similar., (Published by Elsevier Ltd.)

The rosette-forming glioneuronal tumor (RGNT) of the fourth ventricle is a recently described, rare, and distinct tumor of the glioneuronal family. The presentation, natural history, and treatment response of these tumors has been unclear as there are no significant series of a sizeable population with long-term follow-up. We report a comprehensive analysis of 41 patients with RGNT to provide the most current understanding of this rare tumor. Treatment of these patients has consisted of resection via the transvermian and telovelar approaches, with one patient requiring radiotherapy due to tumor recurrence. Various unique imaging characteristics may allow for the preoperative identification of these tumors. Resection via the telovelar approach should be considered for symptomatic tumors and those that pose a risk of obstructive hydrocephalus. Due to their benign nature and low propensity for recurrence, subtotal resection may be appropriate for those that are adherent to the brainstem. Radiotherapy may be considered for patients with tumor recurrence., (Copyright © 2012 Elsevier Ltd. All rights reserved.)