Intramedullary SOL
- 1. Preoperative case presentation Dr. Md. Toufiq Hasan Resident, Phase-A(R-9) Department Of Neurosurgery Dhaka Medical College Hospital On behalf of NSU-Green Unit
- 2. Particulars of the patient Name : Mr. Alamin Age : 22 years Sex : Male Occupation : Salesman Marital status : Unmarried Address : Jurain Railgate, Postagola,Dhaka Registration no : 82285/85 Ward : 200 Bed No : 07 (Non paying) DOA : 28/05/2023
- 3. Chief Complaints Heaviness on lower limb during walking for 2 month Upper back pain for same duration. Constipation and Difficulty in micturition for same duration.
- 4. History of present illness According to the statement of the patient, he was reasonably well 2 months back. Then, he developed heaviness on lower limb during walking primarily on right then both limb which was insidious, intermittent, intensity of weakness gradually progressive with duration of walking ,day by day activities and relieved by stopping walking, activities and taking rest on bed.
- 5. History of present illness (Cont.) He also complained upper back pain which was insidious onset, gradually progressive, mild to moderate in intensity, dull aching in nature with no radiation, aggravated at night during sleep and partially relieved after taking analgesics.
- 6. History of present illness (Cont.) He gave history of bowel and bladder dysfunction in form of constipation and difficulty in micturition followed by hesitancy and urgency. During the course of his illness, he gave no history of headache, neck pain, trauma, prolonged fever, unexplained weight loss, anorexia, cough, hemoptysis, prolong use of steroid or close contact with known TB patient.
- 7. History of present illness (Cont.) With the above complaints, he visited Mugda Medical college hospital and then referred to Neurosurgery department ,DMCH for better management.
- 8. Associated illness He has no history of Diabetes, Hypertension,any heart, kidney ,lung disease
- 9. Past medical history He has no H/O major childhood illness, previous surgery, accident or injury.
- 10. Immunization History Vaccinated as per EPI schedule and 1 dose of covid vaccine
- 11. Family history Nothing significant. Boy of a non consanguineous married parents. Other family members are leading a healthy life.
- 12. Personal history He is non smoker, non alcoholic, non betel nut chewer
- 13. Socio economic history He belongs to a family with low socio-economic condition
- 15. General Physical Examination Appearance: Anxious Body built: Average Co-operative Decubitus: On choice Nutritional status: Average Pulse: 84 b/m BP: 130/80 mmHg Temp: Not raised RR: 18 /m Jaundice Clubbing Cyanosis Anemia Leukonychia Edema Dehydration Koilonychia Lymphadenopathy Catheter in situ No abnormality detected
- 16. Systemic Examination Cardiovascular System-No abnormality detected Respiratory System-No abnormality detected Alimentary System-No abnormality detected
- 17. Nervous System Examination Higher psychic function: Intact Memory: Intact GCS: E₄V₅M₆ Gait: Spastic Right handed person Cranial nerves Intact Speech : Normal No sign of cerebellar dysfunction No sign of meningeal irritation
- 18. Motor examination of upper limb Right Left Tone Normal Normal Bulk Normal Normal Fasciculation Absent Absent Power Elbow flexors 5 5 Wrist extensors 5 5 Elbow extensors 5 5 Finger flexors 5 5 Finger adductors 5 5 Jerks Biceps ++ ++ Triceps ++ ++ Supinator ++ ++ Hoffman Negative Negative
- 19. Motor examination of Lower limb Right Left Tone Increased Increased Bulk Normal Normal Fasciculation Absent Absent Power Hip flexors 4+ 4+ Knee extensors 4+ 4+ Ankle Dorsiflexion 4+ 4+ EHL 4+ 4+ FHL 4+ 4+ Jerks Knee ++++ +++ Ankle ++++ +++ Planter Extensor Extensor Clonus Present Absent
- 20. Sensory Examination Sensory examination reveals pain, touch, pressure, vibration, proprioception intact.
- 21. Examination of spine No scoliosis, gibbus, kyphotic deformity No visible midline or paraspinal mass Overlying skin condition –normal Local temperature –not raised Focal tenderness is absent
- 23. Provisional diagnosis A case of spastic paraparesis due to dorsal spinal Space occupying lesion
- 24. INVESTIGATIONS
- 25. MRI of Dorsal Spine with screening of whole spine
- 26. MRI of Dorsal spine T2WI with multiple sagittal section with screening of whole spine
- 27. MRI of dorsal Spine T1W1 multiple sagittal section
- 28. MRI of dorsal Spine T2W1 multiple sagittal section
- 29. MRI of dorsal spine with multiple Sagittal section with contrast
- 31. T2WI Multiple axial section
- 32. MRI of dorsal spine with multiple axial section with contrast
- 34. Clinico radiological diagnosis Spastic paraparesis due to Intradural intramedullary space occupying lesion @C7 to D1 level
- 36. Plan Laminotomy and laminoplasty of C7 and D1 vertebra and excision of intradural intramedullary SOL
- 38. Dissection of paraspinal muscle
- 39. Laminotomy of C7 & D1
- 40. Durotomy
- 41. Removal of SOL
- 42. Laminoplasty Various methods commonly used for laminoplasty. (a) Single-door suture technique. (b) Double-door allograft. (c) Single door allograft. (d) Single-door plate fixation.
- 43. Complication 1. Risks of spinal cord or nerve root injury 2. CSF leak 3. Infection 4. Dural scarring 5. Postoperative hematoma
- 44. THANK YOU
- 46. Points in favour Points against Schwannoma Most common nerve sheath mass • "dumbbell-shaped' transforaminal mass • Hemorrhage, cystic, or fatty degeneration • Solitary spinal lesion more likely schwannoma than NF • Bony remodeling– Thinned pedicle . • No uniform enhancement pattern Neurofibroma • Target sign • Hemorrhage, cystic, or fatty degeneration Bulky multilevel spinal nerve root tumors in patient with stigmata of neurofibromatosis type 1 extramedullary ependymoma Ependymoma: Unusual differential for a totally No Cap sign: Hemosiderin at cranial or caudal margin
Editor's Notes
- #20: Reflexes can be graded 0= absent +-= present only with reinforcement 1+=present but depressed 2+= Normal 3+= increased 4+= clonus
- #27: Showing iso to hypointense lesion at the level of C7 and D1 vertebra with fusiform dilatation of spinal cord at this level. Hyperintense signal change above the lesion up to C6 and below the lesion up to D2 vertebra Cervical lordotic curvature is straightening with normal disc space . Anterior and posterior CSF column is maintained. Rest of the spine screening is normal.
- #28: Showing iso to hyperintense lesion at the level of C7 to D1 vertebra with fusiform dilatation of spinal cord at this level.
- #29: Showing iso to hypointense oval shaped lesion at the level of C7 to D1 with peripheral hyperintense signal change extending superiorly up to C6 and inferiorly up to D2 vertebra
- #30: Homogenous contrast enhanced ovoid shaped lesion at the level of C7 to D1 vertebra.
- #31: Iso intense lesion in the central portion of the spinal cord with poorly demarcated outline
- #32: Iso to hyperintense lesion in the central portion of the spinal cord with poorly demarcated outline
- #33: Homogenous contrast enhanced circular lesion on central portion of the cord
- #35: • Target sign more common with NF than schwannoma • Hemorrhage, cystic, or fatty degeneration more common with schwannoma Solitary spinal lesion more likely schwannoma than NF Bony remodeling due to large intraspinal or transforaminal mass – Thinned pedicle, enlarged neural foramen, vertebral body scalloping, widened interpedicular distance Spinal Meningioma • Thoracic tumor in female patient is more likely meningioma • dural "tail" • calcification Broad dural attachment • Strong homogeneous enhancement Neurofibroma Bulky multilevel spinal nerve root tumors in patient with stigmata of neurofibromatosis type 1 Target sign on T2WI Ependymoma Cap sign: Hemosiderin at cranial or caudal margin
- #36: Ependymoma Astrocytoma Ganglioglioma