Freiburg Neuropathology Case Conference

Excerpt

A 66-year-old woman presented in our outpatient clinic complaining of diffuse “blocks” in her back and spasms in her legs since 1 year, which had been increasing in the past 6 months. Clinical examination revealed a paraspasticity accentuated on the left side and a severe sensory deficit caudally from D5. In addition, she reported incontinence at night as well as partially during daytime. Under the clinical diagnosis of thoracic myelopathy magnetic resonance imaging (MRI) of the thoracic spine was performed, revealing an intradural, intramedullary lesion (Fig. 1 and 2). Given the increasing clinical myelopathy, surgery was performed with continuous electrophysiological monitoring with motor evoked potentials (MEP), somatosensory evoked potentials (SEP) and corticospinal motor evoked potentials (D‑wave): the dura was exposed via a midline approach with laminotomy of D5 and D6. Noticeable was an extensive venous congestion of the dura not common with other intramedullary tumors. The dura was opened under microscopic view and the massively swollen spinal cord was exposed. Myelotomy was performed medial from the dorsal root entry zone on the left side and the lesion was reached 1.5 mm below the surface. It showed a smooth surface and was well delineated from the cord. After removal of a small biopsy, the tumor was progressively resected. During the resection of the tumor mass it appeared that the anterior aspect of the lesion directly reached the anterior pia. Although the tumor could easily be removed from the cord without substantial manipulation in a caudal direction, it was adherent to the cord at the cranial pole in the anterior aspect and showed no delineation to the left anterior nerve root D5. As the potentials of the intraoperative electrophysiology diminished when reaching these parts of the tumor, resection was stopped at that point. After watertight closure of the dura refixation of the laminotomy block was achieved with titanium miniplates. Postoperatively the patient showed a new proximal paresis of the left leg and constant sensory deficits which both regressed during rehabilitation.

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