Name:
FOCUS25824video12
Description:
FOCUS25824video12
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Duration:
T00H05M07S
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https://cadmoreoriginalmedia.blob.core.windows.net/b4ea946d-d08b-4904-a4b0-170aa0dda5c2/12. 25-18.mp4?sv=2019-02-02&sr=c&sig=EZynLbDV4EhFfS3Ex8vZrN%2BZpLbQ3uHRMBk5uqGpeok%3D&st=2026-04-05T07%3A54%3A35Z&se=2026-04-05T09%3A59%3A35Z&sp=r
Upload Date:
2025-12-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER: This case is of a 53-year-old man who presented
SPEAKER: with neck and left shoulder pain many years ago. Seven years prior to presentation to our clinic, he underwent a C4–5 ACDF for this neck and left shoulder pain, which did not help. His examination was normal, with the exception of some numbness in the left hand and the C7 and C8 distribution, perhaps the ulnar distribution. Here is his original MRI scan prior to his C4–5 ACDF.
SPEAKER: You can clearly see the C4–5 disc herniation. But down by C6, there's an abnormality of the spinal cord on the sagittal T2-weighted images, which are on your left. Enhanced images, which are the middle and right-sided images, do not show any enhancement. He underwent that C4–5 ACDF. His symptoms were somewhat improved, but he still had some residual paresthesia in the hand.
SPEAKER: This is a follow-up MRI scan 1 year after that surgery, showing really no change in that lesion at C6. Six years later, he presented to our office with worsening symptoms, now with a paresthesia and really bothersome pain in his hand. And this is his MRI scan 6 years later. As you can see, the lesion appears to be somewhat larger, but he also has a disc herniation at C6–7, which is clearly causing compression of the cord.
SPEAKER: So the question is, is this a tumor which is getting larger and causing symptoms, or are symptoms due to the disc herniation? Diagnostic considerations present this. So neurologically, with the exception of some numbness in his hand, he was neurologically normal. We were very reticent to biopsy the cord for really a diffuse lesion in someone who's neurologically normal.
SPEAKER: So what we did was a C6 corpectomy with a plan to decompress the spinal cord and see what happened and follow him with further imaging. Surgery went fine. His symptoms didn't change. And this is follow-up imaging 6 months later. As you can see at this point, there's been a significant change in the imaging of the spinal cord lesion.
SPEAKER: It now is a discrete tumor with a cystic cap, which he did not have before. He was taken back to the OR for a posterior approach for a complete resection of the tumor. The tumor had the appearance of an ependymoma at the time of recurrence. The apical cap was very helpful in terms of establishing the margins of the tumor, which was removed.
SPEAKER: The case was complicated by a pseudomeningocele. Interestingly, the leak was from one of the needle holes in the dura that we had used to tack up the dura. It created a ball valve effect, which led to the large pseudomeningocele, which we went back and fixed a few weeks after surgery. His neurological examination was slightly worse following this operation, with paresthesia bilaterally from the armpits down.
SPEAKER: Pathology came back as a grade 2 ependymoma, and he was treated postoperatively with radiation therapy. His last MRI scan 5 years ago showed no recurrence, and his exam has been stable since that time. This is the 1-year follow-up MRI scan. The 5-year follow-up MRI scan looks identical. So opportunities for improvement. Should we have explored the tumor sooner?
SPEAKER: We were very reticent to do so because it was essentially asymptomatic. We think the vast majority of symptoms were coming from the disc herniation, at least we thought so preoperatively. Turns out we were mistaken. The tumor was relatively diffuse, and we were very worried about doing a biopsy on a diffuse lesion in the spinal cord.
SPEAKER: Was the decompressive surgery unnecessary? Well, in retrospect, that corpectomy probably was unnecessary. If we were going to do a posterior laminectomy infusion anyway, he did not require that first operation. That was an unnecessary operation. What explains the postop paresthesia? His sensory level is somewhat odd, but we think we can probably explain it based on interruption of the spinothalamic tracts.
SPEAKER: And was postop radiation necessary? The literature regarding radiation of ependymomas in the spine is not clear-cut. Because it was grade 2, we decided to basically catabolize the cranial literature and treated him with radiation therapy. So what did this case teach us? Well, we're taught in medical school always to find a single diagnosis to explain the entire clinical picture.
SPEAKER: This principle is called Occam's razor. But sometimes, there's more than one thing going on. And this is Hickam's dictum— that a man can have as many diseases as he damn well pleases. Close clinical and radiographic follow-up of atypical cases is necessary. And it's important to communicate with the patient throughout the process.
SPEAKER: Before doing that corpectomy, we had a long talk with the family and explained to them that we may be coming back to do a second operation in the future. And the reason we did the corpectomy was to try to not disturb the posterior tissues, to keep the door open for us to do a potentially posterior decompression later in the future. Thank you very much.
SPEAKER:
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