Miscellaneous Extramedullary Pathology

Extramedullary masses may be neoplastic or non-neoplastic. Dermoids, epidermoids, lipomas, teratomas, and neurenteric cysts are inclusion lesions that result from disordered embryo-genesis.39 They may occur throughout the spinal canal but are more common in the thoracolumbar and lumbar spine. Intramedullary locations have also been reported. Associated anomalies such as cutaneous lesions, sinus tracts, occult anterior or posterior rachischisis, or split cord malformations may be present. Inclusion tumors and cysts generally occur as masses, but recurrent meningitis, tethered cord syndrome, or congenital deformities may be the predominant clinical finding.

Paragangliomas are rare tumors of neural crest origin, which may arise from the filum terminale or cauda equina.17,27 These are benign and usually nonfunctioning tumors, which histologically resemble extra-adrenal paraganglia. They appear grossly as a well-circumscribed vascular tumor and may be clinically and radiographically indistinguishable from filum terminale ependymomas. Identification of dense-core neurosecretory granules on electron microscopy establishes the diagnosis. Complete removal can be accomplished in most cases. Cavernous malformations, hemangioblastomas, and ganglioneuromas may involve an intradural nerve root and occur as an extramedullary mass. These lesions may clinically occur as a nerve sheath tumor with early radicular symptoms.

Non-neoplastic lesions such as arachnoid cysts may occur as extramedullary masses. These are most common in the thoracic spine and are usually dorsal to the spinal cord.3 Herniated intervertebral disks have occasionally been reported to rupture through the dura and occur as an intradural, extramedullary

mass.39

Inflammatory pathologies such as sarcoidosis, tubercu-loma, or subdural empyema rarely occur as intradural mass lesions. Although spinal carcinomatous meningitis often complicates systemic cancer, secondary metastatic mass lesions of the intradural, extramedullary compartment are rare. Malignant intracranial neoplasms that are in apposition to the subarach-noid space or ventricles are the most likely intracranial tumors to demonstrate CSF drop metastasis into the spinal subarach-noid space.5 Systemic cancer accesses the subarachnoid space either through direct dural root sleeve penetration, or more commonly, hematogenously via the choroid plexus.

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