Adult Intramedullary Teratoma of the Spinal Cord: A Case Report and Review of Literature

Case Report

Adult Intramedullary Teratoma of the Spinal Cord: A Case Report and Review of Literature Nefize Turan1, Sameer H. Halani1, Griffin R. Baum1, Stewart G. Neill2, Constantinos G. Hadjipanayis3

Key words Intramedullary - Mature teratoma - Spinal cord neoplasm -

Abbreviations and Acronyms

b-hCG: b-Human chorionic gonadotropin EMG-NCV: Electromyographyenerve conduction velocity H&E: Hematoxylin and eosin MEP: Motor evoked potentials MRI: Magnetic resonance imaging SCM: Split cord malformation From the Departments of 1Neurosurgery and 2Pathology, Emory University School of Medicine, Atlanta, Georgia; and 3 Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA To whom correspondence should be addressed: Constantinos G. Hadjipanayis, M.D., Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2016) 87:661.e23-661.e30. http://dx.doi.org/10.1016/j.wneu.2015.10.053 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2016 Elsevier Inc. All rights reserved.

INTRODUCTION Teratomas are germ cell tumors that include all three embryonic germ layers: endoderm, mesoderm, and ectoderm. Primary cranial teratomas are known to arise in the pineal gland and suprasellar region in the central nervous system1e3; however, teratomas in the spinal cord are extremely rare in adults. Spinal teratomas can be located intramedullary or extramedullary and can be mature, immature, and malignant based on histological degree of differentiation. Reported cases have demonstrated that intramedullary teratomas are seen predominantly in the thoracic and lumbar region,4e13 and only a few reports document spinal teratoma in the cervical spine.14e17 In this report, we present a case of intradural intramedullary mature cystic teratoma of the conus medullaris and review reported thoracolumbar intramedullary teratoma cases to define the characteristics and treatment modalities of thoracolumbar teratomas in adults.

- BACKGROUND:

Teratomas of the spinal cord constitute 0.1% of all spinal tumors, and these lesions are extremely rare in adults. The authors describe a rare case of intradural intramedullary teratoma of the conus medullaris and perform review of literature of intramedullary teratomas seen in the thoracolumbar region.

- CASE

DESCRIPTION: A 48-year-old man presented with fasciculations in the bilateral upper and lower extremities. Radiologic findings revealed an L2eL3 level intradural, nonenhancing, extramedullary cystic mass measuring 15 3 13 mm with a 6-mm enhancing nodule at the level of the conus medullaris. The patient was followed up for 1 year, during which time enlargement of the lesion with new areas of patchy contrast enhancement were observed. L1eL2 decompressive laminectomies were performed, and gross total resection of the lesion was achieved. Histopathologic examination confirmed the diagnosis of benign mature cystic teratoma. A literature review revealed no incidence difference in intramedullary teratomas between males and females (P > 0.05). The mean age at the time of diagnosis was 36.4  12.3 years for men and 41.3  11.6 for women (P < 0.05). The mean symptom duration before treatment was 64.6  79.4 months for females and 20.7  13.8 months for men (P < 0.05). Complete resection was achieved in 48.1% of the cases.

- CONCLUSIONS:

Teratomas should be taken into consideration in the differential diagnosis of intramedullary lesions when the imaging reveals variable signal intensity because of tissue heterogeneity. A partial resection is a viable treatment option when the lesion is attached to vital structures because of the low recurrence rates reported in the literature.

CASE REPORT History and Examination A 48-year-old man had a 2-month history of muscle fasciculations and cramping in the face, tongue, and upper and lower extremities. The patient reported no motor weakness or sensory loss, and he denied having any bowel or bladder dysfunction or lower back pain. He had no history of prior spinal procedures or spinal surgery. The onset of the fasciculations was initially thought to be attributable to muscle fatigue, as the patient was an avid runner. The patient, however, developed increased frequency of fasciculations during rest after stopping exercise. His past medical history was significant for hypertension and he underwent hemorrhoidectomy 8 years before the clinical

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presentation. He was taking ramipril 5 mg daily by mouth for blood pressure regulation. The initial physical examination was unremarkable except 4þ/5 strength in the left extensor hallucis longus muscle. The patient had normal deep tendon reflexes and was not found to have a positive Babinski reflex. Cutaneous examination revealed no abnormalities or dermal sinus tracts. On the review of system, the patient denied having any bowel bladder dysfunction, lower back pain, or gait difficulties. Complete workup was performed to rule out amyotrophic lateral sclerosis because the patient exhibited muscle fasciculations. The result of the workup were unremarkable, including an electromyographyenerve conduction velocity

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(EMG-NCV) test. Moreover, upon physical examination, the patient was noted to have fasciculations present only in the right gastrocnemius. Although the patient confirmed infrequent upper extremity and facial fasciculations, they were not observed during multiple neurological examinations, and therefore were suspected to be unrelated to the current problem. All routine laboratory examination results were within normal limits. Imaging Initial magnetic resonance imaging (MRI) of the lumbar spine demonstrated an L2eL3 level intradural extramedullary cystic mass, slightly paracentral to the right, measuring 15  13 mm with a 6-mm enhancing nodule at the level of the conus medullaris (Figure 1). MRI of the brain showed no abnormalities. Despite the recommendation for surgical intervention, the patient elected to be managed conservatively with clinical follow-up for 12 months. During this time, he continued to have persistent, worsening muscle fasciculations in the lower extremities. He also developed muscle cramping in his calves and feet while sleeping, and the pain awaken him. He continued to have normal bowel and bladder function. One year after the initial presentation, the patient was discovered to have a partial left foot drop and some patchy sensory loss in the left foot and right lower extremity in a nondermatomal distribution. His follow-up MRI showed growth and enlargement of the conus medullaris lesion at the L2eL3 level with some new patchy contrast enhancement present (Figure 2). Operation and Pathologic Findings The patient underwent L1eL2 decompressive laminectomies and gross total resection of the lesion. A midline incision of the dura mater revealed a cystic intradural intramedullary lesion with a nodular component. Microsurgical technique was then used to separate the tumor gently from the involved nerve roots. Neurophysiology monitoring of somatosensory evoked potentials and motor evoked potentials were performed during the surgery. A large amount of mucinous fluid was decompressed from the cystic portion

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ADULT SPINAL CORD TERATOMA

of the tumor. Tumor was resected in a gross total fashion using a cardiac beaver blade (Figure 3). Pathologic investigation of the mass revealed the presence of multiple germ cell layers, including adipose cells, transitional epithelial cells, glial cells, and ganglia in addition to fibrovascular structures, mucinous glands and ductular structures resembling salivary gland with ductal space inflammatory cell infiltration. The final histopathologic diagnosis was that of a benign mature cystic teratoma (Figure 4).

dysfunction, or erectile dysfunction were noted. Nine months after the surgery, follow-up MRI showed no evidence of recurrent or residual tumor (Figure 5). The patient described mild left-foot drop with walking long distances, but it was not appreciable in his day-to-day activities. Of note, the patient denied fasciculations in the upper extremities and the face. Currently, he reports complete resolution of fasciculations in his lower extremities and has returned to running long distances.

Postoperative Course The patient was neurologically intact at discharge. One week after the procedure, he reported to the emergency department with cerebrospinal fluid leakage from the surgical incision site. A lumbar drain was placed, and his symptoms resolved after several days of cerebrospinal fluid drainage. One month after the surgery, the patient reported having mild sensory changes in his right heel and gluteal region. On physical examination, he was found to have 5/5 strength in all extremities. No gait difficulties, bowelebladder

DISCUSSION The literature review was performed using PubMed with a combination of these search terms: spinal, intraspinal, intradural, intramedullary, teratoma, and adult. Reports written in English were used. Thirty-three cases of thoracolumbar intramedullary teratomas were revealed (Table 1). Data analysis of these reported cases, including the present case, was performed to determine the characteristics, treatment modalities and outcomes to better characterize the thoracolumbar intramedullary spinal teratomas in adults.

Figure 1. L2eL3 level intradural nonenhancing extramedullary cystic mass measuring 15  13 mm with a 6-mm enhancing nodule at the level of the conus medullaris was seen at the presentation. (A) Sagittal T1-weighted magnetic resonance image. (B) Sagittal T2-weighted magnetic resonance image.

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Figure 2. Growth and enlargement of the lesion and a new patchy contract enhancement was seen 1 year after follow-up. (A and C) Sagittal T1- and T2-weighted magnetic resonance image at presentation. (B and D) Sagittal T1- and T2-weighted magnetic resonance image after 1 year of follow-up.

In the 33 cases, 51.5% (n ¼ 17) of the patients were male and there was no difference in incidence between sexes (P > 0.05). The mean age at the time of diagnosis was 36.4  12.3 years for men and 41.3  11.6 for women, which was significantly different between sexes (P < 0.05). Overall, the mean age at the time of diagnosis was 38.7  12.0 years. Conus medullaris was involved in 36.3% (n ¼ 12) of the cases, and the lesions were predominantly located between lower the thoracic region starting at T8 as the upper level and L5 as the lower level in lumbar region. The mean symptom duration before treatment was 64.6  79.4 months for women and 20.7  13.8 months for men. Significant difference for symptom duration was found between women and men, and women had a longer symptomatic period before they underwent surgery (P < 0.05). Moreover, the overall mean

symptom duration before undergoing surgical treatment was 42.6  60.3 months. The symptom duration was 24 months for intradural conus medullaris and cauda equine tumors, 33 months for intramedullary ependymomas, and even shorter for malignant lesions.33,34 Moreover, longer preoperative symptomatic duration of teratomas may be explained by the benign and slowly progressing nature of these lesions. On the other hand, the stark difference in symptom duration between genders can be due to delayed diagnosis in women, as back pain is usually the initial presenting symptom in these lesions. Women have a greater risk of developing chronic back pain syndromes.35,36 This association may influence the physicians’ incentive to rule out a pathologic lesion as the cause of pain, thus delaying the diagnosis. Thirty-seven point five percent of the cases had some type of congenital anomaly associated with the lesion, such as anomalous vertebra fusion, spina bifida, congenital scoliosis, and split cord malformation (SCM). All patients were treated with decompressive laminectomy, and complete resection was achieved in 48.1% of cases, whereas partial resection was achieved in the remaining patients for reasons such as attachment of the fibrotic capsule of the lesion to vital structures. One patient was treated with gabapentin for neuropathic pain after surgery, and her

Figure 3. Intraoperative pictures showing the exposure of the lesion. (A) Operative view after midline durotomy. (B) Lesion after the pia has been excised. (C) Lesion is visible on the dorsal aspect of the conus. (D) Resection of the cavity after the removal of the lesion.

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Figure 4. Photomicrographs depicting the involvement of all three germ layers. (A) Adipose tissue, mucinous glands, and ganglion cells. Hematoxylin and eosin (H&E) stain; original magnification 10. (B) Fibrovascular tissue (H&E stain, original magnification 10). (C) Glial tissue

symptoms were partially responsive to medical therapy.8 Mean follow-up time after the operation was 30.6  38.0 months, and recurrence was reported in only 1 patient (0.03%) after a period of 10 years. Partial or full recovery was noted in all patients except 1 patient (0.03%) who reported no change in the symptoms.10 Bladder dysfunction was the most common residual symptom. Teratomas are classified as lesions composed of all three primitive germ layers. The exact mechanism of teratoma formation in the spine is not known; however, there are two theories proposed to explain the phenomenon: misplaced germ cell theory and dysembryogenic theory. First theory proposes that teratomas originate from disordered migration and misplacement of the primordial germ cells from the yolk sac, typically into

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(H&E stain, original magnification 20). (D) Adipose tissue and ganglia (H&E stain, original magnification 20). (E) Mucinous glands and adipose tissue (H&E stain, original magnification 10). (F) Ductal transitional epithelium and ductal inflammation (H&E stain, original magnification 10).

midline location, and are not true neoplastic lesions, whereas the latter theory suggests that teratomas are caused by disordered differentiation of pluripotent cells in an aberrant developmental environment in the primitive streak or caudal cell mass.37,38 Congenital anomalies and dysraphic malformations are thought to support the dysembryogenic theory. In our literature review, 37.5% of the cases had an associated congenital anomaly; however, majority of the cases were seen without an associated malformation. Therefore, some authors support the misplaced germ cell theory more strongly and explain the formation of dysraphisms caused by disruption of embryogenesis by the growth of the teratoma. Intramedullary tumors are rarely known to produce the pathognomonic nerve root pain that is more closely associated with

extramedullary tumors.39 In the intramedullary teratoma case that we present, the patient also did not complain of nerve root pain and exhibited progressive lower motor neuron symptoms, followed by foot drop and later sensory loss that was patchy. Typically, increased reflexes and loss of vesical and rectal control are detected early in the symptomology with intramedullary tumors.39 The patient in the present case remained normoreflexic and did not develop bowel or bladder dysfunction within 1 year of the start of his symptoms. The symptoms related to intramedullary teratomas are not specific, and our literature review revealed that patients with thoracolumbar teratomas most commonly demonstrate symptoms related pain, motor weakness in the lower extremities and gait disturbance.

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Figure 5. No evidence of recurrent or residual tumor was documented 9 months after the operation. (A) Sagittal T1-weighted magnetic resonance

Although the progression of symptoms related to the mature teratomas does not seem to be associated with acute worsening, intratumoral hemorrhage and rapid decline were described in a case of adult intramedullary immature teratoma in the cervical region.40 Rarely, conus medullaris lesions have been associated with neurogenic bladder4 and chronic renal failure at presentation.5 MRI is the most valuable technique for determining the precise localization and morphology of the lesion, and tissue heterogeneity manifested by mixed signals with inhomogeneous intensities on T1and T2-weigthed images should raise the suspicion of teratoma in the differential diagnosis, as this variability could represent different tissue types found in solid and cystic components of the teratomas, such as fat, calcification, or mucoid secretions.16,31,41,42 Moreover, concurrent vertebral and spinal cord abnormalities, such as spina bifida and split cord malformation, should increase the suspicion of a teratoma.42 Plain radiography can be helpful to show bony erosion of vertebral bodies, widening of the interpedicular space, and the presence of vertebral anomalies; however it is of limited use for diagnostic purposes.15,16 Computed

image (MRI). (B) Sagittal T2-weighted MRI. (C) Axial T1-weighted MRI. (D) Axial T2-weighted MRI.

tomography can be helpful to demonstrate variable tumor density and the presence of calcification.15 A mild elevation in a tumor marker such as serum b-human chorionic gonadotropin (b-hCG) in a patient with a spinal teratoma was documented, and the b-hCG levels were shown to decrease to normal range postoperatively, suggesting that patients with spinal teratomas can have mild elevations in b-hCG because of secreted components of the tumor.43 Therefore, b-hCG can be checked if there is a suspicion of teratoma. Histopathologic examination is the gold standard for definite diagnosis. Although teratomas are classified classically by the presence of all three germ layers, it has been suggested that the total number of layers may be difficult to ascertain in some cases because of overgrowth of 1 or 2 germ layers; therefore, the diagnosis cannot be ruled out if all three layers cannot be demonstrated in the histologic specimen.7 The treatment of choice for intramedullary teratomas is surgical excision to prevent progressive deterioration as reported in many of the cases, including the present case. As our literature review revealed, complete excision is accomplished in only half of the cases, most

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likely because of adhesion of the lesion to surrounding nerve roots and spinal cord. Recurrence was noted in only 1 patient after 10 years. However, it is important to note that mean follow-up time was 30.6  38.0 months, much shorter than 10 years; therefore it is hard to draw a conclusion about the recurrence rates. It can be concluded that, if the recurrence happens, it occurs at a later stage and the lesion is slow growing in nature.43 Therefore, gross total resection can be favored to prevent postoperative complications if the lesion is attached to vital structures. If the teratoma harbors any malignant histologic features, radiotherapy is recommended as an adjuvant therapy to prevent recurrence.43 Moreover, the potential use of b-hCG as a tumor marker for monitoring tumor recurrence in the clinical setting remains to be investigated. Teratomas should be considered in the differential diagnosis of thoracolumbar intramedullary lesions when the imaging reveals variable signal intensity because of tissue heterogeneity. A partial resection can be undertaken as a viable treatment option when the lesion is attached to vital structures, because of the low recurrence rates reported in the literature.

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Case No.

Sex

Age (years)

Lower Level

Symptom Duration

Associated Anomaly

Rewcastle and Francocur,196418

1

Female

34

T10

T10

7 months

Absent

Hansebout and Bertrand, 196519

1

Male

47

L1

L3

2 years

Enestrom and von Essen, 197720

1

Male

36

T11

L1

Rosenbaum et al.,197821

1

Male

49

T9

Garrison et al.,19809

1

Male

23

Padovani et al., 198312

1

Female

Nicoletti et al., 199415

1

Male

Al-sarraj et al., 199822

1

Male

35

Conus

Conus

—

Yes

10 years

Poeze et al., 199923

1

Male

23

T12

L1

12 months

Absent

Partial

No

6 years

Improved

Arai et al., 20004

1

Female

54

L2

L5

9 years

Tuft of hair, spina bifida.

Complete

No

6 months

Improved

—

Fan et al., 200113

1

Female

43

Conus

Conus

Tuft of hair, congenital ventriculus terminalis, syrinx

Complete

No

13 months

Improved

—

Nonomura et al., 20027

1

Female

33

T12

L1

9 years

Absent

Partial

No

8 years

Improved

—

2

Male

56

T12

L2

2 years

Absent

Partial

No

—

Improved

Urinary disturbance, paralysis

1

Female

45

L2

L4

2 years

Absent

Complete

No

1 year

Improved

Hypoesthesia

2

Male

20

L2

L4

n/a

Absent

Complete

No

3 months

Improved

1

Female

40

Conus

Conus

15 years

Absent

Partial

No

7 years

Improved

Hejazi et al., 200324

Caruso and Colonnese, 200625

Recurrence

Follow-up Duration

Outcome

Partial

No

9 months

Improved

Paralysis of left leg

Scoliosis, vertebral anomalies

Complete

No

14 weeks

Improved

Sexual dysfunction

3 years

Congenital scoliosis

Partial

No

8 years

Improved

Extensor paralysis of left foot

T9

4 years

SCM

Complete

No

—

Improved

—

L2

Conus

5 months

Absent

Complete

No

4 months

Improved

—

33

L1

L3

2 years

Absent

Complete

No

1 month

Improved

Urinary disturbance

47

T12

L4

2 years

Absent

Partial

No

6 months

No change

Gait disturbance, urinary disturbance, sensory and motor deficits

—

—

—

Resection

—

Residual Symptom

— Gait difficulty, absent ankle jerk reflex

— Urinary disturbance

Female

41

Conus

Conus

15 years

Absent

Partial

No

6 years

Improved

—

1

Female

42

Conus

Conus

1 year

Absent

Complete

No

—

Improved

—

Tsitsopoulos et al., 200627

1

Female

44

T8

T10

5 year

SCM, spina bifida

Partial

No

15 months

Improved

—

Mut et al., 20078

1

Female

34

L1

L2

6 weeks

SCM

Partial

No

3 months

Improved

—

CASE REPORT

2 Kahilogullari et al., 200626

ADULT SPINAL CORD TERATOMA

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Upper Level

Study, Year

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Table 1. Adult Thoracolumbar Intramedullary Teratoma Cases Reported in the Literature

CASE REPORT

—

—

—

—

—

—

—

—

—

—

—

—

—

Improved 9 months

5. Mohindra S, Chhabra R, Gupta R, Dass Radotra B. Cystic, exophytic teratoma of conus medullaris presenting with chronic renal failure. Surg Neurol. 2008;69:81-83; discussion: 84.

No

Improved 74 months No

Partial

Partial

Improved 3 months No Complete

Improved

Improved 2 months

2 months No

No Complete

Complete

— — — —

—

— —

— —

— —

—

— — — —

— — —

Tuft of hair

Spina bifida, tethered cord, lipomeningocele

SCM

SCM

Absent

Absent

Absent

Absent

Absent

Absent

4 months

4 months

20 years

5 months

3 years

2.5 years

2 years

1 month

3 months

3 months

14 months

14 months

Conus

S1

L2

T11

L3

T11

T10

Conus

Conus

L2

L3

Conus

Conus

Conus

T10

T11

L1

T11

T10

Conus

Conus

T12

T12

Conus

68

52

51

31

30

32

32

18

57

22

24

48

Female

Female

Female

Male

Male

Male

Male

Male

Male

Female

Female

Male

SCM

Absent

2 years Conus Conus 35 Male

—

Improved 12 months No

Absent

Symptom Duration Lower Level

Partial

Improved 3 years No

4. Arai Y, Takahashi M, Takeda K, Shitoto K. Adultonset intradural spinal teratoma in the lumbar spine: a case report. J Orthop Surg (Hong Kong). 2000;8:69-74.

7. Nonomura Y, Miyamoto K, Wada E, Hosoe H, Nishimoto H, Ogura H, et al. Intramedullary teratoma of the spine: report of two adult cases. Spinal Cord. 2002;40:40-43. 8. Mut M, Shaffrey ME, Bourne TD, Jagannathan J, Shaffrey CI. Unusual presentation of an adult intramedullary spinal teratoma with diplomyelia. Surg Neurol. 2007;67:190-194.

Upper Level

Complete

Improved No Complete

12 months

Recurrence

3. Shibui S, Nomura K. Statistical analysis of pineal tumors based on the data of brain tumor registry of Japan. Prog Neurol Surg. 2009;23:1-11.

6. Li Y, Yang B, Song L, Yan D. Mature teratoma of the spinal cord in adults: an unusual case. Oncol Lett. 2013;6:942-946.

Age (years)

9. Caruso R, Antonelli M, Cervoni L, Salvati M. Intramedullary teratoma: case report and review of the literature. Tumori. 1996;82:616-620. 10. Nicoletti GF, Passanisi M, Platania N, Lanzafame S, Albanese V. Intramedullary spinal cystic teratoma of the conus medullaris with caudal exophytic development: case report. Surg Neurol. 1994;41:106-111. 11. Jian W, Ying W, Chao Y. Intramedullary spinal teratoma of the conus medullaris: report of two cases. Acta Neurochir (Wien). 2010;152:553-554. 12. Padovani R, Tognetti F, Sanpaolo P, Pozzati E, Gaist G, Kuba I. Intramedullary cystic teratoma. Acta Neurochir (Wien). 1982;62:101-108. 13. Fan X, Turner JE, Turner TM, Elrod JP, Clough JA, Howell EI, et al. Carcinoid tumor development in an intramedullary spinal cord mature teratoma. AJNR Am J Neuroradiol. 2001;22:1778-1781.

1

1

1

2

1

5

4

3

2

1

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Present case

Suocheng and Yazhou, 201432

Li et al., 201331

Jian et al., 2010

11

Sharma et al., 2009

1 Benes et al., 2009

30

1 Ijiri et al., 200928

Mohindra et al., 20085

29

1

14. Arvin B, Pohl U, David K. Intramedullary cervical teratoma in an adult. Spine J. 2009;9:e14-18. SCM, Split chord malformation.

Associated Anomaly

1. Sawamura Y, Kato T, Ikeda J, Murata J, Tada M, Shirato H. Teratomas of the central nervous system: treatment considerations based on 34 cases. J Neurosurg. 1998;89:728-737. 2. Liu Z, Lv X, Wang W, An J, Duan F, Feng X, et al. Imaging characteristics of primary intracranial teratoma. Acta Radiol. 2014;55:874-881.

Sex Case No. Study, Year

Table 1. Continued

ADULT SPINAL CORD TERATOMA

REFERENCES

Resection

Follow-up Duration

Outcome

Residual Symptom

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15. Makary R, Wolfson D, Dasilva V, Mohammadi A, Shuja S. Intramedullary mature teratoma of the cervical spinal cord at c1-2 associated with occult spinal dysraphism in an adult. Case report and review of the literature. J Neurosurg Spine. 2007;6: 579-584. 16. Moon HJ, Shin BK, Kim JH, Kwon TH, Chung HS, Park YK. Adult cervical intramedullary teratoma: first reported immature case. J Neurosurg Spine. 2010;13:283-287.

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17. Ghostine S, Perry E, Vaynman S, Raghavan R, Tong KA, Samudrala S, et al. The rare case of an intramedullary cervical spinal cord teratoma in an elderly adult: case report and literature review. Spine (Phila Pa 1976). 2009;34:E973-978. 18. Rewcastle NB, Francoeur J. Teratomatous cysts of the spinal canal; with “sex chromatin” studies. Arch Neurol. 1964;11:91-99. 19. Hansebout RR, Bertrand G. Intraspinal teratoma simulating protruded intervertebral disc. J Neurosurg. 1965;22:374-379. 20. Enestrom S, von Essen C. Spinal teratoma. Acta Neurochir (Wien). 1977;39:121-126. 21. Rosenbaum TJ, Soule EH, Onofrio BM. Teratomatous cyst of the spinal canal. Case report. J Neurosurg. 1978;49:292-297.

ADULT SPINAL CORD TERATOMA

teratoma and diastematomyelia in an adult. Spinal Cord. 2006;44:632-635. 28. Ijiri K, Hida K, Yano S, Iwasaki Y. Huge intradural ossification caused by a mature spinal teratoma: case report. Neurosurgery. 2009;64:E1200-1201; discussion: E1201. 29. Benes V 3rd, Barsa P, Mikulastik J, Suchomel P. Exophytic intramedullary mature teratoma of the conus medullaris: Case report and review of the literature. Cent Eur Neurosurg. 2009;70:154-160. 30. Sharma MC, Jain D, Sarkar C, Suri V, Garg A, Singh M, et al. Spinal teratomas: a clinicopathological study of 27 patients. Acta Neurochir (Wien). 2009;151:245-252; discussion: 252. 31. Awwad EE, Backer R, Archer CR. The imaging of an intraspinal cervical dermoid tumor by MR, CT, and sonography. Comput Radiol. 1987;11:169-173.

22. al-Sarraj ST, Parmar D, Dean AF, Phookun G, Bridges LR. Clinicopathological study of seven cases of spinal cord teratoma: a possible germ cell origin. Histopathology. 1998;32:51-56.

32. Suocheng G, Yazhou X. A review on five cases of intramedullary dermoid cyst. Childs Nerv Syst. 2014; 30:659-664.

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Portions of this work have been presented in oral presentation form at the Georgia Neurosurgical Society Fall Meeting, Greensboro, Georgia, USA, December 7, 2014. Received 7 July 2015; accepted 10 October 2015 Citation: World Neurosurg. (2016) 87:661.e23-661.e30. http://dx.doi.org/10.1016/j.wneu.2015.10.053 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2016 Elsevier Inc. All rights reserved.

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