orthopedic paper IV
Lipoma under soft spinal membrane complicated with high paraplegia
AAlthough 85% of intraspinal tumors are extramedullary tumors, infraspinal lipoma is rare. Because its location is close to the spinal cord, the resulting pathological changes and clinical symptoms are easy to be mixed with intramedullary tumors. However, due to its benign nature, surgical management and prognosis are quite different. One case was treated in our hospital and has been followed up for half a year after the operation. It has now recovered. This is reported as follows.
A 39-year-old farmer from our county, married with medical record No.1340, was admitted to our hospital on March 28, 1979.
Numbness and weakness of both lower limbs with band-like stabbing pain in the right chest for half a year, difficulty in urination and defecation, inability to walk and stand for two months, and elevation of the plane of paralysis to the level of nipples with poor breathing for two weeks.
体检: 第二肋间以下浅感觉基本消失，以右侧为重，左侧遗有部分刺痛区。腹壁、提睾反射不能引出，两下肢肌力 8-4 级，无踝阵挛。上胸段脊柱棘突叩击痛，但无畸形。脊柱胸段X线片阴性。奎肯氏试验示蛛网膜下腔完全梗阻，脑脊液化验: 潘氏试验(+)，细胞数10个/立方毫米，呈弗洛因氏征(Froin)。截瘫指数2-4 (感觉2，运动1，括约肌1)。
The superficial sensation under the second intercostal space almost disappeared, with the focus on the right side, and some stabbing pain areas were left. Abdominal wall and cremaster reflex could not be extracted, and the muscle strength of both lower limbs was grade 8–4, with no ankle clonus. The spinous process of the upper thoracic spine was impacted with pain, but there was no deformity. X-rays of the thoracic spine were negative. A Kuiken’s test showed complete obstruction of the subarachnoid space, and cerebrospinal fluid tests: Pan Shi test (+), with 10 cells/mm3 and Froin. Paraplegia index was 2–4 (sensation 2, movement 1, sphincter 1).
Pre-operative diagnosis: tumor in cervical and thoracic spinal canal with paraplegia, extramedullary.
On April 4, the spinal canal was explored under local anesthesia. Through posterior midline approach, complete laminectomy was performed for thoracic region 7–12, and cervical region 6–thoracic region 5 spinal canal was cut open. Epidural fat was uniformly distributed and there was no local absorption, nor was there any local bulge or thickening, and no hard degeneration area was found in palpation. However, during the operation, the QUAKENBI test of thoracic 4-puncture still showed obstruction, and the dura mater was incised. It was shown that thoracic 1:2 spinal cord was slightly to the right at the dorsal side, and there were 35x20x12 cm fat-like yellow soft vegetation, which caused the spinal cord to be compressed by 1/2, which was the factor of subarachnoid space obstruction. Stripping resection was performed under the soft spinal membrane. Due to the close proximity, only 80% of the vegetation was removed to avoid spinal cord injury. The pathology was sent for examination, marked with silver clips, and the operation field was rinsed. At this time, the spinal cord recovered to weak pulsation, and the dura mater was not sutured, which was allowed to open for decompression. The soft tissues were routinely sutured, and no drainage was performed.
The burning sensation developed in both lower limbs 48 hours after the operation, and the movement and sensation gradually recovered. The urinary catheter was removed 19 days after surgery to urinate on his own, and he could also turn over on his own at this time. She was hospitalized for 36 days and discharged for rest without complications.
Pathological report: The neoplastic organism was “adipose tissue”, pathological No.4724.
Half a year after the operation, the patient could walk under the crutch, and all of his feelings recovered. His stool was normal, and his range of urination was the same as normal. He had good food and nutrition, and could do manual work like weaving.
Submucosal tumors of spinal cord are vegetations covered on the spinal cord, which cause space-occupying compression and spinal canal obstruction. Unlike intramedullary tumors that directly destroy the spinal cord structure, they can not only cause space-occupying pathological changes, but also damage spinal cord function. The former are mostly benign lesions, while the latter are mainly malignant. However, both of them are closely related to the spinal cord, so the paraplegia can occur early and the disease progresses quickly. The “lipoma” in this case was a benign lesion with a course of only half a year, which also caused a severe case of complete spinal canal obstruction.
Intramedullary malignancies, such as gliomas, and paraplegia occur early and completely. Benign lesions adjacent to the spinal cord often present with clinically severe ipsilateral paralysis due to the deviation of the neoplasm to one side, the so-called Brown-sequard syndrome. In this case, the degree of bilateral paralysis was different, and the right “intercostal neuralgia” appeared in the early stage, which was consistent with the vegetation leaning to the right during the operation. At the same time, bladder and rectum dysfunction is not complete.
In the clinical practice of progressive paraplegia, the Kwechsler test showed obstruction, which meant that there was mechanical compression factor. It was advisable to carry out early surgical exploration of the lesion and timely decompress. Because even benign lesions, prolonged compression can cause irreversible damage to the spinal cord. It’s called flaccid paralysis, and you can’t recover from it for weeks. In our case, surgical decompression was performed in time with good results.
According to the plane of clinical paralysis and the Quirrell test and myelography, we can often understand the situation of spinal canal obstruction and indicate the location. The decompression effect was judged according to the recovery of spinal cord pulsation during the operation. In cases where the neoplasm cannot be completely removed, decompression with an open dura is necessary.
软脊膜下脂肪瘤，组织柔软，又系良性，在硬膜上不造成脂肪被吸收，又无局部隆起及发硬区，故不能在硬膜外被察出; 当切开硬脊膜，透过软膜，可以清楚地被识出: 一块黄色赘生物盖在脊髓上，血管增多，分布异常，脊髓受压变扁。
The lipoma under the soft spinal membrane has soft tissue and is benign. It does not cause fat absorption on the dura mater, and there is no local uplift and hard area, so it cannot be detected outside the dura mater. When the dura mater was incised and the soft membrane was penetrated, it was clearly recognized that a yellow vegetation covered the spinal cord, with an increase in blood vessels, an abnormal distribution, and the compressed and flattened spinal cord.
In this paper, we report a rare case of infraspinal lipoma with paraplegia, as well as its treatment and recovery. The differential diagnosis from intramedullary tumor was analyzed from the pathological and clinical aspects, and the diagnosis and treatment were proposed. It was pointed out that the operation should be performed as soon as possible without risking “complete” resection of the tumor, and spinal cord decompression was necessary.
By Mingjie Li, Nanling Hospital Surgery Department