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07-APRIL-2013 AHMAD MAMDOUH MALKAWI 48
YEARS INTRAMEDULLARY EPENDYMOMA OF THE SPINAL CORD AT C4 AND C5
The patient came
to the clinic 27-March-2013 complaining of
limping during walking due to weak right leg for
MRI cervical spine done 24-March-2013 showing
intramedullary tumor at the level of C4 and C5
with syrinx extending from C2 down to mid-dorsal
level. MRI of the brain was normal.
On examination: The patient is limping. There is
slight pain when turning the head toward the
right shoulder. Hypotrophy of the interossii
muscles right hand. The grip and extension of
the right hand 4/5, so the right triceps muscle.
Hoffmann positive right side with the deep
reflexes exaggerated in the right side. SLRS was
degrees both sides
without pain. There is
weak dorsi and planterflexion right foot -4/5 and
right quadriceps femoris 4/5. There is
hypalgesia right leg below the knee joint.
Babinski is positive in the right with brisk
clonus right foot.
Using IOM Inomed ISIS,
cervical tumor scenario with MEP SEP. D-wave
proximal and distal with running EMG was setup,
to keep real time monitoring of the neurological
status of the patient. Laminectomy of C4 and C5
was done. The dura was opened longitudinally.
The tumor is seen under the arachnoid of the
spinal cord and dissection of the spinal cord
over the tumor was carried out at the area where
there was no fibers with preservation of the
smallest arteries and veins. Biopsy was done:
ependymoma. The tumor was followed with its
border and practical total resection of the
tumor was achieved. The cleavage was proper in
the right side, but at the left side it was more
adherent to the spinal cord. The spinal cord
became lax and the CSF coming from all
directions and the spinal cord regained normal
shape. The D-waves, MEP and SEP were acceptable
to the end of the total resection. Water-tight
closure of the dura with routine closure of the
wound. Before extubating the patient, another
MEP, SEP and running EMG confirmed the integrity
of the spinal cord.
Routine closure of the wound.
Smooth postoperative recovery.
The weakness of the right lower leg became more
pronounced, but moving and feeling them
The lesion before surgery looking as ependymoma,
because of syrinx formation. It is hard to tell
exactly if it is ependymoma or glioma.