Diagnosis :. Plasmocytoma of the entire C7 with circumferential involvement and extradural compression with subsequent paraplegia.
A 63 years old patient was transferred to Al-Shmaisani hospital 20.12.1999 complaining of neck pain, inability to move his lower limbs and gross weakness of the right hand . The patient was with cystofix with bed sore at the sacral area . The patient started to complain of chest and lower neck pain 20.11.1999. Cardiac causes were sought , which were normal. 29.11.1999 the patient got severe abdominal pain with difficulty of walking . The next day the weakness progressed and the patient became paraplegic. The patient was transferred to Al-Bashir hospital 30.11.1999. MRI was performed 04.12.1999 showing the lesion of the C7 level. Cystofix was inserted the first day of admission. The patient is not diabetic, nor hypertensive . He did not underwent previous surgeries. He left smoking since 1975. Glaucoma for what receiving cosmolol ED for 1 year. Eczema of both knees for 2 years. 1 year ago got neck pain with intrascapular pain for 1 week after lifting heavy object and the pain disappeared completely.
On examination: The patient a gentle man with preserved higher functions . The cranial nerves were intact . the distal muscles of the right upper limb were weak 2/5 and complete paraplegia below D1 with anaesthesia. The deep reflexes were exaggerated both sides with Babinski present in both sides. The patient had bed sore at the sacral area.
Radiological investigations before and after the operation.
The patient was operated 21.12.1999; In the supine position anterior approach to the cervical spine was performed and corporectomy of the tumorous C7 was done. The frozen section was that of plasocytoma. The disk material of the adjacent levels was removed and using the high speed drill a partial tunnel was created to fit a compact bone graft harvested from the right fibular bone and fixed with 48 mm cervical miniplate with 8 screws of 20 mm length. The wounds were closed and the patient repositioned prone and skeletonization of C5-D2 was done. The remnants of the tumor were removed and using Hartchel rectangle with 8 sublaminar wires the posterior elements, 2 laminae above and 2 laminae below were fixed. The tumor was totally extradural with intact dura. The wound was closed and 2 units of blood were transfused during the procedure.
Postoperative course was smooth with rapid improvement of the neurological status. The patient could feel all toes both feet and could feel fullness of the bladder and he could void spontaneously the next postoperative day. The cystofix was removed and the patient could move his left lower limb and the weakness regressed within hours. The right lower limb started to improve , but with lesser degree . The patient could set down on the chair the third postoperative day. Control CT-scan and cervical X-rays were performed when necessary. The constructs and the screws were in acceptable position. The final histological verification was that of plasmocytoma. Bone marrow aspirate showed erythroblasts 34%, promyelocytes 4%, myelocytes 8%, metamyelocytes 7%, neutrophils 34%, lymphocytes 11%, plasma cells 1% and eosinophils 1%. M/E ratio was 1.6. Erythropoesis was normoblastic , myelopoesis unremarkable with no evidence of plasma cell proliferation. LDH was 651 U/L with Ca 7.6 MG/DL. The stitches in the neck were removed 29.12.1999 . The stitches in the right foreleg were removed after 1 week. The patient discharged 30.12.1999 to be seen and treated at the nuclear medicine. Radiotherapy was recommended to minimize the recurrence rate locally, but the patient disappeared to come after one year without performing the above mentioned recommendations. The patient underwent second surgery 1 year later for recurrence in the right lateral aspect of the tumor bed, then sent to chemo and radiotherapy. He is till today of publication, neurologically free and recurrence free.
Diagnosis : Pancoast tumor invading D1, D2 and D3 vertebral bodies and the underlying paravertebral muscles.
63 years old patient was seen 31.04.1999 complaining of inability to walk with deep paraparesis at the level of C7 and below with more involvement of the right side of the body with atrophy of the thinar and hypothinar muscles right hand. Hypalgesia at the level T1 and below in the right side more profound in the lower extremity.
The patient was a known case of pancoast tumor underwent several times chemotherapy with taxol, gemcytabine and platinum and radiotherapy at the onco-hematological center in Geneva by Dr. C. Irle during the 1997 and 1998. The patient progressed pneumonia and was treated successfully in January 1998. Patientís neurological state started to deteriorate the last month. MRI was requested and done, showed the extent of the cervical spinal lesion. The patient mentioned that the thinar atrophy was an old event not related to his underlying disease.
CEA was performed 21.04.1999 and it was 10.7 ng/ml. CT-scan of the brain was normal . His hematological picture was acceptable. Considering these data the patient underwent corporectomy of D2 with partial resection of the D1 and 3 with fixation of the posterior elements by using Acromed fixating device to fix and hold the D1 and D3 laminas with sublaminar hooks and with compression element. Bone cement was filled to the tumor resection cavity between the bodies. Artificial bone cement was added . The skin incision showed oozing from the lowermost point and serous fluid was seen for a week after removal of the stitches. The wound became dry 17.05.1997. The patient was discharged, moving all limbs with gross weakness of the proximal muscles of the thighs and grip of the left hand . The patient was advised to undergo aggressive physiotherapy with consideration of chemotherapy after 4-5 weeks later. The patient kept in trental 400 mg three times a day, methycobal 500 mg twice daily decadron tab 3 times a day. Tramal 50 mg twice daily , zantac tab 150 mg twice daily, noctamide 1 mg abt, disflatyl 2 tab three times a day, septrin 2 tab twice daily, cipram 1 tab daily, dolculax supp. S.O.S