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HELLENIC NEUROSURGERY
SEPTEMBER - DECEMBER 2008, Volume 15, Number 3

CONTENTS
Prospective Clinical Study
Treatment of cervical spondylosis with the use of PEEK cages.......................................................................... 126
A. Prassas, A. Iordanidis, C. Picolas, A. Athanasiou, D. Nikolaidis, I. Kampelis

Clinical Study
Endoscopic Neurosurgery and Endoscopic-assisted Microsurgery for the treatment
of septum pellucidum lesions...................................................................................................................................... 133
M. Fratzoglou, V. Panagiotopoulos, E. Hatzidakis, P. Grunert

Case Reports
Filum terminale arteriovenous fistula: Case report and review of the literature................................................ 141
N. Sakellaridis, S. Pomonis, G. Savvanis, D. Floros
Symptomatic cystic dialation ventriculus terminalis - Case report and literature review................................. 146
D. Kazantzis, P. Pachniotis, C. Lilimpakis, A. Spanos
Brain hemangiopericytoma and its epidural metastases diachronic evolution
while the first diagnosis was meningioma................................................................................................................ 151
C. Tzikas, O. Avramidis, F. Iordanidis, E. Vafiadis, S. Markopoulos, V. Kalpakidis, P. Palladas


- 2008, 15, 3

PEEK......................................... 126
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.......................................... 133
. , B. , . , P. Grunert

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.............................................................................. 141
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.......................................................... 146
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.................................... 151
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 2008, 15(3):126-132
HELLENIC NEUROSURGERY 2008, 15(3):126-132

Prospective CLINICAL STUDY

PEEK

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 127

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Grade 0 Signs and symptoms of root involvement; no
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Grade 1 Signs of spinal cord involvement; normal gait
Grade 2 Slight difficulty in walking; full time employment not prevented
Grade 3 Difficulty in walking; prevent employment but
ambulant without support
Grade 4 Able to walk only with help or frame
Grade 5 Chair bound; bed ridden

128

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130

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 131

SU M M A RY
Treatment of cervical spondylosis with the use of PEEK cages
Iordanidis A., Prassas A., Picolas C., Athanasiou A., Nikolaidis D., Kampelis I.
Department of Neurosurgery, Papageorgiou General Hospital, Thessaloniki, Greece

PURPOSE To study the effectiveness of a new synthetic material (Polyetheretherketone PEEK) that was used
for the treatment of cervical discopathy in 1 or 2 levels. METHODOLOGY 18 patients ranging 29 to 72 years
old, (median 47.7 years, 9 male, 9 female) were treated the past 2.5 years with cervical disk herniation in one
or two levels, using PEEK cages. The patients were treated with frontal microsurgical cervical discectomy in
one or two levels, without the use of plate in 17 cases and with the use of a plate in 1 case. The follow-up period
post-surgically ranged from 9 to 26 months and consisted of clinical examinations, cervical x-rays F+P and
flexion-extension x-rays. RESULTS All patients showed clinical amelioration. Patients with root syndrome
(rhizopathy) and cervical pain showed improvement of the symptoms. Patients with myelopathy also showed
important improvement based on the Nurick scale. Imaging control did not show any material migration
while the percentage of accomplished bone fusion was 100%. CONCLUSIONS Frontal microsurgical cervical
discectomy with the use of PEEK cages is a safe and effective procedure. Long-term follow-up is needed to
extract final conclusions on possible complications of the method using the particular material (cage migration, adjacent level disease etc).
key words: cage, cervical spondylosis, fusion, microsurgical, PEEK

1. Brantigan JW, Stefee AD. A carbon fiber implant to aid

interbody lumbar fusion. Two year clinical results in the
first 26 patient. Spine 15:2106-2107, 1993.
2. Bucciero A, Zordzi T, Piscopo GA. PEEK cage assisted
anterior cervical discectomy and fusion at four levels:
clinical and radiographic results. J Neurosurg Sci 52:3740, 2008.
3. Celic SE, Kara A, Celic S. A comparison of changes over
time in cervical foraminal height and tricortical iliac
graft of polyetheretherketone cage placement following
anterior discectomy. J Neurosurg Spine 6:10-16, 2007.
4. Cho DY, Liau WR, Lee WY, et al. Preliminary experience
using a polyetherethercetone (PEEK) cge in the treatment
of cervical disk disease. Neurosurg 51:1343-1350, 2002.
5. Chiang CJ, Kuo YJ, Chiang YF, et al. Anterior cervival
fusion using a polyetherethercetone cage containing
abovine xenograft: three to five year follow up. Spine
33:2524-2528, 2008.
6. Delepine F, Jund S, Schlatterer B, et al. Experience with
(PEEK) cages and locking plate for anterior cervical fusion
in the treatment of spine trauma without cord injury. Rev
Chir Orthop Reparatrice Appar Mot 93:789-797, 2007.
7. De Palma A, Subin D. Study of the cervical syndrome.
Clin Orthop 38:135-141, 1965.
8. Emery SE, Bohlman HH, Bolesta MJ, et al. Anterior cervical decompression and arthrodesis for the treatment of
cervical spondylotic myelopathy. Two to seventeen year

follow up. J bone Joint Surg Am 80:941-951, 1998.

9. Hillibrand AS, Carlson GD, Palumbo MA, et al. Radiculopathy and myelopathy at segments adjacent to the site
of a previous anterior cervical arthrodesis. J Bone Joint
Surg 81:519-528, 1999.
10. Kandziora F, Pflugmacher R, Schaefer J, et al. Biomechanical comparison of expandable cages for vertebral
body replacement in the cervical spine. J Neurosurg spine
99:91-97, 2002.
11. Kao FC, Niu CC, Chen LH, et al. Maintenance of interbody
spacer in one and two level anterior cervical interbody
fusion: comparison of the effectiveness of autograft allograft and cage. Clin Orthop relat Res 430:108-116, 2005.
12. Kulkarni AG, Hee HT, Wong HK. Solis cage (Peek) for
anterior cervical fusion: preliminary radiological results
with emphasis on fusion and Subsidence. Spine J 7:205209, 2007.
13. Malone Q, Lynn J. Surgical outcome for anterior cervical
discectomy and fusion using the Signus Rabea PEEK cage.
Proceedings of the NASS 18th Annual Meeting. The Spine
Journal 3:129S-130S, 2003.
14. Mastronardi L, Ducati A, Ferrante L. Anterior cervical
fusion with PEEK cages in the treatment of degenerative
disk disease. Preliminary observation in 36 consecutive
cases with a minimum 12 months follow up. Acta Neurochir (Wien) 148:307-312, 2006.
15. Mooreland DB, Asch HL, Clabeaux DE, et al. Anterior

132

cervical discectomy and fusion with implantable titanium

cages: initial impressions, patients outcomes and comparison to fusion with allograft. Spine J 4:184-91, 2004.
Erratum in Spine J May-Jun: following toc, 2004.

, . 15, 3, 2008

domized comparison of rectangular titanium cage fusion

and iliac crest fusion in patients undergoing anterior
cervical discectomy. J Neurosurg Spine 4:1-9, 2006.

16. Sassa RC, Smucker JD, Hacker RJ, et al. Artificial disk
versus fusion: a prospective randomized study with 2-tear
follow-up on 99 patients. Spine 32:2933-40; discussion
2941-2942, 2007.

19. Tumialan LM, Pan J, Roddts GE, et al. The safety and
efficacy of anterior cervical discectomy and fusion with
polyetherethercetone spacer and recombinant human
bone morphogenetic protein-2: a review of 200 patients.
J Neurosurg Spine 8:529-535, 2008.

17. Sung Kon HA, Jung Yul Park, Se-Hoon Kim, et al. Radiological assessment of subsidence in stand-alone Cervical
(PEEK) cage. J Korean Neurosurg Soc 44:370-374, 2008.

20. Vaidya R, Sethi A, Bartol S, et al. Complications in the use

of rhBMP-2 in PEEK cages for interbody spinal fusions.
J Spinal Disord Tech 21:557-562, 2008.

18. Thome C, Leheta O, Krauss JK, et al. A prospective ran-


CLINICAL STUDY

2008, 15(3):133-140
HELLENIC NEUROSURGERY 2008, 15(3):133-140

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SU M M A RY
Endoscopic Neurosurgery and Endoscopic-assisted Microsurgery for the treatment
of septum pellucidum lesions
Fratzoglou M.1, Panagiotopoulos V.2, Hatzidakis E.1, Grunert P.3
1

Department of Neurosurgery, General Hospital of Nikea, Pireas, 2Department of Neurosurgery, University

Hospital of Patras, 3Department of Neurosurgery, Medical School, University of Mainz, Germany

We prospectively evaluated the role of endoscopic neurosurgery and endoscope-assisted microsurgery in the
management of septum pellucidum lesions in 8 patients. Endoscopic surgery was used to treat 4 patients with
symptomatic cysts of the septum pellucidum. All four patients underwent endoscopic cyst fenestration with
a rigid endoscope. In two patients frameless neuronavigation was accomplished with the optical tracking

 139

system (Radionics, Burlington, USA). Additionally, 4 more patients with septum pellucidum tumours (two
pilocytic astrocytomas, one subependymoma and one neurocytoma) were operated using the endoscopeassisted technique to remove them. In one of the four patients, neuronavigation was used for guidance. All
symptoms related to pressure effect of the septum pellucidum cysts to the neighbouring brain structures
resolved after surgery. Regarding the tumours, complete excision was achieved in all patients and there were
no postoperative complications. Endoscopic neurosurgery and endoscope-assisted microneurosurgery, provide
sufficient treatment of septum pellucidum space occupying lesions. Additionally, frameless neuronavigation
is a usefull tool in planning the surgical approach and improving intraoperative orientation.
Key words: Endoscopic neurosurgery; Endoscope-assisted microsurgery; Septum pellucidum lesions; Neuronavigation

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 2008, 15(3):141-145
HELLENIC NEUROSURGERY 2008, 15(3):141-145

CASE REPORT

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Summary
Filum terminale arteriovenous fistula: Case report and review of the literature.
Sakellaridis N, Pomonis S, Savvanis G, Floros D.
1

Neurosurgical Department of KAT National Hospital, Kifissia, Attica, Greece, Neurosurgical Department
of Euromedica Hospital, Athens, Greece, Micromedica Pathological Laboratory, Athens, Greece

We describe the clinical course, neuroradiological findings, treatment and long term follow-up of a very rare
case of filum terminale arteriovenous fistula. We discuss its classification and provide a pathologic specimen
of ischemia from the area of its myelopathy, giving insight into its pathophysiology.
Key words: Arteriovenous fistula, filum terminale

 145

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of the filum terminale with dural arteriovenous fistula.
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Intradural extramedullary spinal arteriovenous malformations fed by the anterior spinal artery. Surg Neurol 8:
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normal vascularization of the intradural filum terminale
in man. Surg Radiol Anat 10: 201-209, 1988.
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arteriovenous fistulas fed by medullary arteries. Neurology
37: 969-979, 1987.
7. Halbach VV, Higashida RT, Dowd CF. Treatment of giant intradural arteriovenous fistulas. Neurosurgery 33:
972-980, 1993.
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Naessens PJ. Direct spinal arteriovenous fistula: A new
type of spinal AVM. J Neurosurg 64: 134-139, 1986.
9. Hida K, Iwasaki Y, Goto K, Miyasaka K, Abe H. Results
of the surgical treatment of perimedullary arteriovenous
fistulas with special reference to embolization. J Neurosurg
90: 198-205, 1999.
10. Hurst RW, Bagley LJ, Marcotte P, Schut L, Flamm ES.
Spinal cord arteriovenous fistulas involving the conus
medullaris: presentation, management, and embryologic
considerations. Surg Neurol 52: 95-99, 1999.
11. Lasjaunias P, Berenstein A. Surgical Neuroangiography,
vol.5. Springer-Verlag, Berlin, Heidelberg, 1992.

12. Lundqvist C, Berthelsen B, Sullivan M, Svendsen P, Anderson O. Spinal arteriovenous malformations: Neurological
aspects and results of embolization. Acta Neurol Scand
82: 51-58, 1990.
13. Meisel HJ, Lasjaunias P, Brock M. Modern management
of spinal and spinal cord vascular lesions. Minim Invasive
Neurosurg 38:138-345, 1995.
14. Merland JJ, Riche MC, Chiras J. Intraspinal extramedullary arteriovenous fistulae draining into the medullary
veins [French]. J Neuroradiol 7: 271-320, 1980.
15. Mull M, Nijenhuis RJ, Backes WH, Krings T, Wilmink JT,
Thron A. Value and Limitations of Contrast-Enhanced
MR Angiography in Spinal Arteriovenous Malformations
and Dural Arteriovenous Fistulas. AJNR 28: 1249-1258,
2007.
16. Rich MC, Melki JP, Merland JJ. Embolization of spinal
cord vascular malformations via the anterior spinal artery.
AJNR 4: 378-381, 1983.
17. Rich MC, Modenesi-Freitas J, Djindjian M, Merland
JJ. Arteriovenous malformations of the spinal cord in
children. Neuroradiology 22: 171, 1982.
18. Riina H, Detwiler P, Porter R, Spetzler R. Classification
of spinal cord vascular lesions; in Youmans Neurological
Surgery, Winn R (ed.). 5th ed., v.2, Saunders: Philadelphia,
5th ed., 2004, pp. 2352-2362.
19. Spetzler RF, Detwiler PW, Riina H, Porter RW. Modified
classification of spinal cord vascular lesions. J Neurosurg
(Spine) 96: 145-156, 2002.
20. Vitarbo EA, Sultan A, Wang D, Morcos JJ, Levi AD.
Split cord malformation with associated type IV spinal
cord perimedullary arteriovenous fistula. Case report. J
Neurosurg Spine 3:400-404, 2005.
21. Zozulya Y, Slinko E, Al-Qashqish I. Spinal arteriovenous
malformations: new classification and surgical treatment.
Neurosurg Focus 20(5):E7, 2006.

 2008, 15(3):146-150
HELLENIC NEUROSURGERY 2008, 15(3):146-150

CASE REPORT

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 147

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 149

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Nassar et al

1968

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1970

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1991

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SU M M A RY
Symptomatic cystic dialation ventriculus terminalis - Case report and literature review
Kazantzis D., Pachniotis P., Lilimpakis C., Spanos A.
Neurosurgery Department St. Savvas Athens Anticancer Hospital

The ventriculus terminalis is a small cavity inside the conus medullaris that is formed during the 5th week of
the embryonic development and reaches its final size at the end of the 2nd year of life. The mechanism underlying its dilation is still unknown. We report a rare case (23 cases published in the international literature) of
symptomatic, post-traumatic, cystic dilation of ventriculus terminalis requiring neurosurgical intervention.
We describe the clinical and neuroradiological findings, differential diagnosis and treatment. The classification of the cystic dilation of ventriculus terminalis in 3 clinical types according to L.M. Batista et al. provides
the management option, which is conservative in type I and surgical in types II and III.
Key words: Conus medularis, cystic dilation, ventriculus terminalis.

150

, . 15, 3, 2008

1. Agrillo U, Tirendi MN, Nardi PV. Symptomatic cystic

dilatation of V ventricle: case report and review of literature. Eur Spine J 6: 281283, 1997.
2. Brisman JL, Li M, Hamilton D, et al. Cyst dilatation of
the conus ventriculus terminalis presenting as an acute
cauda equina syndrome relieved by decompression and
cyst drainage: case report. Neurosurgery 58: E585, 2006.
3. Celli P, DAndrea G, Trill G, et al. Cyst of the medullary
conus: malformative persistence of terminal ventricle or
compressive dilatation? Neurosurg Rev 25: 103106, 2002.
4. Choi BH, Kim RC, Suzuki M, et al. The ventriculus terminalis and filum terminale of the human spinal cord.
Hum Pathol 23: 916920, 1995.
5. Ciappetta P, DUrso PI, Luzzi S, et al. Cystic dilation of
the ventriculus terminalis in adults. J Neurosurg Spine 8:
92-99, 2008.
6. Coleman LT, Zimmerman RA, Rorke LB. Ventriculus
terminalis of the conus medullaris: MR findings in children. AJNR 16: 1421-1426, 1995.
7. Batista ML, Acioly MA, Carvalho CH, et al. Cystic Lesion
of the Ventriculus Terminalis: Proposal for a New Clinical
Classification. J Neurosurg Spine 8: 163-168, 2008.
8. Dullerud R, Server A, Berg-Johnsen J. MR imaging of
ventriculus terminalis of the conus medullaris. A report
of two operated patients and a review of the literature.
Acta Radiol 44: 444446, 2003.
9. Kriss VM, Kriss TC, Babcock DS. The Ventriculus Terminalis of the Spinal Cord in the Neonate: A Normal
Variant on Sonography. AJR 165: 1491-1493, 1995.
10. Korosue K, Shibasaki H, Kuroiwa Y, et al. Cyst of the co-

nus medullaris manifesting amyotrophic lateral sclerosis

syndrome. Folia Psychiatr Neurol Jpn 35: 507510, 1981.
11. Liccardo G, Ruggeri F, Cerchio LD, et al. Fifth ventricle:
an unsual cystic lesion of the conus medullaris. Spinal
Cord 43: 381384, 2005.
12. Matsubayashi R, Uchino A, Kato A, et al. Cystic dilatation
of the ventriculus terminalis in adults: MRI. Neuroradiology 40: 4547, 1998.
13. Nassar SI, Correl JW, Housepian EM. Intramedullary
cystic lesions of the conus medullaris. J Neurol Neurosurg
Psychiat 3: 106109, 1968.
14. Saito K, Morita A, Shibahara J, et al. Spinal intramedullary
ependymal cyst; a case report and review of the literature.
cta Neuroochir (Wien) 147: 443-446, 2005.
15. Sansur CA, Sheehan JP, Sherman JH, et al. Ventriculus
terminalis causing back pain and urinary retention. Folia
Psychiatr Neurol Jpn 148: 919920, 2006.
16. Sigal R, Denys A, Halimi O, et al. Ventriculus terminalis
of the conus medullaris: MR imaging in four patients with
congenital dilatation. AJNR 12: 733737, 1991.
17. Stewart DH Jr, King RB, Lourie H. Surgical drainage
of cyst of the conus medullaris. Report of three cases. J
Neurosurg 33: 106110, 1970.
18. Storer KP, Toh J, Stoodley MA. The central canal of the
human spinal cord: a computerised 3-D study. J Anat 192:
565-572, 1998.
19. Van Rillaer O, Vandaele P, Ramboer K. Malformative
persistence of terminal ventricle. JBR-BTR 92: 178-179,
2009.

 2008, 15(3):151-157
HELLENIC NEUROSURGERY 2008, 15(3):151-157

CASE REPORT

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SU M M A RY
Brain hemangiopericytoma and its epidural metastases diachronic evolution
while the first diagnosis was meningioma
Tzikas C.,1 Avramidis O.,1 Iordanidis F.,2 Vafiadis E.,1 Markopoulos S.,3 Kalpakidis V.,1 Palladas P.1
1

Department of CT and MRI, 2Department of Pathologic Anatomy, 3Department of Neurosurgery

G. Papanikolaou Hospital Thessaloniki

Hemangiopericytoma is a rare sarcoma, representing less than 1% of primary CNS tumors and 2-4% of all
meningeal tumors. It is a sarcoma related to neoplastic transformation of pericytes, contractile cells about
capillaries. It is usually located sypratentorial and typically involves falx, tentorium or dural sinuses. Its often
larger than 4 cm and seems as lobular dural-based extra-axial mass withn narrow pedicle or broad-based dural
attachment. Hemangiopericytoma may mimic meningioma and it might be confusing in its diagnosis. The
aim of this assignment is to present a similar case and to outline its difficulty in approaching imaging findings
and also to underline the epidural metastases that hemangiopericytoma may cause. Male patient 35 years old,
underwent in a surgical operation, 15 years ago, because of meningioma in his right parietal lobe. 7 years ago
he underwent a new surgical operation because of meningioma recidivation but istopathological examination
revealed hemangiopericytoma. 5 years ago he presented with paraparesis and RI of thoracic spinal column
revealed epidural metastases. He underwent a new surgical operation in thoracic spinal column and istopathological examination confirmed the metastases from hemangiopericytoma. One month ago he presented with
pain in thoracic spinal column and consisting headache. RI of thoracic spinal column and of brain were
suggested. Recidivation of hemangiopericytoma was revealed at the left cerebellum hemisphere and relapse of
epidural metastases was revealed in thoracic spinal column. MRI is specific and sensitive and the investigation
of choice in diagnosing hemangiopericytoma and can reveals its epidural metastases.
Key words: Hemangiopericytoma, Bone Erosion, Dural Sinuses Occlusion

1. Bailey P, Cushing H, Eisenchardt L. Angioblastic meningioma. Arch Pathol Lab Med 6:45390, 1928.
2. Galanis E, Buckner JC, Scheithauer BW, et al.Management
of recurrent haemangiopericytoma. Cancer 82:191520,
1998.[Medline]
3. Mena H, Jorge L, Gholam H, et al. Haemangiopericytoma
of the central nervous system: a review of 94 cases. Hum
Pathol 22:8491, 1991.[Medline]
4. Nonaka M, Kohmura E, Hirata M, et al. Metastatic meningeal haemangiopericytoma of thoracic spine. Clin Neurol

Neurosurg 100:22830, 1998.[Medline]

5. Osborn Ann. Diagnostic Imaging: Brain I 6:118-121, 2004.
6. Prakasha B, Jacob R, Dawson A, et al. Haemangiopericytoma diagnosed from a metastasis 11years after surgery
for atypical meningioma. British Journal of Radiology
74:856-858, 2001.
7. Rees JH, Kitchen ND, Beaney RP, et al. Cerebral haemangiopericytoma treated with conservative surgery and
radiotherapy. Clin Oncol (R Coll Radiol) 12:1247, 2000.

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