A case report of an intramedullary cervical teratoma in an adult patient with cervical spondylotic radiculopathy

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An axial CT image of T11 shows the trabecular structure and the lytic areas within the vertebral body and posterior elements of the vertebra." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Suat Canbay, Ali Erhan Kayalar, Gulce Gel, Hakan Sabuncuoğlu" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Suat" "apellidos" => "Canbay" ] 1 => array:2 [ "nombre" => "Ali Erhan" "apellidos" => "Kayalar" ] 2 => array:2 [ "nombre" => "Gulce" "apellidos" => "Gel" ] 3 => array:2 [ "nombre" => "Hakan" "apellidos" => "Sabuncuoğlu" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147318300873?idApp=UINPBA00004B" "url" => "/11301473/0000003000000005/v1_201909060632/S1130147318300873/v1_201909060632/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "Case Report" "titulo" => "A case report of an intramedullary cervical teratoma in an adult patient with cervical spondylotic radiculopathy" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "238" "paginaFinal" => "242" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Parménides Guadarrama-Ortíz, José Alberto Choreño-Parra, Martha Carnalla-Cortés, Carlos Sánchez-Garibay, Ulises Palacios-Zúñiga" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Parménides" "apellidos" => "Guadarrama-Ortíz" "email" => array:1 [ 0 => "dr.guadarrama.ortiz@cennm.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "José Alberto" "apellidos" => "Choreño-Parra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Martha" "apellidos" => "Carnalla-Cortés" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Carlos" "apellidos" => "Sánchez-Garibay" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "Ulises" "apellidos" => "Palacios-Zúñiga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Departamento de Neurocirugía, Centro Especializado en Neurocirugía y Neurociencias México (CENNM), Mexico City, Mexico" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Investigación, Centro Especializado en Neurocirugía y Neurociencias México (CENNM), Mexico City, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Neuropatología, Instituto Nacional de Neurología y Neurocirugía “Manuel Velasco Suárez”, Mexico City, Mexico" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Neurocirugía, Módulo de Columna, Hospital Regional 1° de Octubre, ISSSTE, Mexico City, Mexico" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Teratoma intramedular cervical en un paciente adulto con radiculopatía espondilótica. Reporte de caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1120 "Ancho" => 1750 "Tamanyo" => 539214 ] ] "descripcion" => array:1 [ "en" => "(A)–(B) Intraoperative photographs showing a tumor located just below spinal artery that is covered by a thin layer of connective tissue belonging to leptomeninges. (C)–(D) Tissue dissection revealed a heterogeneous cystic tumor compressing the spinal cord. (E) Complete resection of the spinal cord tumor. (F) Microphotograph of a tissue section from the resected tumor showing a mature teratoma with well differentiated components of cartilage, adipose, glandular and epithelial tissue; H&E staining, 400×." ] ] ] "textoCompleto" => "IntroductionTeratomas are the most frequent variant among germ cell tumors. They are characterized histologically by containing tissue elements derived from the three germ lines. Broadly, teratomas are classified as mature, immature and with a malignant component depending on their differentiation degree. In general, mature forms are considered benign lesions that can be localized in different organs.<a class="elsevierStyleCrossRefs" href="#bib0150">1,2</a> The central nervous system (CNS) is one of the less frequently affected anatomical sites.<a class="elsevierStyleCrossRef" href="#bib0155">2</a> They are preferentially observed among children and typically arise from intracranial midline structures such as the pineal gland or third ventricle.<a class="elsevierStyleCrossRefs" href="#bib0160">3–6</a> Only 0.5% of CNS teratomas occur in the spinal cord.<a class="elsevierStyleCrossRef" href="#bib0180">7</a> Most of the spinal cord teratomas are extramedullary lesions predominantly involving thoracolumbar levels and frequently associated with vertebral structural alterations, principally congenital dysraphisms.<a class="elsevierStyleCrossRef" href="#bib0185">8</a> There are few reports of cervical intramedullary teratomas in adults, and their association with other non-congenital abnormalities of the spine has not been previously described.Clinical caseA 59-year-old woman attended to our hospital complaining of intense cervical pain and numbness radiating to upper limbs, as well as to thoracolumbar back and right lower limb. She had a history of fecal incontinence of intermittent nature (frequency once a week) which increased in stressful situations, accompanied by sensory gait of right predominance from the age of 9 years. She was evaluated by several gastroenterologists who prescribed antidiarrheal drugs with no clinical improvement. Thus, the patient adapted to her disability. At the age of 56 years, she started with cervical pain radiating to both upper limbs with right predominance that increased in intensity over time. Physical examination showed distal muscle hypotrophy as well as abolishment of bicipital, tricipital and brachioradialis reflexes of the right arm, preserving proximal strength. Also, hiporreflexia and loss of proprioception in the right lower limb was observed conditioning sensory gait. The MRI scan showed an intramedullary mass at C7-T1 levels of the spinal cord hyperintense in T2-weighted images. Also, subligamentous protrusion of C6/C7- and C7/T-1 intervertebral discs with dural sac compression and stenosis of the lateral recess were observed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The patient underwent surgical resection of the tumor and decompression of radiculopathy by a one-stage posterior–anterior surgical approach. First, posterior C7-T1 laminectomies were performed. Upon opening the dura mater, a right paracentral lesion covered by a thin layer of connective tissue belonging to leptomeninges was observed. A blunt myelotomy through posterior spinal sulcus was performed, and the heterogeneous cystic lesion was totally resected (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A–E). Afterward, an anterior cervical approach was made through a paramedian incision to reach vertebral bodies C6, C7 and T1. A C6-C7 and C7-T1 discectomies were performed and arthrodesis was achieved by placement of cervical interbody cages.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The histopathologic examination of the tumor showed a mature teratoma with well-differentiated components, including cartilage, adipose tissue, epithelium, and glandular tissue (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>F). The patient evolved with clinical improvement and neurological functions were re-established progressively, even fecal incontinence and sensory gait, as shown in the supplementary video attached to this article. Postoperative MRI showed no residual tumor, but iatrogenic kyphosis was observed which had not clinical relevance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C), as patient only presented mild hypoesthesia in the right upper limb one year after surgery. Written informed consent was obtained from the patient for publication of this case report and the accompanying images/video.DiscussionSpinal cord teratomas are rarely observed in adults.<a class="elsevierStyleCrossRef" href="#bib0190">9</a> Among them, intramedullary tumors are even less frequent. Currently, just ten cases of teratomas involving the cervical spinal cord have been reported, including the one presented here (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0195">10–18</a> Also, this is the first report of a spinal cord teratoma associated with spondylotic radiculopathy at the same level of the spine in an adult.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The pathogenesis and origin of these tumors have been widely discussed elsewhere. One theory argues that they arise due to the misplacement of germ cells.<a class="elsevierStyleCrossRefs" href="#bib0205">12,19</a> Other authors rather suggest a dysembryogenic origin of teratomas based on their frequent location in the terminal spinal cord, which is supported by experimental work showing that the vertebrate tailbud can originate tissues from the three germ layers.<a class="elsevierStyleCrossRefs" href="#bib0245">20,21</a> Intramedullary teratomas do not have particular clinical features allowing to differentiate them from other tumors affecting the spinal cord. Signs and symptoms result from compression to the spinal cord and depend on the level at which they arise. Most patients affected by an intramedullary teratoma present symptom of insidious onset, usually progressive numbness in lower limbs.<a class="elsevierStyleCrossRef" href="#bib0180">7</a> In children, the frequent occurrence of spinal malformations as spina bifida can help to direct diagnosis.<a class="elsevierStyleCrossRef" href="#bib0185">8</a> Intramedullary teratomas generally have a slow rate of growth, and clinical signs appear progressively before any additional anatomical damage occur,<a class="elsevierStyleCrossRefs" href="#bib0220">15,16</a> as observed in the case reported here, in which the tumor was revealed until patient developed intense radicular pain.Although other cases of spinal tumors accompanied by spondylosis have been described before, the authors considered such clinical association anecdotal.<a class="elsevierStyleCrossRef" href="#bib0255">22</a> Conversely, we propose two possibilities to explain the clinical association observed in the present report. First, cervical spondylosis may have occurred as an independent degenerative event, which is in fact feasible due to the high incidence of degenerative diseases of the spine at the age of our patient. On the other hand, spondylotic radiculopathy could have arisen as a result of the tumor growth, which is supported by the exact location of both alterations. Thus, the long evolution of the teratoma together with chronic neurological deficits conditioned by the tumor could impact structural stability of the spine. Then, cervical radicular pain, which was the main reason for consultation, unmasked underlying teratoma causative of neurological manifestations affecting the patient from a very early age. However, other cases of teratomas in adult patients were not associated with spondylosis, which may be explained because affected individuals were younger.<a class="elsevierStyleCrossRefs" href="#bib0210">13-15</a> Additionally, the only other case of an older adult (65-year-old) with an intramedullary cervical teratoma did not present spondylosis maybe because of its upper location (C1).<a class="elsevierStyleCrossRef" href="#bib0225">16</a> Either way, our report provides evidence of the natural history and clinical characteristics of long-term spinal cord teratomas.Definitive treatment of intramedullary teratomas is surgery.<a class="elsevierStyleCrossRef" href="#bib0210">13</a> Our patient also met criteria for surgical treatment of cervical spondylosis.<a class="elsevierStyleCrossRef" href="#bib0260">23</a> It is well known that anterior and posterior approaches are equally effective addressing both cervical spondylosis and intramedullary spinal cord tumors.<a class="elsevierStyleCrossRefs" href="#bib0265">24,25</a> Also, the merit of the alternative far lateral approach for cervical spinal tumors has been described.<a class="elsevierStyleCrossRef" href="#bib0275">26</a> However, due to tumor localization, a posterior approach was the most adequate procedure. A first-stage posterior approach for tumor resection followed by a second-stage surgical decompression of the spine would be a suitable option for the management of our patient, as there is evidence in favor of a two-stage procedure in individuals with severe multilevel circumferential compression to the cervical spinal cord.<a class="elsevierStyleCrossRef" href="#bib0280">27</a> As in other developing countries, our patient had a low economic income that did not allow her to cover the costs of a two-stage procedure. Given the need to solve both clinical problems with minimum risk of complications and the lower cost, we performed a one-stage posterior–anterior surgical approach which has been previously described for tumor resection and vertebral fusion in other clinical scenarios.<a class="elsevierStyleCrossRef" href="#bib0285">28</a> Also, the rationale for the double approach in one-stage procedure was based on the instability that injury to posterior arch due to multilevel laminectomies would cause on the spine. Therefore, anterior approach aimed to achieve decompression and provide stability through arthrodesis of the affected vertebral segments. The surgical procedure resulted safe and neurological functions were recovered despite occurrence of iatrogenic kyphosis, a complication that may result from anterior or posterior approaches. Such deformity must be corrected in symptomatic individuals with mechanical neck pain,<a class="elsevierStyleCrossRef" href="#bib0290">29</a> but our patient remains asymptomatic one year after surgery. So, the relevance of this report beyond the surgical approach performed lies in the rarity of the case, as the occurrence of spondylotic radiculopathy exactly the same location as a spinal cord teratoma has not been previously described.ConclusionsIntramedullary teratomas located at lower cervical segments and their association with degenerative diseases of the spine is rare. To our knowledge, this is the first case report of an intramedullary cervical teratoma associated with spondylosis at the same level. We provide here evidence of the clinical features, diagnosis and management of long-term teratomas, contributing to the knowledge of physiopathology of germ cell tumors affecting the spinal cord.Conflict of interestThe authors declare that they do not have any personal, financial or institutional conflict of interest to report. The current report has not received any type of funding from public and commercial organizations." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1239287" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1150155" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1239286" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1150156" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:2 [ "identificador" => "xack424247" "titulo" => "Acknowledgments" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-01-29" "fechaAceptado" => "2018-09-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1150155" "palabras" => array:5 [ 0 => "Spinal cord tumors" 1 => "Teratomas" 2 => "Spinal cord teratoma" 3 => "Cervical spondylosis" 4 => "Cervical radiculopathy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1150156" "palabras" => array:5 [ 0 => "Tumores espinales" 1 => "Teratoma" 2 => "Teratoma medular" 3 => "Espondilosis cervical" 4 => "Radiculopatía cervical" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Spinal cord teratomas are rare. There are few reports of teratomas affecting the cervical spine and their association with spondylotic radiculopathy has not been described. A 59-year-old woman with history of fecal incontinence attended with cervical radicular pain radiating to upper limbs. Physical examination showed distal muscle hypotrophy and abolishment of bicipital, tricipital, and brachioradialis reflexes of the right arm, preserving proximal strength. Also, hiporreflexia and loss of proprioception in the right lower limb was observed. Magnetic resonance imaging showed an intramedullary mass at C7-T1, accompanied by intervertebral disk protrusions and dural sac compressions at the same level. One-stage posterior–anterior operative approach for tumor resection, decompression of the radiculopathy and replacement of intervertebral discs was performed. The histopathological diagnosis was for a mature teratoma. We described the first case of an intramedullary cervical teratoma associated with radiculopathy in an adult, providing evidence of rare long-lasting teratomas affecting the cervical spine." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Los teratomas medulares son raros. La asociación de teratomas cervicales con radiculopatía espondilótica no ha sido descrita. Una mujer de 59 años con historia de incontinencia fecal acudió con dolor radicular cervical irradiado a miembros superiores. La exploración física reveló hipotrofia distal, arreflexia bicipital, tricipital y braquiorradial del brazo derecho, conservando la fuerza proximal. Se observó hiporreflexia y pérdida de la propiocepción en el miembro inferior derecho. La resonancia magnética reveló una masa intramedular en C7-T1, así como hernias discales y compresión del saco dural en dichos segmentos. Se realizó un doble abordaje posterior-anterior en un solo tiempo para resecar el tumor, descomprimir la radiculopatía y reemplazar los discos afectados. El diagnóstico histopatológico fue de un teratoma maduro. Describimos el primer caso de un teratoma intramedular cervical con radiculopatía espondilótica en un adulto, aportando evidencia sobre los teratomas raros de larga evolución que afectan a la columna cervical." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "Physical examination of the patient described in this report shows recovery of neurological functions one year after surgery. Muscle strength in both upper and lower right limbs is conserved, as well as deep tendon reflexes. Gait is more regular without deviations from the midline and equilibrium test demonstrates absence of alterations of the deep sensitivity. In addition, the patient preserves dynamics of neck movements with mild limitation of active range of motion. In the clinical interview, she claims to be asymptomatic and that the fecal incontinence which affected her during 50 years has resolved. The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0035" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 664 "Ancho" => 1700 "Tamanyo" => 175681 ] ] "descripcion" => array:1 [ "en" => "(A) Contrasted MRI T2-weighted sagittal view of the spinal cord that shows an intramedullary hyperintense mass with cystic component in C7-T1, as well as intervertebral disk herniations in C6-C7 and C7-T1 (arrows). (B) MRI T2-weighted axial view showing the intramedullary localization of the tumor and compression of the dural sac by disk protrusions (arrow). (C) Postoperative MRI T2-weighted sagittal image that reveals no evidence of residual tumor but occurrence of iatrogenic cervical kyphosis." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1120 "Ancho" => 1750 "Tamanyo" => 539214 ] ] "descripcion" => array:1 [ "en" => "(A)–(B) Intraoperative photographs showing a tumor located just below spinal artery that is covered by a thin layer of connective tissue belonging to leptomeninges. (C)–(D) Tissue dissection revealed a heterogeneous cystic tumor compressing the spinal cord. (E) Complete resection of the spinal cord tumor. (F) Microphotograph of a tissue section from the resected tumor showing a mature teratoma with well differentiated components of cartilage, adipose, glandular and epithelial tissue; H&E staining, 400×." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Year \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Location \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Stage of differentiation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Surgical management \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Aggregated alterations \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dereymaeker<a class="elsevierStyleCrossRef" href="#bib0195">10</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1954 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43yr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C5–T2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mature \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subtotal resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spina bifida T2–T3, non-union C1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Padovani<a class="elsevierStyleCrossRef" href="#bib0200">11</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1982 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21yr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C6–T1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mature \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Laminectomy with subtotal resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ak<a class="elsevierStyleCrossRef" href="#bib0205">12</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43yr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C2–C4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mature \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Laminectomy with total resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Midline nodular soft skin mass connecting intradural at C3 level \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Paterakis<a class="elsevierStyleCrossRef" href="#bib0210">13</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62yr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C2–C5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mature \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Laminectomy with partial resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fusion of vertebral bodies and non-union of C1 anteriorly and posteriorly \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Makary<a class="elsevierStyleCrossRef" href="#bib0215">14</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46yr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C1–C2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mature \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete resection through spina bifida tract \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spina bifida at C2, incomplete segmentation of C2 and C3 and marked scoliosis with mild spondylosis at C3 and C4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Arvin<a class="elsevierStyleCrossRef" href="#bib0220">15</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34yr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C4–C6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mature \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Laminoplasty+subtotal excision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C6 spina bifida \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ghostine<a class="elsevierStyleCrossRef" href="#bib0225">16</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65yr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mature \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Laminectomy and partial suboccipital craniotomy with subtotal resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moon<a class="elsevierStyleCrossRef" href="#bib0230">17</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35yr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C6–C7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Immature \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Laminectomy+subtotal resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Han<a class="elsevierStyleCrossRef" href="#bib0235">18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30yr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C1–C2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Immature \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Laminectomy+subtotal resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Present case \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2017 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59yr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C6–T1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mature \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Laminectomy+total resection of+ fixation of spine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spondylosis at C6–T1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2117593.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Previous reported cases of intramedullary teratomas arising at cervical spinal cord in adult patients." ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 141970957 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0150" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Teratomas: a multimodality review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.M. 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Case Report

A case report of an intramedullary cervical teratoma in an adult patient with cervical spondylotic radiculopathy

Teratoma intramedular cervical en un paciente adulto con radiculopatía espondilótica. Reporte de caso

Parménides Guadarrama-Ortíza,

Autor para correspondencia

dr.guadarrama.ortiz@cennm.com

Corresponding author.

, José Alberto Choreño-Parrab, Martha Carnalla-Cortésc, Carlos Sánchez-Garibayc, Ulises Palacios-Zúñigad

a Departamento de Neurocirugía, Centro Especializado en Neurocirugía y Neurociencias México (CENNM), Mexico City, Mexico

b Departamento de Investigación, Centro Especializado en Neurocirugía y Neurociencias México (CENNM), Mexico City, Mexico

c Departamento de Neuropatología, Instituto Nacional de Neurología y Neurocirugía “Manuel Velasco Suárez”, Mexico City, Mexico

d Servicio de Neurocirugía, Módulo de Columna, Hospital Regional 1° de Octubre, ISSSTE, Mexico City, Mexico

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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41;&#8211;&#40;B&#41; Intraoperative photographs showing a tumor located just below spinal artery that is covered by a thin layer of connective tissue belonging to leptomeninges&#46; &#40;C&#41;&#8211;&#40;D&#41; Tissue dissection revealed a heterogeneous cystic tumor compressing the spinal cord&#46; &#40;E&#41; Complete resection of the spinal cord tumor&#46; &#40;F&#41; Microphotograph of a tissue section from the resected tumor showing a mature teratoma with well differentiated components of cartilage&#44; adipose&#44; glandular and epithelial tissue&#59; H&#38;E staining&#44; 400&#215;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Teratomas are the most frequent variant among germ cell tumors&#46; They are characterized histologically by containing tissue elements derived from the three germ lines&#46; Broadly&#44; teratomas are classified as mature&#44; immature and with a malignant component depending on their differentiation degree&#46; In general&#44; mature forms are considered benign lesions that can be localized in different organs&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#44;2</span></a> The central nervous system &#40;CNS&#41; is one of the less frequently affected anatomical sites&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> They are preferentially observed among children and typically arise from intracranial midline structures such as the pineal gland or third ventricle&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#8211;6</span></a> Only 0&#46;5&#37; of CNS teratomas occur in the spinal cord&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a> Most of the spinal cord teratomas are extramedullary lesions predominantly involving thoracolumbar levels and frequently associated with vertebral structural alterations&#44; principally congenital dysraphisms&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> There are few reports of cervical intramedullary teratomas in adults&#44; and their association with other non-congenital abnormalities of the spine has not been previously described&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 59-year-old woman attended to our hospital complaining of intense cervical pain and numbness radiating to upper limbs&#44; as well as to thoracolumbar back and right lower limb&#46; She had a history of fecal incontinence of intermittent nature &#40;frequency once a week&#41; which increased in stressful situations&#44; accompanied by sensory gait of right predominance from the age of 9 years&#46; She was evaluated by several gastroenterologists who prescribed antidiarrheal drugs with no clinical improvement&#46; Thus&#44; the patient adapted to her disability&#46; At the age of 56 years&#44; she started with cervical pain radiating to both upper limbs with right predominance that increased in intensity over time&#46; Physical examination showed distal muscle hypotrophy as well as abolishment of bicipital&#44; tricipital and brachioradialis reflexes of the right arm&#44; preserving proximal strength&#46; Also&#44; hiporreflexia and loss of proprioception in the right lower limb was observed conditioning sensory gait&#46; The MRI scan showed an intramedullary mass at C7-T1 levels of the spinal cord hyperintense in T2-weighted images&#46; Also&#44; subligamentous protrusion of C6&#47;C7- and C7&#47;T-1 intervertebral discs with dural sac compression and stenosis of the lateral recess were observed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A and B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The patient underwent surgical resection of the tumor and decompression of radiculopathy by a one-stage posterior&#8211;anterior surgical approach&#46; First&#44; posterior C7-T1 laminectomies were performed&#46; Upon opening the dura mater&#44; a right paracentral lesion covered by a thin layer of connective tissue belonging to leptomeninges was observed&#46; A blunt myelotomy through posterior spinal sulcus was performed&#44; and the heterogeneous cystic lesion was totally resected &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#8211;E&#41;&#46; Afterward&#44; an anterior cervical approach was made through a paramedian incision to reach vertebral bodies C6&#44; C7 and T1&#46; A C6-C7 and C7-T1 discectomies were performed and arthrodesis was achieved by placement of cervical interbody cages&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The histopathologic examination of the tumor showed a mature teratoma with well-differentiated components&#44; including cartilage&#44; adipose tissue&#44; epithelium&#44; and glandular tissue &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>F&#41;&#46; The patient evolved with clinical improvement and neurological functions were re-established progressively&#44; even fecal incontinence and sensory gait&#44; as shown in the supplementary video attached to this article&#46; Postoperative MRI showed no residual tumor&#44; but iatrogenic kyphosis was observed which had not clinical relevance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#44; as patient only presented mild hypoesthesia in the right upper limb one year after surgery&#46; Written informed consent was obtained from the patient for publication of this case report and the accompanying images&#47;video&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Spinal cord teratomas are rarely observed in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> Among them&#44; intramedullary tumors are even less frequent&#46; Currently&#44; just ten cases of teratomas involving the cervical spinal cord have been reported&#44; including the one presented here &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">10&#8211;18</span></a> Also&#44; this is the first report of a spinal cord teratoma associated with spondylotic radiculopathy at the same level of the spine in an adult&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The pathogenesis and origin of these tumors have been widely discussed elsewhere&#46; One theory argues that they arise due to the misplacement of germ cells&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">12&#44;19</span></a> Other authors rather suggest a dysembryogenic origin of teratomas based on their frequent location in the terminal spinal cord&#44; which is supported by experimental work showing that the vertebrate tailbud can originate tissues from the three germ layers&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">20&#44;21</span></a> Intramedullary teratomas do not have particular clinical features allowing to differentiate them from other tumors affecting the spinal cord&#46; Signs and symptoms result from compression to the spinal cord and depend on the level at which they arise&#46; Most patients affected by an intramedullary teratoma present symptom of insidious onset&#44; usually progressive numbness in lower limbs&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a> In children&#44; the frequent occurrence of spinal malformations as spina bifida can help to direct diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> Intramedullary teratomas generally have a slow rate of growth&#44; and clinical signs appear progressively before any additional anatomical damage occur&#44;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">15&#44;16</span></a> as observed in the case reported here&#44; in which the tumor was revealed until patient developed intense radicular pain&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Although other cases of spinal tumors accompanied by spondylosis have been described before&#44; the authors considered such clinical association anecdotal&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a> Conversely&#44; we propose two possibilities to explain the clinical association observed in the present report&#46; First&#44; cervical spondylosis may have occurred as an independent degenerative event&#44; which is in fact feasible due to the high incidence of degenerative diseases of the spine at the age of our patient&#46; On the other hand&#44; spondylotic radiculopathy could have arisen as a result of the tumor growth&#44; which is supported by the exact location of both alterations&#46; Thus&#44; the long evolution of the teratoma together with chronic neurological deficits conditioned by the tumor could impact structural stability of the spine&#46; Then&#44; cervical radicular pain&#44; which was the main reason for consultation&#44; unmasked underlying teratoma causative of neurological manifestations affecting the patient from a very early age&#46; However&#44; other cases of teratomas in adult patients were not associated with spondylosis&#44; which may be explained because affected individuals were younger&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">13-15</span></a> Additionally&#44; the only other case of an older adult &#40;65-year-old&#41; with an intramedullary cervical teratoma did not present spondylosis maybe because of its upper location &#40;C1&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> Either way&#44; our report provides evidence of the natural history and clinical characteristics of long-term spinal cord teratomas&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Definitive treatment of intramedullary teratomas is surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a> Our patient also met criteria for surgical treatment of cervical spondylosis&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> It is well known that anterior and posterior approaches are equally effective addressing both cervical spondylosis and intramedullary spinal cord tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">24&#44;25</span></a> Also&#44; the merit of the alternative far lateral approach for cervical spinal tumors has been described&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> However&#44; due to tumor localization&#44; a posterior approach was the most adequate procedure&#46; A first-stage posterior approach for tumor resection followed by a second-stage surgical decompression of the spine would be a suitable option for the management of our patient&#44; as there is evidence in favor of a two-stage procedure in individuals with severe multilevel circumferential compression to the cervical spinal cord&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> As in other developing countries&#44; our patient had a low economic income that did not allow her to cover the costs of a two-stage procedure&#46; Given the need to solve both clinical problems with minimum risk of complications and the lower cost&#44; we performed a one-stage posterior&#8211;anterior surgical approach which has been previously described for tumor resection and vertebral fusion in other clinical scenarios&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> Also&#44; the rationale for the double approach in one-stage procedure was based on the instability that injury to posterior arch due to multilevel laminectomies would cause on the spine&#46; Therefore&#44; anterior approach aimed to achieve decompression and provide stability through arthrodesis of the affected vertebral segments&#46; The surgical procedure resulted safe and neurological functions were recovered despite occurrence of iatrogenic kyphosis&#44; a complication that may result from anterior or posterior approaches&#46; Such deformity must be corrected in symptomatic individuals with mechanical neck pain&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a> but our patient remains asymptomatic one year after surgery&#46; So&#44; the relevance of this report beyond the surgical approach performed lies in the rarity of the case&#44; as the occurrence of spondylotic radiculopathy exactly the same location as a spinal cord teratoma has not been previously described&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Intramedullary teratomas located at lower cervical segments and their association with degenerative diseases of the spine is rare&#46; To our knowledge&#44; this is the first case report of an intramedullary cervical teratoma associated with spondylosis at the same level&#46; We provide here evidence of the clinical features&#44; diagnosis and management of long-term teratomas&#44; contributing to the knowledge of physiopathology of germ cell tumors affecting the spinal cord&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any personal&#44; financial or institutional conflict of interest to report&#46; The current report has not received any type of funding from public and commercial organizations&#46;</p></span></span>"
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    "fechaRecibido" => "2018-01-29"
    "fechaAceptado" => "2018-09-25"
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            0 => "Spinal cord tumors"
            1 => "Teratomas"
            2 => "Spinal cord teratoma"
            3 => "Cervical spondylosis"
            4 => "Cervical radiculopathy"
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            0 => "Tumores espinales"
            1 => "Teratoma"
            2 => "Teratoma medular"
            3 => "Espondilosis cervical"
            4 => "Radiculopat&#237;a cervical"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Spinal cord teratomas are rare&#46; There are few reports of teratomas affecting the cervical spine and their association with spondylotic radiculopathy has not been described&#46; A 59-year-old woman with history of fecal incontinence attended with cervical radicular pain radiating to upper limbs&#46; Physical examination showed distal muscle hypotrophy and abolishment of bicipital&#44; tricipital&#44; and brachioradialis reflexes of the right arm&#44; preserving proximal strength&#46; Also&#44; hiporreflexia and loss of proprioception in the right lower limb was observed&#46; Magnetic resonance imaging showed an intramedullary mass at C7-T1&#44; accompanied by intervertebral disk protrusions and dural sac compressions at the same level&#46; One-stage posterior&#8211;anterior operative approach for tumor resection&#44; decompression of the radiculopathy and replacement of intervertebral discs was performed&#46; The histopathological diagnosis was for a mature teratoma&#46; We described the first case of an intramedullary cervical teratoma associated with radiculopathy in an adult&#44; providing evidence of rare long-lasting teratomas affecting the cervical spine&#46;</p></span>"
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      "es" => array:2 [
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Los teratomas medulares son raros&#46; La asociaci&#243;n de teratomas cervicales con radiculopat&#237;a espondil&#243;tica no ha sido descrita&#46; Una mujer de 59 a&#241;os con historia de incontinencia fecal acudi&#243; con dolor radicular cervical irradiado a miembros superiores&#46; La exploraci&#243;n f&#237;sica revel&#243; hipotrofia distal&#44; arreflexia bicipital&#44; tricipital y braquiorradial del brazo derecho&#44; conservando la fuerza proximal&#46; Se observ&#243; hiporreflexia y p&#233;rdida de la propiocepci&#243;n en el miembro inferior derecho&#46; La resonancia magn&#233;tica revel&#243; una masa intramedular en C7-T1&#44; as&#237; como hernias discales y compresi&#243;n del saco dural en dichos segmentos&#46; Se realiz&#243; un doble abordaje posterior-anterior en un solo tiempo para resecar el tumor&#44; descomprimir la radiculopat&#237;a y reemplazar los discos afectados&#46; El diagn&#243;stico histopatol&#243;gico fue de un teratoma maduro&#46; Describimos el primer caso de un teratoma intramedular cervical con radiculopat&#237;a espondil&#243;tica en un adulto&#44; aportando evidencia sobre los teratomas raros de larga evoluci&#243;n que afectan a la columna cervical&#46;</p></span>"
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            "apendice" => "<p id="par0065" class="elsevierStylePara elsevierViewall">Physical examination of the patient described in this report shows recovery of neurological functions one year after surgery&#46; Muscle strength in both upper and lower right limbs is conserved&#44; as well as deep tendon reflexes&#46; Gait is more regular without deviations from the midline and equilibrium test demonstrates absence of alterations of the deep sensitivity&#46; In addition&#44; the patient preserves dynamics of neck movements with mild limitation of active range of motion&#46; In the clinical interview&#44; she claims to be asymptomatic and that the fecal incontinence which affected her during 50 years has resolved&#46; The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Contrasted MRI T2-weighted sagittal view of the spinal cord that shows an intramedullary hyperintense mass with cystic component in C7-T1&#44; as well as intervertebral disk herniations in C6-C7 and C7-T1 &#40;arrows&#41;&#46; &#40;B&#41; MRI T2-weighted axial view showing the intramedullary localization of the tumor and compression of the dural sac by disk protrusions &#40;arrow&#41;&#46; &#40;C&#41; Postoperative MRI T2-weighted sagittal image that reveals no evidence of residual tumor but occurrence of iatrogenic cervical kyphosis&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41;&#8211;&#40;B&#41; Intraoperative photographs showing a tumor located just below spinal artery that is covered by a thin layer of connective tissue belonging to leptomeninges&#46; &#40;C&#41;&#8211;&#40;D&#41; Tissue dissection revealed a heterogeneous cystic tumor compressing the spinal cord&#46; &#40;E&#41; Complete resection of the spinal cord tumor&#46; &#40;F&#41; Microphotograph of a tissue section from the resected tumor showing a mature teratoma with well differentiated components of cartilage&#44; adipose&#44; glandular and epithelial tissue&#59; H&#38;E staining&#44; 400&#215;&#46;</p>"
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                  \t\t\t\t">Dereymaeker<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1954&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">43yr&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">C5&#8211;T2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Mature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Subtotal resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spina bifida T2&#8211;T3&#44; non-union C1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Padovani<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1982&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21yr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C6&#8211;T1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laminectomy with subtotal resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ak<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43yr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C2&#8211;C4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laminectomy with total resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Midline nodular soft skin mass connecting intradural at C3 level&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paterakis<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62yr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C2&#8211;C5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laminectomy with partial resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fusion of vertebral bodies and non-union of C1 anteriorly and posteriorly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Makary<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46yr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C1&#8211;C2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete resection through spina bifida tract&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spina bifida at C2&#44; incomplete segmentation of C2 and C3 and marked scoliosis with mild spondylosis at C3 and C4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Arvin<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34yr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C4&#8211;C6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laminoplasty<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>subtotal excision&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C6 spina bifida&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ghostine<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65yr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laminectomy and partial suboccipital craniotomy with subtotal resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moon<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35yr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C6&#8211;C7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Immature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laminectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>subtotal resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Han<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30yr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C1&#8211;C2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Immature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laminectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>subtotal resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Present case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59yr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C6&#8211;T1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mature&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laminectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>total resection of&#43; fixation of spine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spondylosis at C6&#8211;T1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
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          "identificador" => "bibs0015"
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            0 => array:3 [
              "identificador" => "bib0150"
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Información del artículo

ISSN: 11301473
Idioma original: Inglés

DOI:10.1016/j.neucir.2018.09.001

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