Outcome predictors and complications in the management of intradural spinal tumours

Intentional Dural Resection during en bloc Spinal Resection Could Provide a Secure Surgical Margin for Patients with Recurrent Spinal Tumors

OBJECTIVE

It is always difficult to obtain a comfortable surgical margin for patients with recurrent malignant or invasive benign spinal tumors. Tumor intraspinal invasion and dural adhesion are the essential reasons. There are always residual tumor cells maintained at the edge of dura. Dural resection is a key point to obtain a comfortable surgical margin for such cases. Whether such patients benefit from this risky surgical procedure is unknown. This study aims to understand better the oncological results, associated risks, and neurological function of this risky surgical procedure.

METHODS

We retrospectively reviewed clinical data from six consecutive patients who registered spinal tumors in our institute and underwent dural resection during en bloc spinal resection from June 2013 to May 2020. The demographic and perioperative data, oncological outcomes, complications, and neurological status were collected and analyzed.

RESULTS

All six patients were followed up for 24 to 46 months (mean follow-up time: 32.8 months). Local recurrence was detected in one patient (1/6, 16.7%) at 36 months postoperatively and in five patients with no evidence of disease at the last follow up (survival rate 83.3%). Eleven complications occurred in four patients (66.7%), and the dural resection-related complications included only four cases of cerebrospinal fluid leakage (CSFL), which accounted for 36.4% (4/11) of all complications. Neurologic status evaluated by the Frankel grade showed improvement of one grade in one case and deterioration of one to two grades in five patients immediately after surgery. All deterioration cases recovered to the preoperative level 6 months after the operation.

CONCLUSION

Dural resection is significant for patients with dura matter invaded by recurrent primary malignant or invasive benign spinal tumors with the purpose of clinical cure. This study demonstrated that in strictly selected cases, intentional dural resection could provide satisfying local control and long-term disease-free survival with acceptable complications and satisfying neurological function.

Single-Center Experience of Resection of 120 Cases of Intradural Spinal Tumors

BACKGROUND

Our study presents a single-center experience of resection of intradural spinal tumors either with or without using intraoperative computed tomography-based registration and microscope-based augmented reality (AR). Microscope-based AR was recently described for improved orientation in the operative field in spine surgery, using superimposed images of segmented structures of interest in a two-dimensional or three-dimensional mode.

METHODS

All patients who underwent surgery for resection of intradural spinal tumors at our department were retrospectively included in the study. Clinical outcomes in terms of postoperative neurologic deficits and complications were evaluated, as well as neuroradiologic outcomes for tumor remnants and recurrence.

RESULTS

112 patients (57 female, 55 male; median age 55.8 ± 17.8 years) who underwent 120 surgeries for resection of intradural spinal tumors with the use of intraoperative neuromonitoring were included in the study, with a median follow-up of 39 ± 34.4 months. Nine patients died during the follow-up for reasons unrelated to surgery. The most common tumors were meningioma (n = 41), schwannoma (n = 37), myopapillary ependymomas (n = 12), ependymomas (n = 10), and others (20). Tumors were in the thoracic spine (n = 46), lumbar spine (n = 39), cervical spine (n = 32), lumbosacral spine (n = 1), thoracic and lumbar spine (n = 1), and 1 tumor in the cervical, thoracic, and lumbar spine. Four biopsies were performed, 10 partial resections, 13 subtotal resections, and 93 gross total resections. Laminectomy was the common approach. In 79 cases, patients experienced neurologic deficits before surgery, with ataxia and paraparesis as the most common ones. After surgery, 67 patients were unchanged, 49 improved and 4 worsened. Operative time, extent of resection, clinical outcome, and complication rate did not differ between the AR and non-AR groups. However, the use of AR improved orientation in the operative field by identification of important neurovascular structures.

CONCLUSIONS

High rates of gross total resection with favorable neurologic outcomes in most patients as well as low recurrence rates with comparable complication rates were noted in our single-center experience. AR improved intraoperative orientation and increased surgeons' comfort by enabling early identification of important anatomic structures; however, clinical and radiologic outcomes did not differ, when AR was not used.

Predictive Factors of Long-Term Neurologic Outcome and Progression-Free Survival in Intramedullary Spinal Cord Tumors: A 10-year Single-Center Cohort Study and Review of the Literature

BACKGROUND

Intramedullary spinal cord tumors (IMSCTs) are a rare subgroup of neoplasms, encompassing both benign, slow-growing masses, and malignant lesions; radical surgical excision represents the cornerstone of treatment for such pathologies regardless of histopathology, which, on the other hand, is a known predictor of survival and neurologic outcome postsurgery. The present study aims to investigate the relevance of other factors in predicting survival and long-term functional outcomes.

METHODS

We conducted a review of current literature on functional outcomes of IMSCTs, as well as a 10-years prospective analysis of a wide cohort of patients with diagnosis of IMSCTs who underwent surgical resection at our institution.

RESULTS

Our series encompasses 60 patients with IMSCTS, among which 36 ependymomas, 6 cavernous angiomas, 5 hemangioblastomas, 6 WHO Grade I-IV astrocytomas, 3 intramedullary spinal metastases and 4 miscellaneous tumors. GTR was achieved in 76,67% of patients, with high preoperative McCormick grade, syringomyelia and changes at neurophysiologic monitoring being the strongest predictors at multivariate analysis (P = 0.0027, P = 0.0017 and P = 0.001 respectively).

CONCLUSIONS

Consistently with literature, preoperative neurologic function is the most important factor predicting long-term functional outcome (0.17, CI 0.069-0.57 with P = 0.0018), advocating for early surgery in the management of IMSCTs, whereas late complications such as myelopathy and neuropathic pain were present regardless of preoperative function.

Primary intradural extramedullary lesions: a longitudinal study of 212 patients and analysis of predictors of functional outcome

BACKGROUND

Primary intradural extramedullary (IDEM) lesions are rare, with an incidence of about 1/100,000 person-years. The aim of this study was to investigate their demographic, clinical, imaging, management, histopathological and outcome parameters. Another objective was to evaluate the various predicting factors leading to long-term favorable outcomes, thereby answering the controversial question: when to operate?

METHODS

This study observed 212 patients of primary IDEM lesions and followed-up for a mean of 53.80 months. The patient's outcome using McCormick grade at follow-up was correlated with age, sex, duration of symptoms, preoperative McCormick grade, tumor location and extent, extradural spread, extent of excision, vascularity, WHO grade and histopathological tumor type.

RESULTS

Benign nerve sheath tumors were the commonest lesions (47.17% schwannoma, 4.72% Neurofibroma), followed in incidence by meningioma (19.34%). There was predominance of males (57.08%), except in meningiomas (male: female ratio 1:2.15). Pain was the commonest initial symptom (51.88%). Limb weakness was the most common presenting complaint (88.68%). Gross total excision was achieved in 81.60% of cases and 70.75% of patients improved following surgery. The significant factors predicting favorable outcome included preoperative McCormick grade (P=0.001), the vertical extent of the tumor (P=0.027), histopathological tumor type (P=0.023) and WHO grading (P=0.015); and extent of excision had an odds ratio of 1: 2.5.

CONCLUSIONS

Significant predictors of functional outcome following surgery in IDEM lesions included preoperative McCormick grade, extent of the tumor, tumor type, WHO grading and extent of resection. The authors recommend surgery with the intent of complete tumor excision, before the onset of substantial symptoms, for better outcome.

Does the degree of preoperative gait disturbance remain after tumor resection in patients with intradural extramedullary spinal cord tumors?

STUDY DESIGN

Retrospective comparative study.

OBJECTIVE

This study aimed to determine whether the degree of preoperative gait disturbance remains following surgical resection in patients with intradural extramedullary spinal cord tumors (IDEMSCTs), and to investigate any factors that may influence poor improvement in postoperative gait disturbance.

SETTING

The single institution in Japan.

METHODS

In total, 78 IDEMSCTs patients who required surgical excision between 2010 and 2019 were included. According to the degree of preoperative gait disturbance using modified McCormick scale (MMCS) grade, they were divided into the Mild and Severe groups. The mean postoperative follow-up period was 50.7 ± 17.9 months. Data on demographic and surgical characteristics were compared between the two groups.

RESULTS

There was no significant difference in terms of age at surgery, sex, tumor size, surgical time, estimated blood loss, tumor histopathology, and postoperative follow-up period between the Mild and Severe groups. At the final follow-up, 84.6% of IDEMSCTs patients were able to walk without support. Gait disturbance improved after surgery in most of the patients with preoperative MMCS grades II-IV, but remained in approximately half of patients with preoperative MMCS grade V. Age at surgery was correlated with poor improvement in postoperative gait disturbance in the Severe group.

CONCLUSIONS

Regardless of the degree of preoperative gait disturbance, it improved after tumor resection in most of the IDEMSCTs patients. However, in the preoperative MMCS grade III-V cases, older age at surgery would be an important factor associated with poor improvement in postoperative gait disturbance.

The Role of Prolonged Bed Rest in Postoperative Cerebrospinal Fluid Leakage After Surgery of Intradural Pathology-A Retrospective Cohort Study

BACKGROUND

Postoperative cerebrospinal fluid leakage (CSFL) is a feared complication after surgery on intradural pathologies and may cause postoperative complications and subsequently higher treatment costs.

OBJECTIVE

To assess whether prolonged bed rest may lower the risk of CSFL.

METHODS

We performed a retrospective cohort study including patients with intradural pathologies who underwent surgery at our department between 2013 and 2021. Cohorts included patients who completed 3 days of postoperative bed rest and patients who were mobilized earlier. The primary end point was the occurrence of clinically proven CSFL.

RESULTS

Four hundred and thirty-three patients were included (female [51.7%], male [48.3%]) with a mean age of 48 years (SD ±20). Bed rest was ordered in 315 cases (72.7%). In 7 cases (N = 7/433, 1.6%), we identified a postoperative CSFL. Four of them (N = 4/118) did not preserve bed rest, showing no significant difference to the bed rest cohort (N = 3/315; P = .091). In univariate analysis, laminectomy (N = 4/61; odds ratio [OR] 8.632, 95% CI 1.883-39.573), expansion duraplasty (N = 6/70; OR 33.938, 95% CI 4.019-286.615), and recurrent surgery (N = 5/66; OR 14.959, 95% CI 2.838-78.838) were significant risk factors for developing CSFL. In multivariate analysis, expansion duraplasty was confirmed as independent risk factor (OR 33.937, 95% CI 4.018-286.615, P = .001). In addition, patients with CSFL had significant higher risk for meningitis (N = 3/7; 42.8%, P = .001).

CONCLUSION

Prolonged bed rest did not protect patients from developing CSFL after surgery on intradural pathologies. Avoiding laminectomy, large voids, and minimal invasive approaches may play a role in preventing CSFL. Furthermore, special caution is indicated if expansion duraplasty was done.

Predictors of Cerebrospinal Fluid Leak Following Dural Repair in Spinal Intradural Surgery

OBJECTIVE

We aim to compare the effectiveness of dural closure techniques in preventing cerebrospinal fluid (CSF) leaks following surgery for intradural lesions and seek to identify additional factors associated with CSF leaks. Surgical management of spinal intradural lesions involves durotomy which requires a robust repair to prevent postoperative CSF leakage. The ideal method of dural closure and the efficacy of sealants has not been established in literature.

METHODS

We performed a retrospective analysis of all intradural spinal cases performed at a tertiary spine centre from 1 April 2015 to 29 January 2020 and collected data on patient bio-profile, dural repair technique, and CSF leak rates. Multivariate analysis was performed to identify predictors for postoperative CSF leak.

RESULTS

A total of 169 cases were reported during the study period. There were 15 cases in which postoperative CSF leak was reported (8.87%). Multivariate analysis demonstrated that patient age (odds ratio [OR], 0.942; 95% confidence interval [CI], 0.891-0.996), surgical indication listed in the "others" category (OR, 44.608; 95% CI, 1.706-166.290) and dural closure with suture, sealant and patch (OR, 22.235; 95% CI, 2.578-191.798) were factors associated with CSF leak. Postoperative CSF leak was associated with the risk of surgical site infection with a likelihood ratio of 8.704 (χ² (1) = 14.633, p < 0.001).

CONCLUSION

Identifying predictors for CSF leaks can assist in the counselling of patients with regard to surgical risk and expected postoperative recovery.

Functional Outcome in Spinal Meningioma Surgery and Use of Intraoperative Neurophysiological Monitoring

Data on intraoperative neurophysiological monitoring (IOM) during spinal meningioma (SM) surgery are scarce. The aim of this study was to assess the role of IOM and its impact on post-operative functional outcome. Eighty-six consecutive surgically treated SM patients were included. We assessed pre and post-operative Modified McCormick Scale (mMCS), radiological and histopathological data and IOM findings. Degree of cord compression was associated with preoperative mMCS and existence of motor or sensory deficits (p < 0.001). IOM was used in 51 (59.3%) patients (IOM-group). Median pre and post-operative mMCS was II and I, respectively (p < 0.001). Fifty-seven (66.3%) patients showed an improvement of at least one grade in the mMCS one year after surgery. In the IOM group, only one patient had worsened neurological status, and this was correctly predicted by alterations in evoked potentials. Analysis of both groups found no significantly better neurological outcome in the IOM group, but IOM led to changes in surgical strategy in complex cases. Resection of SM is safe and leads to improved neurological outcome in most cases. Both complication and tumor recurrence rates were low. We recommend the use of IOM in surgically challenging cases, such as completely ossified or large ventrolateral SM.

Risk Factors for Postoperative Cerebrospinal Fluid Leakage After Intradural Spine Surgery

OBJECTIVE

Well-defined risk factors for cerebrospinal fluid leakage (CSFL) after intradural spine surgery are scarce in the literature. The aim of the present study was to identify patient- and surgery-related risk factors and the incidence of CSFL.

METHODS

For the present retrospective cohort study, we identified consecutive patients who had undergone intradural spine surgery between 2009 and 2021 at our department. The primary endpoint was the incidence of clinically or radiologically proven CSFL. The effects of the clinical and surgical factors on the occurrence of CSFL were analyzed.

RESULTS

A total of 375 patients (60.3% women; mean age, 54 ± 16.5 years) were included. Of the 375 patients, 30 (8%) had experienced postoperative CSFL and, thus, a significantly greater risk of wound healing disorders (odds ratio [OR], 24.9; 95% confidence interval [CI], 9.3-66.7) and surgical site infections (OR, 8.4; 95% CI, 2.6-27.7; P < 0.01 for each). No patient-related factors were associated with the development of CSFL. Previous surgery at the index level correlated significantly with the occurrence of postoperative CSFL (OR, 2.76; 95% CI, 1.1-6.8; P = 0.03) on multivariate analysis. Furthermore, patients with intradural tumors tended to have a greater risk of CSFL (OR, 2.3; 95% CI, 0.9-5.8; P = 0.07). Surgery-related factors did not influence the occurrence of CSFL. Surgery on the thoracic spine had resulted in a significantly lower postoperative CSFL rate compared with surgery on the cervical or lumbar spine (OR, -2.5; 95% CI, 1.3-4.9; P = 0.02).

CONCLUSIONS

Our study found no modifiable risk factors for preventing CSFL after intradural spine surgery. Patients with previous surgery at the index level had a greater risk of CSFL. The occurrence of CSFL resulted in significantly more wound healing disorders and surgical site infections, necessitating further therapy.

Laminectomy Versus Laminectomy with Fusion for Intradural Extramedullary Tumors: A Systematic Review and Meta-Analysis

OBJECTIVE

The primary objective of our systematic review and meta-analysis was to systematically compare the reported outcomes between laminectomy and laminectomy with fixation/fusion (LF) for the treatment of intradural extramedullary tumors (IDEMTs). Our secondary objective was to compare the outcomes between different laminectomy exposure techniques.

METHODS

PubMed and Embase were queried for literature on laminectomy and LF for IDEMTs. Reports of transforaminal approaches, interlaminar approaches, corpectomy, pediatrics patients, intramedullary tumors, technical studies, animal or cadaver studies, and literature reviews were excluded. The outcome measures recorded were pain, neurologic function, functional independence, cerebrospinal fluid leak, and wound infection. Where possible, the laminectomy technique (partial laminectomy [PL] vs. total laminectomy [TL]) was specified. Stata, version 17, was used for the fixed effects inverse variance meta-analysis.

RESULTS

Of 1849 reports assessed, 17 were included. The meta-analysis revealed that laminectomy (PL or TL) resulted in higher rates of postoperative sagittal instability compared with LF (odds ratio, 1.81; P < 0.001). No differences in any other postoperative outcome were observed between laminectomy and LF (P = 0.44). The systematic review also revealed no differences in postoperative pain, neurologic function, or functional independence or disability between PL and TL. Some evidence suggested that TL might result in greater rates of sagittal instability compared with PL.

CONCLUSIONS

No differences between LF, PL, or TL in pain, neurologic deficit, functional independence, cerebrospinal fluid leak, or wound infection were reported. Laminectomy had greater odds of sagittal instability compared with LF. Patients with preoperative sagittal instability requiring extensive removal of the posterior spinal column to achieve adequate resection of large tumors might benefit from LF.

Prediction of Discharge Status and Readmissions after Resection of Intradural Spinal Tumors

Objective

Intradural spinal tumors are uncommon and while associations between clinical characteristics and surgical outcomes have been explored, there remains a paucity of literature unifying diverse predictors into an integrated risk model. To predict postresection outcomes for patients with spinal tumors.

Methods

IBM MarketScan Claims Database was queried for adult patients receiving surgery for intradural tumors between 2007 and 2016. Primary outcomes-of-interest were nonhome discharge and 90-day postdischarge readmissions. Secondary outcomes included hospitalization duration and postoperative complications. Risk modeling was developed using a regularized logistic regression framework (LASSO, least absolute shrinkage and selection operator) and validated in a withheld subset.

Results

A total of 5,060 adult patients were included. Most surgeries utilized a posterior approach (n=5,023, 99.3%) and tumors were most commonly found in the thoracic region (n=1,941, 38.4%), followed by the lumbar (n=1,781, 35.2%) and cervical (n=1,294, 25.6%) regions. Compared to models using only tumor-specific or patient-specific features, our integrated models demonstrated better discrimination (area under the curve [AUC] [nonhome discharge] = 0.786; AUC [90-day readmissions] = 0.693) and accuracy (Brier score [nonhome discharge] = 0.155; Brier score [90-day readmissions] = 0.093). Compared to those predicted to be lowest risk, patients predicted to be highest-risk for nonhome discharge required continued care 16.3 times more frequently (64.5% vs. 3.9%). Similarly, patients predicted to be at highest risk for postdischarge readmissions were readmitted 7.3 times as often as those predicted to be at lowest risk (32.6% vs. 4.4%).

Conclusion

Using a diverse set of clinical characteristics spanning tumor-, patient-, and hospitalization-derived data, we developed and validated risk models integrating diverse clinical data for predicting nonhome discharge and postdischarge readmissions.

Factors Influencing Surgical Outcomes for Intradural Spinal Tumours: A Single-Centre Retrospective Cohort Study

Introduction

Intradural spinal tumours are relatively uncommon tumours of the central nervous system. In this study, we sought to assess our current practice and determine the factors which affect the surgical outcomes of intradural spinal tumour resection.

Methods

All consecutive patients who underwent surgical resection of intradural spinal tumours from December 2011 to November 2018 were retrospectively reviewed. The Modified McCormick Scale (MMS) was used to grade patients’ neurological status both pre-operatively and at the latest follow-up. The associations between changes in MMS and variables such as patient demographics, tumour location, number and experience of consultants involved in the procedure, use of intraoperative neuro-monitoring, bony spinal exposure and dural closure methods were assessed. A multivariable binary logistic regression model was performed to identify independent predictors of improvements in MMS. All analyses were performed using IBM SPSS 22 (IBM Corp. Armonk, NY), with p<0.05 deemed to be indicative of statistical significance throughout.

Results

A total of 145 patients met the inclusion criteria, with a median age of 56.5 years; of whom 119 had extramedullary tumours and 26 had intramedullary tumours. Methods of dural closure were variable, and there was an increasing trend over time towards using the laminoplasty approach for bony exposure. Neither the experience of consultants (p=0.991) nor the number of consultants involved (p=0.084) was found to be significantly associated with the change in MMS, with the strongest predictor being the baseline MMS (p<0.001). Patients who had adjuvant therapy were also significantly more likely to have a poorer neurological outcome (p=0.001).

Conclusion

A good neurological baseline is a significant positive predictor of an improved functional outcome. The number and seniority of consultant surgeons involved in intradural spinal tumour resections did not significantly alter the postoperative outcomes of patients in our single-unit retrospective study.

Analysis of Factors Influencing the Long-term Outcome in Primary Spinal Cord Tumors: Review of Literature

Introduction Primary spinal cord tumors are amenable to total surgical excision but the outcomes are still diverse.

Objective The purpose of this study is to identify the significant factors which influence the long-term outcome of spinal cord tumors.

Materials and Methods A total of 84 consecutive spinal cord tumor patients who underwent microsurgical excision during April 2003 to 2014 were retrospectively studied. Patients operated after April 2014 were not considered. Ten factors were taken and correlated with the outcome. Multiple regression analysis was used. Patients were periodically evaluated at 1, 6 months, 1, 2, and 5 years. In 72 cases, postoperative MRI scans were performed. The follow-up period ranged between 5 to 15 years.

Results In our study, we had 64 extramedullary tumors and 21 intramedullary tumors with varied pathology. Axial location of the tumour (20.294/0.000), extent of the resection of the tumour (13.827/0.001), preoperative Nurick grade (11.349/0.023), and location of the tumour in the spine with respect to vertebral segments (8.151/0.017) were significant predictive factors. We had good outcomes in 65 cases and poor outcomes in 19 cases.

Conclusion Our results show location of the tumor with respect to axial plane and vertebral segments were the main contributing factors. They influence the extent of excision of the spinal cord tumor. Preoperative neurological status is the fourth factor which independently determines the long-term outcome. It is one of the few papers where patients have been followed-up for a long period ranging from 5 to 15 years.

Reliability of Early Ambulation after Intradural Spine Surgery : Risk Factors and a Preventive Method for Cerebrospinal Fluid Leak Related Complications

Objective

Cerebrospinal fluid leakage related complications (CLC) occasionally occur after intradural spinal surgery. We sought to investigate the effectiveness of early ambulation after intradural spinal surgery and analyze the risk factors for CLC.

Methods

For this retrospective cohort study, we enrolled 314 patients who underwent intradural spinal surgery at a single institution. The early group contained 79 patients who started ambulation after 1 day of bedrest without position restrictions, while the late group consisted of 235 patients who started ambulation after at least 3 days of bed rest and were limited to the prone position after surgery. In the early group, Prolene 6–0 was used as the dura suture material, while black silk 5–0 was used as the dura suture material in the late group.

Results

The overall incidence rate of CLC was 10.8%. Significant differences between the early and late groups were identified in the rate of CLC (2.5% vs. 13.6%), surgical repair required (1.3% vs. 7.7%), and length of hospital stay (2.99 vs. 9.29 days) (p<0.05). Logistic regression analysis revealed that CLC was associated with practices specific to the late group (p=0.011) and the revision surgery (p=0.022).

Conclusion

Using Prolene 6–0 as a dura suture material for intradural spinal surgery resulted in lower CLC rates compared to black silk 5–0 sutures despite a shorter bed rest period. Our findings revealed that suture - needle ratio related to dura defect was the most critical factor for CLC. One-day ambulation after primary dura closure using Prolene 6–0 sutures appears to be a cost-effective and safe strategy for intradural spinal surgery.

Age at Diagnosis and Baseline Myelomalacia Sign Predict Functional Outcome After Spinal Meningioma Surgery

Objective: Spinal meningioma (SM) accounts for 12% of all meningiomas. Clinical and immunohistochemical factors were analyzed with regard to functional outcome, surgical adverse events, and tumor recurrence.

Methods: One-hundred and twenty-three consecutive SM patients underwent surgery and were retrospectively reviewed with regard to demographic parameters, imaging features, neurological function, and immunohistochemical items. Neurological function was graded according to the Modified McCormick Scale (MMS) and dichotomized as “good (grade I + II)” and “poor (grade III–V)” function.

Results: One-hundred and fourteen (92.7%) WHO grade I and 9 (7.3%) WHO grade II SM were included in this study. Univariate analysis identified a baseline T2 hyperintensity of the spinal cord, baseline symptom duration ≥4 weeks, age ≥66 years, and dural tail sign as predictors of poor MMS. Baseline T2 hyperintensity of the spinal cord [Odds ratio (OR) = 13.3, 95% CI = 3.4–52.1, p < 0.001] and age ≥66 years (OR = 10.3, 95% CI = 2.6–41.1, p = 0.001) were independent predictors of a poor MMS grade at discharge after SM surgery in the multivariate binary logistic regression analysis. The 12- and 24-month recurrence-free survival rates were 98.7 % (1/80) and 94.7% (2/38), respectively. In those patients with tumor recurrence of the SM, highly increased MIB-1 (≥5%) labeling indices were observed.

Conclusion: Baseline T2 hyperintensity, especially in the elderly patients, is a strong predictor of poorer recovery after spinal meningioma surgery. SMs with high proliferative activity should be followed-up closely despite maximal safe resection.

Tumor Occupancy Ratio-An Imaging Characteristic Prognosticating the Surgical Outcome of Benign Intradural Extramedullary Spinal Cord Tumors

BACKGROUND

Intradural extramedullary (IDEM) spinal cord tumors are two thirds of all spinal tumors. We have prospectively analyzed the importance of the tumor occupancy ratio as a factor for predicting the course of the disease and in prognosticating the surgical outcome in patients with IDEM tumors.

METHODS

We prospectively analyzed 44 consecutive cases of IDEM tumors, diagnosed as cervical, thoracic, and lumbar IDEM tumors (excluding conus/cauda equina lesion) by magnetic resonance imaging (MRI), that were operated on at our institution between 2014 and 2016. We measured the tumor occupancy ratio and noted the sagittal and axial location of the tumor in the preoperative MRI and performed the laminectomy and unilateral medial facetectomy. A primary outcome has been noted according to the gait disability score in the preoperative period and in the follow-up period of 1 year. In the statistical analysis, categorical variables were compared using a chi-square test, and an analysis of variance and student t tests were used for the continuous variables. P < .05 was considered statistically significant.

RESULTS

The tumor occupancy ratio showed a significant association to the preoperative gait disability score (P < .001) and also predicted that the surgical outcome is much better in patients with tumors with a low tumor occupancy ratio than in patients with tumors with a high occupancy ratio (P < .001). No difference in the tumor occupancy ratio was noted in 2 different pathological tumors, and there was also no difference in the tumor occupancy ratio at different sagittal and axial locations of the tumor.

CONCLUSION

Tumor occupancy ratio has shown a significant impact on the preoperative course and also predicts the surgical outcome in patients with IDEM tumors. Hence, it is an important imaging characteristic to prognosticate the outcome in IDEM tumors and should be noted in each case.

Complete Excision of Intradural-Extraforaminal Spinal Tumors Using a Minimally Invasive 2-Incision Technique With Fixed Tubular Retractors

Spinal tumors are rare, of which intradural-extramedullary lesions form the majority of primary spinal tumors. Occasionally these may even be large, dumbbell shaped, with both intraspinal and extraspinal components. Complete gross total resection is the gold standard in the removal of these tumors since most are benign in nature. Traditionally this has been achieved using large open midline approaches that involve significant muscle dissection, extensive laminectomy, and even facetectomy. This may lead to instability, requiring stabilization to prevent deformity. Minimally invasive surgical approaches using fixed tubular retractors may obviate this need by minimizing the amount of muscle stripping and bony resection required for complete tumor excision. By utilizing facet sparing corridors, the authors describe a novel 2-incision minimally invasive surgical technique that combines a paramedian and a far-lateral approach to access both the intraspinal and extraforaminal, paraspinal portions of the tumor for achieving complete excision. Three illustrative cases are discussed with tumors in 2 different spinal locations that highlights the versatility of this technique-1 in the cervical region and the other 2 in the thoracolumbar region.

Management of Extramedullary Intradural Spinal Tumors: The Impact of Clinical Status, Intraoperative Neurophysiological Monitoring and Surgical Approach on Outcomes in a 12-Year Double-Center Experience

Objective: Intradural Extramedullary (IDEM) tumors are usually treated with surgical excision. The aim of this study was to investigate the impact on clinical outcomes of pre-surgical clinical conditions, intraoperative neurophysiological monitoring (IONM), surgical access to the spinal canal, histology, degree of resection and intra/postoperative complications.

Methods: This is a retrospective observational study analyzing data of patients suffering from IDEM tumors who underwent surgical treatment over a 12 year period in a double-center experience. Data were extracted from a prospectively maintained database and included: sex, age at diagnosis, clinical status according to the modified McCormick Scale (Grades I-V) at admission, discharge, and follow-up, tumor histology, type of surgical access to the spinal canal (bilateral laminectomy vs. monolateral laminectomy vs. laminoplasty), degree of surgical removal, use and type of IONM, occurrence and type of intraoperative complications, use of Ultrasonic Aspirator (CUSA), radiological follow-up.

Results: A total number of 249 patients was included with a mean follow-up of 48.3 months. Gross total resection was achieved in 210 patients (84.3%) mostly in Schwannomas (45.2%) and Meningiomas (40.4%). IONM was performed in 162 procedures (65%) and D-wave was recorded in 64.2% of all cervical and thoracic locations (99 patients). The linear regression diagram for McCormick grades before and after surgery (follow-up) showed a correlation between preoperative and postoperative clinical status. A statistically significant correlation was found between absence of worsening of clinical condition at follow-up and use of IONM at follow-up (p = 0.01) but not at discharge. No associations were found between the choice of surgical approach and the extent of resection (p = 0.79), the presence of recurrence or residual tumor (p = 0.14) or CSF leakage (p = 0.25). The extent of resection was not associated with the use of IONM (p = 0.91) or CUSA (p = 0.19).

Conclusion: A reliable prediction of clinical improvement could be made based on pre-operative clinical status. The use of IONM resulted in better clinical outcomes at follow-up (not at discharge), but no associations were found with the extent of resection. The use of minimally invasive approaches such as monolateral laminectomy showed to be effective and not associated with worse outcomes or increased complications.

Spinal dural resection for oncological purposes: a systematic analysis of risks and outcomes in patients with malignant spinal tumors

OBJECTIVE

Oncological outcomes for many malignant primary spinal tumors and isolated spinal metastases have been shown to correlate with extent of resection. For tumors with dural involvement, some authors have described spinal dural resection at the time of tumor resection in the interest of improving oncological outcomes. The complication profile associated with resection of the spinal dura for oncological purposes, however, and the relative influence of resecting tumor-involved dura on progression-free survival are not well defined. The authors performed a systematic review of the literature and identified cases in which the spinal dura was resected for oncological purposes in the interest of better understanding the associated risks and outcomes of this technique.

METHODS

Electronic databases (PubMed/MEDLINE, Scopus) were systematically searched to identify studies that reported clinical and/or oncological outcomes of patients with malignant spinal neoplasms undergoing resection of tumor-involved dura at the time of surgical intervention.

RESULTS

Ten articles describing 15 patients were included in the analysis. The most common tumor histologies were chordoma (3/15, 20%), giant cell tumor (3/15, 20%), epithelioid sarcoma (2/15, 13.3%), osteosarcoma (2/15, 13.3%), and metastasis (2/15, 13.3%). Procedure-related complications were reported in 40% of patients. A trend was seen toward an increased complication rate in redo (66.7%) versus index (16.7%) operations, but this trend did not reach statistical significance (p = 0.24). New, unexpected postoperative neurological deficits were seen in 3 patients (of 14 reporting, 21.4%). A single patient experienced a profound, unexpected neurological deterioration (paraparesis/paraplegia) after surgery, which reportedly improved considerably at latest follow-up. Tumor recurrence was seen in 3 cases (of 12 reporting, 25%) at a mean of 28.34 ± 21.1 months postoperatively. The overall mean radiographic follow-up period was 49.6 ± 36.5 months.

CONCLUSIONS

Resection of the spinal dura for oncological purposes is rarely performed, although a limited number of reports and small series have demonstrated that it is feasible. Spinal dural resection is primarily performed in patients with isolated, primary spinal neoplasms with an intent to cure. The risk associated with spinal dura resection is nontrivial and the complication profile is significant. The influence of dural resection on oncological outcomes is not well defined, and further study is needed before definitive conclusions may be drawn regarding the oncological benefit of dural resection for any particular patient or pathology.

Cerebrospinal fluid leaks after spine tumor resection: avoidance, recognition and management

Post-operative CSF leaks are a known complication of spine surgery in general, and patients undergoing surgical intervention for spinal tumors may be particularly predisposed due to the presence of intradural tumor and a number of other factors. Post-operative CSF leaks increase morbidity, lengthen hospital stays, prolong immobilization and subject patients to a number of associated complications. Intraoperative identification of unintended durotomies and effective primary repair of dural defects is an important first step in the prevention of post-operative CSF leaks, but in patients who develop post-operative pseudomeningoceles, durocutaneous fistulae or other CSF-leak-related sequelae, early recognition and secondary intervention are paramount to preventing further CSF-leak-related complications and achieving the best patient outcomes possible. In this article, the incidence, risk factors and complications of CSF leaks after spine tumor surgery are reviewed, with an emphasis on avoidance of post-operative CSF leaks, early post-operative identification and effective secondary intervention.

Top Ten Tips Palliative Care Clinicians Should Know About Spinal Tumors

Nearly 20% of cancer patients develop symptomatic spine metastases. Metastatic spine tumors are most commonly extradural tumors that grow quickly and often cause persistent pain, weakness, paresthesias, urinary/bowel dysfunction, and/or paralysis. Surgical intervention aims to achieve more effective pain management, preserve/restore neurological function, provide local tumor control, and stabilize the spinal column. The desired result of treatment is ultimately to improve a patient's quality of life. Neurosurgeons employ multiple decision frameworks and grading scales to assess the need and effectiveness of a variety of surgical interventions ranging from minimally to maximally invasive. Likewise, palliative care offers an array of treatment options that allows the best, individualized plan to be determined for a given patient. Therefore, crossfunctional collaboration between palliative care, radiation oncology, medical oncology, and neurosurgery is crucial both in the maximization of available treatment options and optimization of quality of life for patients.

Spinal Nerves Schwannomas: Experience on 367 Cases-Historic Overview on How Clinical, Radiological, and Surgical Practices Have Changed over a Course of 60 Years

Background

Spinal schwannomas are common benign spinal tumors. Their treatment has significantly evolved over the years, and preserving neurological functions has become one of the main treatment goals together with tumor resection.

Study Design and Aims

Retrospective review focused on clinical assessment, treatment techniques, and outcomes.

Methods

A retrospective study on our surgical series was performed. Clinical and operative data were analyzed. In regard to neurophysiologic monitoring, patients were retrospectively divided into two groups comparing the outcomes before and after introduction of routine intraoperative neurophysiology tests.

Results

From 1951 to 2010, 367 patients overall were treated. Diagnosis was obtained using angiography and/or myelography (pre-CT era), MRI, or CT scan. A posterior spinal approach was used for most patients; complex approaches were adopted for treatment of giant/dumbbell tumors. A trend of neurophysiology monitoring decreasing the rate of post-op neurological deficits was observed but was not statistically significant enough to draft evidence-based conclusions.

Conclusions

Clinical and radiological assessment of spinal schwannomas has markedly changed over the course of 50 years. Diagnostic tools have improved, and detection of recurrence has become way more sensitive. Neurophysiologic monitoring has become a useful intraoperative tool to guide resection and prevent post-op neurological impairment.

Minimally Invasive Microsurgical Resection of Primary, Intradural Spinal Tumors is Feasible and Safe: A Consecutive Series of 83 Patients

BACKGROUND

To date, the traditional approach to intraspinal tumors has been open laminectomy or laminoplasty followed by microsurgical tumor resection. Recently, however, minimally invasive approaches have been attempted by some.

OBJECTIVE

To investigate the feasibility and safety of minimally invasive surgery (MIS) for primary intradural spinal tumors.

METHODS

Medical charts of 83 consecutive patients treated with MIS for intradural spinal tumors were reviewed. Patients were followed up during the study year, 2015, by either routine history/physical examination or by telephone consultation, with a focus on tumor status and surgery-related complications.

RESULTS

Mean age at surgery was 53.7 yr and 52% were female. There were 49 schwannomas, 18 meningeomas, 10 ependymomas, 2 hemangioblastomas, 1 neurofibroma, 1 paraganglioma, 1 epidermoid cyst, and 1 hemangiopericytoma. The surgical mortality was 0%. In 87% of cases, gross total resection was achieved. The complication rate was 11%, including 2 cerebrospinal fluid leakages, 1 asymptomatic pseudomeningocele, 2 superficial surgical site infections, 1 sinus vein thrombosis, and 4 cases of neurological deterioration. There were no postoperative hematomas, and no cases of deep vein thrombosis or pulmonary embolism. Ninety-three percent of patients were ambulatory and able to work at the time of follow-up.

CONCLUSION

This study both demonstrates that it is feasible and safe to remove select, primary intradural spinal tumors using MIS, and augments the previous literature in favor of MIS for these tumors.

Improved patient quality of life following intradural extramedullary spinal tumor resection

OBJECTIVE Resection significantly improves the clinical symptoms and functional outcomes of patients with intradural extramedullary tumors. However, patient quality of life following resection has not been adequately investigated. The aim in this retrospective analysis of prospectively collected quality of life outcomes is to analyze the efficacy of resection of intradural extramedullary spinal tumors in terms of quality of life markers. METHODS A retrospective review of a single institutional neurosurgical administrative database was conducted to analyze clinical data. The Oswestry Disability Index (ODI), visual analog scale (VAS) for pain, and the EQ-5D-3 L descriptive system were used to analyze quality of life preoperatively, less than 1 month postoperatively, 1-3 months postoperatively, 3-12 months postoperatively, and more than 12 months postoperatively. RESULTS The ODI scores increased perioperatively at the < 1-month follow-up from 36 preoperatively to 47. Relative to preoperative values, the ODI score decreased significantly at 1-3, 3-12, and > 12 months to 23, 17, and 20, respectively. VAS scores significantly decreased from 6.1 to 3.5, 2.4, 2.0, and 2.9 at the < 1-month, 1- to 3-, 3- to 12-, and > 12-month follow-ups, respectively. EQ-5D mobility significantly worsened at the < 1-month follow-up but improved at the 3- to 12-and > 12-month follow-ups. EQ-5D self-care significantly worsened at the < 1-month follow-up but significantly improved by the 3- to 12-month follow-up. EQ-5D usual activities improved at the 1- to 3-, 3- to 12-, and > 12-month follow-ups. EQ-5D pain and discomfort significantly improved at all follow-up points. EQ-5D anxiety and depression significantly improved at 1- to 3-month and 3- to 12-month follow-ups. CONCLUSIONS Resection of intradural extramedullary spine tumors appears to significantly improve patient quality of life by decreasing patient disability and pain and by improving each of the EQ-5D domains.

Intramedullary Spinal Cord Tumors: Part II-Management Options and Outcomes

Study Design Broad narrative review. Objectives Intramedullary spinal cord tumors (IMSCT) are uncommon lesions that can affect any age group or sex. However, numerous IMSCT exist and the clinical course of each tumor varies. The following article addresses the various management options and outcomes in patients with IMSCT. Methods An extensive review of the peer-reviewed literature was performed, addressing management options and clinical outcomes of patients with IMSCT. Results Early diagnosis and intervention are essential to obtain optimal functional outcome. Each IMSCT have specific imaging characteristics, which help in the clinical decision-making and prognostication. A comprehension of the tumor pathology and the clinical course associated with each tumor can allow for the proper surgical and nonsurgical management of these tumors, and reduce any associated morbidity and mortality. Recent advances in the operative management of such lesions have increased the success rate of tumor removal while minimizing iatrogenic-related trauma to the patient and, in tandem, improving patient outcomes. Conclusions Awareness and understanding of IMSCT is imperative to design proper management and obtain optimal patient outcomes. Meticulous operative technique and the use of surgical adjuncts are essential to accomplish proper tumor removal, diminish the risk of recurrence, and preserve neurologic function. Operative management of IMSCT should be individualized and based on tumor type, location, and dimensional extensions. To assist with preoperative and intraoperative decision-making, a general algorithm is provided.

Surgical management of intradural spinal cord tumors in children and young adults: A single-center experience with 50 patients

BACKGROUND

Intradural spinal cord tumors (IDSCTs) in children and young adults are rare diseases. This present study is aimed to demonstrate our experience with a large series of children and young adults with IDSCT.

METHODS

A total of 50 patients aged <20 years with IDSCT treated in our department between 1990 and 2010 were included in the study. Clinical, histological, and radiological findings, treatment strategies, and clinical outcome were retrospectively assessed. Depending on the relation to the spinal cord, IDSCT were dichotomized into intramedullary SCT (IMSCT) and extramedullary SCT (EMSCT). The functional outcome was evaluated with the Frankel score assessing the longest available follow-up period.

RESULTS

Mean age was 10.3 years (range 6 months-19 years). IDSCT surgery was performed in 44 patients (88%). A common first symptom in patients with EMSCT was neck and back pain (41%), whereas monoparesis of arms (43%) were often seen in patients with IMSCT. The main duration of the symptoms was longer in patients with IMSCT. The postoperative functional outcome was generally comparable to the preoperative functional condition, while better for EMSCT (P < 0.01). The functional outcome at last follow-up correlated significantly with the preoperative Frankel score (P < 0.002).

CONCLUSION

Due to the mostly mild impact of the surgery on the functional outcome, the surgical treatment of IDSCT in children and young patients can be uniquely advocated.

Occipito-cervical fusion following gross total resection for the treatment of spinal extramedullary tumors in craniocervical junction: a retrospective case series

Background

Previous studies found that the facet joint of the C1 vertebra were removed (C1 facetectomy) before extirpation from the extramedullary tumor in craniocervical junction, leading to postoperative upper cervical instability or deformity. Occipito-cervical fusion (OCF) is a demanding and morbid surgical procedure, which can be used in such patients. This study is to analyze the clinical manifestation and surgical outcome of patients with craniocervical extramedullary tumor undergoing an extirpation of spinal tumors and OCF by one-stage posterior approach.

Methods

The surgical and clinical databases were searched for operative procedures that had been performed for patients with spinal extramedullary tumors in craniocervical junction at a single institution from January 2008 to July 2011. The following inclusion criteria were applied: (1) initial surgery for craniocervical extramedullary tumor, (2) gross total resection and occipito-cervical fusion had been performed, (3) minimum 2-year follow-up, and (4) no previous cervical spine surgery. Medical records included demographic characteristics, clinical assessment, and radiographic studies. Clinical outcomes before and after the surgery were assessed using Frankel grade and the Japanese Orthopaedic Association (JOA) score. Cervical sagittal alignment was evaluated by C0-2 angle and C2-7 angle based on X-ray.

Results

Nine patients were included in the study. Five patients had schwannoma, three patients had meningioma, and only one patient had neurofibroma. All cases were followed up for 24–42 months (average, 34.2 months). At the last follow-up, three patients improved from Frankel grade C to grade D, two patients from Frankel grade C to grade E, and one patient from Frankel grade D to grade E, while two patients remained stationary at the Frankel grade D. The JOA score of the eight patients were 9.0 (range, 6–17) before surgery and were 14.6 (range, 12–17) at the most recent follow-up (p < 0.05). The mean C0-2 angle and the mean C2-7 angle before surgery were 26.2 ± 5.3° and 17.4 ± 13.1°, respectively. At the end of follow-up, the mean C0-2 angle was 25.6 ± 4.8°, and the mean C2-7 angle decreased to 12.7 ± 10.9°. However, this trend did not reach statistical significance (p < 0.05). Two patients suffered from cerebrospinal fluid leaks postoperatively. All patients had a satisfactory fusion and did not exhibit a tumor recurrence during the follow-up period.

Conclusions

OCF following gross total resection appears to be a useful surgical procedure for the craniocervical extramedullary tumors requiring C1 facetectomy and does not cause postoperative kyphosis of the upper cervical spine.

Assessment of outcome in patients undergoing surgery for intradural spinal tumor using the multidimensional patient-rated Core Outcome Measures Index and the modified McCormick Scale

OBJECT

The aim of this study was to evaluate outcome in patients undergoing surgical treatment for intradural spinal tumor using a patient-oriented, self-rated, outcome instrument and a physician-based disease-specific instrument.

METHODS

Prospectively collected data from 63 patients with intradural spinal tumor were analyzed in relation to scores on the multidimensional patient-rated Core Outcome Measures Index (COMI) and the physician-rated modified McCormick Scale, before and at 3 and 12 months after surgery.

RESULTS

There was no statistically significant difference between the scores on the modified McCormick Scale preoperatively and at the 3-month follow-up, though there was a trend for improvement (p = 0.073); however, comparisons between the scores determined preoperatively and at the 12-month follow-up, as well as 3- versus 12-month follow-ups, showed a statistically significant improvement in each case (p < 0.004). The COMI scores for axial pain, peripheral pain, and back-related function showed a significant reduction (p < 0.001) from before surgery to 3 months after surgery, and thereafter showed no further change (p > 0.05) up to 12 months postoperatively. In contrast, the overall COMI score, “worst pain,” quality of life, and social disability not only showed a significant reduction from before surgery to 3 months after surgery (p < 0.001), but also a further significant reduction up to 12 months postoperatively (p < 0.001). The scores for work disability showed no significant improvement from before surgery to the 3-month follow-up (p > 0.05), but did show a significant improvement (p = 0.011) from 3 months to 12 months after surgery. At the 3- and 12-month follow-ups, 85.2% and 83.9% of patients, respectively, declared that the surgical procedure had helped/helped a lot; 95.1% and 95.2%, respectively, declared that they were satisfied/very satisfied with their care.

CONCLUSIONS

COMI is a feasible tool to use in the evaluation of baseline symptoms and outcome in patients undergoing surgery for intradural spinal tumor. COMI was able to detect changes in outcome at 3 months after surgery (before changes were apparent on the modified McCormick Scale) and on later postoperative follow-up. The COMI subdomains are valuable for monitoring the patient’s reintegration into society and the work environment. The addition of an item that specifically covers neurological deficits may further increase the value of COMI in patients with spinal tumors.

Relationship of intraoperative ultrasound characteristics with pathological grades and Ki-67 proliferation index in intracranial gliomas

OBJECTIVE

The purpose of the present study was to investigate the relationship between the intraoperative ultrasonographic appearances and the histopathological characteristics of glial tumors using the pathological grading system and the Ki-67 proliferation index.

MATERIALS AND METHODS

Patients with glial tumors who underwent surgery with the aid of intraoperative ultrasonography (IOUS) between September 2013 and August 2014 were included in the study. The lesions' IOUS characteristics were analyzed and compared with the results of surgical histopathological characteristics. Lesions were classified as low-grade gliomas (grade I-II, LGG) and high-grade gliomas (grade III-IV, HGG). The glioblastoma multiforme (grade IV, GBM) group was classified according to the Ki-67 values for further evaluation. The Chi square test (Fisher's exact test) was used for comparing the ultrasonographic characteristics of the low-grade and high-grade gliomas; HGG with different Ki-proliferation indexes. A value of P < 0.05 was considered statistically significant.

RESULTS

A total of 41 patients were included. The histopathological findings revealed 15 LGG and 26 HGG. Twenty of the 26 HGG were GBM. Differences were found between the intraoperative ultrasonographic characteristics of the low-grade and high-grade glial tumors. The majority of LGGs were mildly hyperechoic and homogeneous, with distinct margins and a regular contour. HGGs were mostly highly hyperechoic, with indistinct margins, irregular contours, and a heterogeneous internal texture. Surrounding edema was seen more often in HGGs. The differences in the echogenicity of the solid parts, the internal echo patterns, margins, contours, and peripheral edema (P < 0.05) were statistically significant, but the difference in the presence of cysts (P > 0.05) was not significant. In the GBM group, all of the lesions with distinct margins and regular contours had Ki-67 values ≤15 %. We compared the intraoperative ultrasonographic characteristics of the Ki-67 > 15 % group with those of the Ki-67 ≤ 15 % group for statistical significance. The difference between the echogenicity of the solid parts, margins, and contours was statistically significant between the groups (P < 0.05). The difference in the internal echo pattern, presence of cyst, and peripheral edema was insignificant (P > 0.05).

CONCLUSIONS

IOUS is a very useful imaging technique not only in defining the borders but also in characterizing the tumoral tissue. The IOUS characteristics of the glial tumors were a valuable tool in differentiating the grades of the glial tumors and might have a relationship with the Ki-67 proliferation index. We think this theory requires further investigation in more detailed comparative studies with larger numbers of patients.

Intraoperative ultrasound in spinal tumor surgery

PURPOSE

Intraoperative ultrasound (ioUS) has become increasingly widespread in brain tumor surgery but it is not yet a standard procedure in spinal surgery. We analyzed intraoperative ultrasonographic findings of different spinal tumors and their influence on the surgical strategy.

METHODS

We evaluated patients who underwent surgery for spinal tumor (extradural, intradural extramedullary, intradural intramedullary) removal, with ultrasound (US) guidance. Intraoperative standard B-mode images were acquired using a 3-11 MHz linear US probe. Before tumor removal the lesion was identified on the two axes and measured and defined as hyperechoic, isoechoic or hypoechoic. Other characteristics of the lesions were considered: the presence of calcifications, cystic/necrotic areas, diffuse or circumscribed appearance, and the relationships with the surrounding anatomical structures.

RESULTS

In all 34 cases it was possible to visualize the lesion, as well as the surrounding neural structures (like dura mater, dentate ligament, arachnoid membranes) and vascular structures. In 9 out of 34 cases, ioUS showed that the surgical approach was not wide enough: therefore it was necessary to enlarge the bony approach before dural opening. In 8 intramedullary cases, ioUS was used to correctly tailor the myelotomy.

CONCLUSIONS

We present our ioUS series findings along with some pictorial essays of different spinal tumors treated at our institution. IoUS is a valuable tool to detect spinal lesions, evaluate the surgical approach and plan the surgical strategy considering the position and relationships of the lesion with bony, neural and vascular structures.

Conus medullaris and cauda equina tumors: clinical presentation, prognosis, and outcome after surgical treatment: clinical article

OBJECT

Intradural cauda equina and conus medullaris tumors (CECMTs) are rare. Only a few large clinical series exist to date. Therefore, clinical symptoms, surgical complications, and outcomes are poorly understood. The aim of the present study was to evaluate outcome after surgery of CECMTs and to identify the factors associated with a worse clinical prognosis based on the results of a series with sufficiently high number of cases.

METHODS

All cases of intradural CECMTs treated surgically at the authors' department between March 2006 and May 2012 were retrospectively evaluated. Arachnoid cysts and multifocal tumors were excluded. Sixty-eight adult patients met the inclusion criteria (35 female and 33 male patients; median age 56 years). Follow-up data were available for 72% (n = 49) in a median period of 9 months.

RESULTS

Overall, 18 tumors were located intramedullary and 50 extramedullary. The majority were nerve sheath tumors (n = 27), ependymomas (n = 17), and meningiomas (n = 9). The most common preoperative symptom was pain. The rate of new transient postoperative impairment was 18% (n = 12), and new permanent deficits were observed in only 6% (n = 4). Overall neurological improvement was achieved in 62%. The reversibility of preoperative symptoms was related to the interval between the time of symptom onset and the time of surgery and to the presence of preoperative neurological deficits. Surgery of ependymoma and carcinoma metastases was associated with a higher rate of morbidity.

CONCLUSIONS

Intradural CECMTs present as a group of tumors with varying histological features and clinical symptoms. Symptomatic manifestation is usually unspecific, mimicking degenerative lumbar spine syndromes. Despite a significant risk of transient deterioration, early surgery is advisable because more than 94% of patients maintain at least their preoperative status and more than 60% improve during follow-up. The reversibility of preoperative symptoms is related to the duration between symptom onset and surgery and to the presence of preoperative neurological deficits. The prognosis for recovery from cauda equina or conus medullaris syndrome is less favorable than for other deficits. Surgery of ependymoma is associated with a higher morbidity rate than other benign entities.

Back pain in patients with degenerative spine disease and intradural spinal tumor: what to treat? when to treat?

BACKGROUND

Back pain is common in industrialized countries and one of the most frequent causes of work incapacity. Successful treatment is, therefore, not only important for improving the symptoms and the quality of life of these patients but also for socioeconomic reasons. Back pain is frequently caused by degenerative spine disease. Intradural spinal tumors are rare with an annual incidence of 2-4/1,00,000 and are mostly associated with neurological deficits and radicular and nocturnal pain. Back pain is not commonly described as a concomitant symptom, such that in patients with both a tumor and degenerative spine disease, any back pain is typically attributed to the degeneration rather than the tumor.

OBJECTIVE

The aim of the present retrospective investigation was to study and analyze the impact of microsurgery on back/neck pain in patients with intradural spinal tumor in the presence of degenerative spinal disease in adjacent spinal segments.

METHODS

Fifty-eight consecutive patients underwent microsurgical, intradural tumor surgery using a standardized protocol assisted by multimodal intraoperative neuromonitoring. Clinical symptoms, complications and surgery characteristics were documented. Standardized questionnaires were used to measure outcome from the surgeon's and the patient's perspectives (Spine Tango Registry and Core Outcome Measures Index). Follow-up included clinical and neuroradiological examinations 6 weeks, 3 months and 1 year postoperatively.

RESULTS

Back/neck pain as a leading symptom and coexisting degenerative spine disease was present in 27/58 (47 %) of the tumor patients, and these comprised to group under study. Patients underwent tumor surgery only, without addressing the degenerative spinal disease. Remission rate after tumor removal was 85 %. There were no major surgical complications. Back/neck pain as the leading symptom was eradicated in 67 % of patients. There were 7 % of patients who required further invasive therapy for their degenerative spinal disease.

CONCLUSIONS

Intradural spinal tumor surgery improves back/neck pain in patients with coexisting severe degenerative spinal disease. Intradural spinal tumors seem to be the only cause of back/neck pain more often than appreciated. In these patients suffering from both pathologies, there is a higher risk of surgical overtreatment than undertreatment. Therefore, elaborate clinical and radiological examinations should be performed preoperatively and the indication for stabilization/fusion should be discussed carefully in patients foreseen for first time intradural tumor surgery.

Anatomical location dictating major surgical complications for intradural extramedullary spinal tumors: a 10-year single-institutional experience

Object

Intradural extramedullary (IDEM) neoplasms are uncommon lesions that can pose a challenge for resection. Numerous factors affect the resectability and ultimately the outcome of these lesions. The authors report their 10-year institutional experience with the resection of IDEM neoplasms, focusing on the effect of location on surgical outcomes.

Methods

The authors performed a retrospective review of 96 consecutive patients who presented with a cervical and/or thoracic IDEM tumor that was resected between February 2000 and July 2009. All patients underwent MRI, and the axial location of the tumor was categorized as anterior, posterior, or lateral. Postoperative complications were assessed, as was neurological status at the patient's last follow-up clinic visit. Major complications assessed included CSF leakage requiring lumbar drainage, reexploration for epidural hematoma, and major postoperative neurological deficits.

Results

The mean ± SD age at presentation was 51.16 ± 17.87 years. Major surgical approach–related complications occurred in 15% of patients. Major non–approach related surgical complications occurred in 7.1% of patients, while minor complications occurred in 14.2% of patients. Postoperative neurological deficits occurred most commonly in the thoracic spine between T-1 and T-8. Based on axial spinal cord location, the surgery-related complications rates for all anterior tumors (n = 12) was 41.6%, whereas that for all lateral tumors (n = 69) was 4.4% and that for all posteriorly located tumors (n = 17) was 0%.

Conclusions

Spinal IDEM tumors that are anteriorly located in the upper thoracic spine were found to have the highest rate of surgery-related complications and postoperative neurological deficits. This finding may be associated with the unforgiving anatomy of the upper thoracic spine in which there is a higher cord-to-canal ratio and a tenuous vascular supply.

Intramedullary medullocervical ependymoma--surgical treatment, functional recovery, and long-term outcome

To evaluate the long-term outcome and functional recovery of intramedullary medullocervical ependymoma (IME), the clinical charts of 38 surgically treated consecutive cases of IME were reviewed. Follow-up was obtained prospectively. The mean age of the patients (19 male and 19 female) was 35.3 years (range: 11-60 years). Complete resection was achieved in 33 (86.8%) patients. Fourteen patients worsened postoperatively; five and seven of these improved to their baseline levels within 1 and 3 months, respectively. By 1 year postoperatively, 17 patients returned to work. After a mean follow-up duration of 81.5 months, 31 patients improved or stabilized, and 3 had recurrence. The means of the modified McCormick grade (mMG) scores before the operation, at discharge, 1 year after the operation, and at the most recent evaluation were 1.76, 2.13, 1.82, and 1.84, respectively. A favorable long-term outcome of the mMG was associated with a good preoperative status (mMG I) (odds ratio [OR] = 9.956, p = 0.008) and well-defined tumor boundary (OR = 7.829, p = 0.035). Improvements in the postoperative walking dysfunction and paresthesia over time were associated with the absence of preoperative walking dysfunction (p = 0.047) and paresthesia (p = 0.028), respectively. The 12-year progression/recurrence-free survival and overall survival rates were 92.0% and 93.7%, respectively. The study suggests that the goal of surgery is to stabilize the preoperative neurological function and that a favorable outcome may be achieved in patients with good preoperative statuses and well-defined tumor boundaries. Surgery should be performed as soon as possible after the diagnoses and before the neurological functions deteriorate.

Spinal cord tumor surgery--importance of continuous intraoperative neurophysiological monitoring after tumor resection

STUDY DESIGN

A retrospective clinical analysis of patients operated on for spinal tumors.

OBJECTIVE

To report on the importance of intraoperative neurophysiological monitoring (INM) throughout the entire surgical procedure.

SUMMARY OF BACKGROUND DATA

Postoperative neurological deterioration, despite unaltered neurophysiological monitoring, has been reported. This might be related to timely restricted monitoring. Thus, the likelihood of alterations in INM from positioning to wound closure was analyzed.

METHODS

Two hundred three patients (age range, 54.9 ± 17.4 yr) undergoing intradural tumor removal were sampled in a prospective database and analyzed for the occurrence of alterations in intraoperative somatosensory- and motor-evoked potentials.

RESULTS

INM alterations were observed in 47 of 203 (23.2%) patients. These alterations were related to tumor resection in 29 (14.3%) cases, whereas these were unrelated to tumor removal in 18 patients: laminotomy in 5 (2.5%) patients, dura opening in 7 (3.5%) patients, dura closure in 5 (2.5%) patients, and laminoplasty in 1 (0.5%) patient caused INM changes.

CONCLUSION

This study demonstrates that monitoring beyond tumor resection is of essential importance in order to detect all critical phases of surgical procedure and to counteract accordingly.

Delay in diagnosis of primary intradural spinal cord tumors

Background:

It has been our impression in recent years that there is a significant delay in diagnosis (DID) of patients in Israel harboring intradural spinal cord tumors (IDSCTs). DID can lead to irreversible deficits and unnecessary suffering. Our goal was to identify the incidence and the specific reasons for DID of IDSCTs in patients operated upon at our institution.

Methods:

A retrospective record review, with additional telephone survey, of 101 patients operated upon at our institute between the years 1996 and 2009 was conducted. The patients who were not diagnosed locally and those who were diagnosed during routine spinal imaging studies as part of their basic disease check-up were excluded. Accordingly, neurofibromatosis and medical tourist patients were excluded.

Results:

The clinical presentation of IDSCTs in our study was similar to the descriptions given in previous reports. The average age was 41.9 ± 23.3 years. Most tumors were ependymomas, astrocytomas, and schwannomas. The most common symptoms were motor or sensory disturbance, back pain, walking disturbance, and sphincter control deficit. The median time to diagnosis was 12.0 ± 37.0 months (range 3 days to 20 years). We found DID in 82.2% of the cases. 62.4% of the cases were defined as “unreasonable delay.” The most common reasons for DID were “classical symptoms with a wrong diagnosis” and “delayed imaging.”

Conclusions:

Based on the results of this study, the incidence of unreasonable delays in diagnosis of primary IDSCTs in Israel is very high. In order to shorten the time to diagnosis, primary and secondary care physicians need to increase their awareness of symptoms that may be associated with these lesions. We hereby offer feedback for care providers, relevant to the diagnostic workup of these patients. Such a feedback must be delivered by neurosurgeons to the community they are serving.

Treatment of spinal cord tumors

Tumors associated with the spinal cord can have devastating effects on patient function and quality of life. Most of these tumors are from metastatic disease, usually to the epidural space. Less frequently, the tumors are intrinsic to the spinal cord itself (ie, primary tumor). Regardless of the etiology, spinal cord tumors often present first with progressive local or radicular pain, or both. Other symptoms include weakness, sensory changes, or sphincter dysfunction. The timeliness of diagnosis of spinal cord tumors and promptness of treatment are important, as they directly affect outcome. Dexamethasone, a corticosteroid, is used as a temporizing measure to improve or stabilize neurologic function until definitive treatment. For nonambulatory patients with epidural metastatic tumors, surgery followed by radiation therapy maximizes neurologic function and modestly lengthens survival. However, palliative radiotherapy alone is recommended for those with neurologic deficits lasting longer than 48 hours, survival prognosis less than 3 months, inability to tolerate surgery, multiple areas of compression, or radiosensitive tumors. An ambulatory patient with a stable spine should be considered for radiation treatment only. The role of chemotherapy for epidural metastatic tumors is not well established. For intramedullary metastases, the role of surgery and chemotherapy remains controversial and radiation is the mainstay. For low-grade or benign primary spinal cord tumors, resective surgery is of benefit and can be curative. For high-grade tumors, the benefit of resection is less clear, and radiotherapy and/or chemotherapy may be helpful. The use of chemotherapy for primary spinal cord tumors has rarely been assessed. Agents reported in the literature for treatment of spinal cord gliomas include temozolomide, irinotecan, cisplatin, and carboplatin. A multidisciplinary approach is often required to maximize the therapeutic and functional outcome of patients with metastatic and primary spinal cord tumors.

Surgery for Spinal Cord Ependymomas

BACKGROUND:

Spinal cord tumors account for 5% to 10% of all primary central nervous system tumors. The most common intramedullary neoplasms are ependymomas, composing 50% to 60% of spinal neuroepithelial tumors in adults.

OBJECTIVE:

To evaluate the clinical and oncological outcomes of patients with spinal ependymoma primarily treated with microsurgery.

METHODS:

Patient charts and operative notes were analyzed to evaluate the clinical and oncological outcomes of 57 patients (33 men, 24 women) undergoing surgery for spinal ependymal tumors between 1987 and 2007. Mean follow-up was 67 months (range, 1-195 months; median, 56 months). Histopathological findings were 1 subependymoma World Health Organization (WHO) grade I, 16 myxopapillary ependymomas WHO grade I, 39 ependymomas WHO grade II, and 1 anaplastic ependymoma WHO grade III. Histopathological diagnoses were reviewed in 52 cases (91%) using the 2007 WHO classification.

RESULTS:

There were 47 complete resections (83%). Only 4 patients (7%) underwent (postoperative) radiotherapy. Forty-nine of 57 patients (86%) had stable or improved McCormick grades directly after surgery. A permanent decrease in the McCormick grade was seen in 4 (7%) patients. Multivariate logistic regression revealed only the preoperative neurological status of the patient as an independent predictor of functional outcome (P = .007). Recurrent tumors were diagnosed 12 to 72 months after surgery in 5 of 57 patients (9%) including 3 of 16 myxopapillary ependymomas (19%). In 4 of 5 patients, the primary tumor was incompletely resected. The progression-free survival rate was 89% and 84% for all patients at 5 and 10 years, respectively. An incomplete resection proved the only independent predictor of progression-free survival (P = .05).

CONCLUSION:

These results support early surgery aiming at complete resection as the primary treatment for presumed spinal ependymomas. The prognosis after surgery for some myxopapillary ependymomas seems worse than generally believed.

Intramedullary low grade astrocytoma and ependymoma. Surgical results and predicting factors for clinical outcome

INTRODUCTION

The optimal time point for surgery of intramedullary spinal astrocytomas and ependymomas is often debated on, as predicting factors are poorly defined. The current single-institutional study was conducted to retrospectively analyze prognostic factors for postoperative functional outcome in these patients.

MATERIAL AND METHODS

All consecutive adult patients with intramedullary astrocytomas or ependymomas (except filum terminale ependymomas) were included. Imaging data, McCormick score (MCS), and detailed neurological evaluation were stringently applied preoperatively, 1 week, and 6 months postoperatively for functional evaluation of all patients. End points were early and late functional outcome. Prognostic factors were obtained from univariate and multivariate logistic regression analysis.

RESULTS

Forty-four patients were included (29 ependymomas World Health Organization (WHO) grades I or II, 8 astrocytomas WHO grade I, and 7 astrocytomas WHO grade II). Overall perioperative morbidity was 34%, and there was no mortality. Complete tumor resection was achieved in 79% of ependymomas, 50% of astrocytomas WHO grade I, and 14% of astrocytomas WHO grade II (significantly more often in ependymomas than in astrocytomas, p < 0.05). Early and late functional outcome were highly intercorrelated (p < 0.01), but not correlated to histology. Preoperative MCS <3 and extent of tumor <5 levels were significantly (p = 0.01 and p < 0.05) associated with a favorable outcome (MCS <3) in early and late follow-up.

CONCLUSION

An MCS of less than 3 and a tumor extent of less than 5 levels are the most important factors for a favorable postoperative functional outcome. Therefore, surgery should be initiated before significant clinical symptomatology or substantial tumor growth occurs.

SPINAL MENINGIOMA SURGERY IN ELDERLY PATIENTS WITH PARAPLEGIA OR SEVERE PARAPARESIS

OBJECTIVE

In a multicenter study, 102 patients aged 70 years or older with paraplegia or severe paraparesis, and who underwent operation for spinal meningiomas, are presented to correlate surgery and outcome and to determine the most influential factors that affected this outcome.

METHODS

Five French neurosurgical centers participated in this retrospective study between 1990 and 2007. Pre- and postoperative neurological status were assessed using a grading system. All patients underwent operation, and neurological evaluations were conducted 3 months and 1 year after surgery. The median follow-up period was 49.5 months (range, 12–169 months). Data were analyzed using a multiple logistic regression model.

RESULTS

Twenty-six patients were paraplegic (Grade 4). Complete tumor removal was obtained in 93 patients. There was no surgical mortality, and morbidity was 9%. Three months after surgery, 7 of the patients were unchanged, 87 patients had improved, and 8 were not evaluated. One year after surgery, 7 of the 100 surviving patients were clinically unchanged and 93 had improved. Of those who had improved, 49 patients experienced complete recovery.

CONCLUSION

Advanced age did not seem to contraindicate surgery, even in patients with severe preoperative neurological deficits and/or an American Society of Anesthesiologists class of III. Quality of life can be improved in most cases.

Pharmacotherapy for adults with tumors of the central nervous system

Tumors of the adult central nervous system are among the most common and most chemoresistant neoplasms. Malignant tumors of the brain and spinal cord collectively account for approximately 1.3% of all cancers and 2.2% of all cancer-related deaths. Novel pharmacological approaches to nervous system tumors are urgently needed. This review presents the current approaches and challenges to successful pharmacotherapy of adults with malignant tumors of the central nervous system and discusses novel approaches aimed at overcoming these challenges.