Regional Spinal Cord Atrophy Is Associated with Poor Outcome After Surgery on Intramedullary Spinal Cord Ependymoma: A New Aspect of Delayed Neurological Deterioration

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.

Multimodal Intraoperative Neurophysiological Monitoring in Intramedullary Spinal Cord Tumors: A 10-Year Single Center Experience

OBJECTIVE

The study aimed at evaluating the efficacy and the ability of D-wave monitoring combined with somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) to predict functional outcomes in intramedullary spinal cord tumor (IMSCT) surgery.

METHODS

Between December 2011 and December 2020, all patients harboring IMSCT who underwent surgery at our institution were prospectively collected in a surgical spinal registry and retrospectively analyzed. Patient charts and surgical and histological reports were analyzed. The multimodal IONM included SSEPs, MEPs, and-whenever possible-D-waves. All patients were evaluated using the modified McCormick and Frankel grade at admission and 3, 6, and 12 months of follow-up.

RESULTS

Sixty-four patients were enrolled in the study. SSEP and MEP monitoring was performed in all patients. The D-wave was not recordable in seven patients (11%). Significant IONM changes (at least one evoked potential modality) were registered in 26 (41%) of the 64 patients. In five cases (8%) where the SSEPs and MEPs lost and the D-wave permanently dropped by about 50%, patients experienced a permanent deterioration of their neurological status. Multimodal IONM (SSEP, MEP, and D-wave neuromonitoring) significantly predicted postoperative deficits (p = 0.0001), with a sensitivity of 100.00% and a specificity of 95.65%. However, D-waves demonstrated significantly higher sensitivity (100%) than MEPs (62.5%) and SSEPs (71.42%) alone. These tests' specificities were 85.10%, 13.89%, and 17.39%, respectively. Comparing the area under ROC curves (AUCs) of these evoked potentials in 53 patients (where all three modalities of IONM were registered) using the pairwise t-test, D-wave monitoring appeared to have higher accuracy and ability to predict postoperative deficits with strong statistical significance compared with MEP and SSEP alone (0.992 vs. 0.798 vs. 0.542; p = 0.018 and p < 0.001).

CONCLUSION

The use of multimodal IONM showed a statistically significant greater ability to predict postoperative deficits compared with SSEP, MEP, and D-wave monitoring alone. D-wave recording significantly increased the accuracy and clinical value of neurophysiological monitoring in IMSCT tumor resection.

Recent Molecular and Genetic Findings in Intramedullary Spinal Cord Tumors

The study of genetic alterations and molecular biology in central nervous system (CNS) tumors has improved the accuracy of estimations of patient prognosis and tumor categorization. Therefore, the updated 2021 World Health Organization (WHO) classification includes various diagnostic genes, molecules, and pathways for diagnosis, as well as histological findings. These findings are expected both to have diagnostic applications and to facilitate new targeted therapies that target tumor-specific genetic changes and molecular biology. Intramedullary spinal cord tumors (IMSCTs) are rare CNS tumors that are difficult to treat because they occur in eloquent areas. Although the genetic underpinnings of IMSCTs remain unclear compared to their intracranial counterparts, the genetic characteristics of these tumors are gradually being revealed. Here, we describe the major changes in the new 2021 WHO classification and review the major types of IMSCTs, with an emphasis on their clinical features and genetic alterations.

Surgery for intramedullary spinal cord ependymomas in the neuromonitoring era: results from a consecutive series of 100 patients

OBJECTIVE

The established treatment of intramedullary spinal cord ependymomas (ISCEs) is resection. Surgical series reporting treatment results often lack homogeneity, as these are collected over long time spans and their analysis is plagued by surgical learning curves and inconsistent use of intraoperative neurophysiological monitoring (IONM). The authors report the oncological and functional long-term outcomes in a modern series of 100 consecutive ISCEs that were resected between 2000 and 2015 by a surgically experienced team that consistently utilized IONM.

METHODS

In this retrospective study, the authors tailored surgical strategy and multimodal IONM, including somatosensory evoked potentials, muscle motor evoked potentials (mMEPs), and D-waves, with the aim of gross-total resection (GTR). Preservation of the D-wave was the primary objective, and preservation of mMEPs was the second functional objective. Functional status was evaluated using the modified McCormick Scale (MMS) preoperatively, postoperatively, and at follow-up.

RESULTS

Preoperatively, 89 patients were functionally independent (MMS grade I or II). A GTR was achieved in 89 patients, 10 patients had a stable residual, and 1 patient underwent reoperation for tumor progression. At a mean follow-up of 65.4 months, 82 patients were functionally independent, and 11 lost their functional independence after surgery (MMS grades III-V). Muscle MEP loss predicted short-term postoperative worsening (p < 0.0001) only, while the strongest predictors of a good functional long-term outcome were lower preoperative MMS grades (p < 0.0001) and D-wave preservation. D-wave monitorability was 67%; it was higher with lower preoperative MMS grades and predicted a better recovery (p = 0.01).

CONCLUSIONS

In this large series of ISCEs, a high rate of GTR and long-term favorable functional outcome were achieved. Short- and long-term functional outcomes were best reflected by mMEPs and D-wave monitoring, respectively.

Multisegmental versus monosegmental intramedullary spinal cord ependymomas: perioperative neurological functions and surgical outcomes

Multiple factors, such as tumor size, lateralization, tumor location, accompanying syringomyelia, and regional spinal cord atrophy, may affect the resectability and clinical prognosis of intramedullary spinal cord ependymomas. However, whether long-segmental involvement of the spinal cord may impair functional outcomes remains unclear. This study was aimed to compare perioperative neurological functions and long-term surgical outcomes between multisegmental ependymomas and their monosegmental counterparts. A total of 62 patients with intramedullary spinal cord ependymoma (WHO grade II) were enrolled, and all of them underwent surgical resection. The patients were classified into the multisegmental group (n = 43) and the monosegmental group (n = 19). Perioperative and long-term (average follow-up period, 47.3 ± 21.4 months) neurological functions were evaluated using the modified McCormick (mMC) scale and the modified Japanese Orthopaedic Association (mJOA) scoring system. Preoperative neurological functions in the multisegmental group were significantly worse than those in the monosegmental group (P < 0.05). However, postoperative short-term neurological functions, as well as long-term functional outcomes, were similar between the two groups (P > 0.05). Logistic regression analysis showed that preoperative mMC and mJOA scores were significantly correlated with neurological improvement during the follow-up period (P < 0.05). Multisegmental involvement of the spinal cord is associated with worse neurological functions in patients with intramedullary spinal cord ependymoma, while the long-term prognosis is not affected. The preoperative neurological status of the patient is the only predictor of long-term functional improvement.

Risk factors for the recurrence of world health organization grade Ⅱ ependymomas of spinal cord in adults after microsurgical resections: A retrospective study of 118 patients in a single center

OBJECTIVE

To identify the risk factors for recurrence of World Health Organization (WHO) grade Ⅱ ependymomas of spinal cord in adults after microsurgical resections.

PATIENTS AND METHODS

A total of 118 adult patients diagnosed with WHO grade Ⅱ ependymomas of spinal cord at west china hospital from January 2010 to December 2016 were reviewed retrospectively. To identify the risk factors for recurrence, we performed univariate analyses and multivariate logistic regression analyses successively.

RESULTS

Twelve patients had a recurrence with a median recurrence time of 30 months [inter-quartile range (IQR) 23.5-75.5 months]. Univariate analysis showed that age (p = 0.030), STR (p < 0.001), index of Ki-67 (p = 0.004), and Vimentin (+, p = 0.004) were associated with postoperative recurrence of ependymomas of spinal cord in adults, while univariate analysis showed that only STR [odds ratio (OR) = 18.838, 95 % confidence interval (CI): 3.068-115.673; p = 0.002], index of Ki-67 (OR = 1.381, 95 % CI: 1.021-1.868; p = 0.036), Vimentin (+; OR = 6.706, 95 % CI: 1.218-36.928; p = 0.029) were independent risk factors for recurrence.

CONCLUSIONS

The recurrence rate of WHO grade Ⅱ ependymomas of spinal cord in adults was about 13.6 %. Subtotal resection is a critical risk factor for recurrence. A high index of Ki-67 is another independent risk factor for recurrence. Positive Vimentin may also play a role in this process. GTR is very important to prevent recurrence after operation if it is safe to conduct. In cases with higher index Ki-67 and Vimentin (+), close follow-ups are necessary.

Spinal cord atrophy following the resection of multiple intraspinal arachnoid cysts: case report and literature review

We report the first case of spinal cord atrophy developing 16 months after resection of multiple intraspinal arachnoid cysts. The patient presented with back pain and the cysts were successfully resected. Sixteen months later, her back pain recurred. Magnetic resonance imaging showed severe atrophy of the spinal cord.

Return to work and clinical outcome after surgical treatment and conservative management of patients with intramedullary spinal cord ependymoma

The ability to return to work after treatment of diseases is an important issue. Aim of this study is to compare surgery and conservative management focusing on clinical outcome and ability to return to work in patients with intramedullary spinal cord ependymoma. Retrospective, single center study. The neurological status at first presentation, as well as in long-term follow-up, were assessed using the modified McCormick Disability Scale and modified Rankin Scale. The study population consisted of 56 patients, 23 (41%) were managed conservatively and 33 (59%) underwent microsurgical resection. The median age was 47.5 years in the conservative group and 44.5 in the surgical group. At first admission 18 of conservatively treated and 28 of surgically treated patients were employed, p = 0.7. At the last follow-up 15 (83%) of conservatively and 10 (36%) of surgically treated patients returned to work, p = 0.002. The median modified McCormick score in both groups (conservative vs. surgical) was at admission 1 vs. 1, p = 1.0 and at last follow up 1 vs. 2.5, p = 0.001. Patients clinical outcome in the surgical group was significantly reduced at last follow up as assessed by the modified Rankin Scale (mRs score of 0-2) at admission 100% vs. 100% and last follow-up 94% vs. 57%, p = 0.007. In our investigated study population, conservatively managed patients revealed a significantly better outcome and were more often able to return to work.

Spinal Cord Gray Matter Atrophy in Amyotrophic Lateral Sclerosis

BACKGROUND AND PURPOSE

There is an emerging need for biomarkers to better categorize clinical phenotypes and predict progression in amyotrophic lateral sclerosis. This study aimed to quantify cervical spinal gray matter atrophy in amyotrophic lateral sclerosis and investigate its association with clinical disability at baseline and after 1 year.

MATERIALS AND METHODS

Twenty-nine patients with amyotrophic lateral sclerosis and 22 healthy controls were scanned with 3T MR imaging. Standard functional scale was recorded at the time of MR imaging and after 1 year. MR imaging data were processed automatically to measure the spinal cord, gray matter, and white matter cross-sectional areas. A statistical analysis assessed the difference in cross-sectional areas between patients with amyotrophic lateral sclerosis and controls, correlations between spinal cord and gray matter atrophy to clinical disability at baseline and at 1 year, and prediction of clinical disability at 1 year.

RESULTS

Gray matter atrophy was more sensitive to discriminate patients with amyotrophic lateral sclerosis from controls (P = .004) compared with spinal cord atrophy (P = .02). Gray matter and spinal cord cross-sectional areas showed good correlations with clinical scores at baseline (R = 0.56 for gray matter and R = 0.55 for spinal cord; P < .01). Prediction at 1 year with clinical scores (R² = 0.54) was improved when including a combination of gray matter and white matter cross-sectional areas (R² = 0.74).

CONCLUSIONS

Although improvements over spinal cord cross-sectional areas were modest, this study suggests the potential use of gray matter cross-sectional areas as an MR imaging structural biomarker to monitor the evolution of amyotrophic lateral sclerosis.