Quality of Life After Craniovertebral Junction Meningioma Resection: Shaping the Real Neurologic and Functional Expectancies About These Surgeries in a Contemporary Large Multicenter Experience

Resection vs. coagulation of dural attachment in patients with spinal meningioma: an updated systematic review and meta-analysis

BACKGROUND

The Simpson grading scale assumes dural resection (grade I) is more effective against recurrence than coagulation (grade II). However, the results of recent studies have raised doubts about this effectiveness in spinal meningiomas. Therefore, we aimed to perform a meta-analysis comparing outcomes between Simpson grades I and II in spinal meningiomas.

METHODS

According to the PRISMA statement, we systematically searched PubMed, EMBASE, and Web of Science for studies involving patients with spinal meningiomas who underwent Simpson grades I, II, III, or IV. Outcomes were radiological tumor recurrence, postoperative neurological deficits, and procedure-related complications.

RESULTS

We included 54 studies with a total of 3334 patients. Simpson grades I, II, III, and IV were performed in 674 (20%), 2205 (66%), 254 (8%), and 201 (6%) patients, respectively. The follow-up ranged from 9 to 192 months, and 95.4% of all tumors were WHO grade 1. There was no difference in radiological tumor recurrence (OR 0.80, 95% CI: 0.46-1.36, P = 0.41; I2 = 0%), postoperative neurological deficits (OR 0.74, 95% CI: 0.32-1.75, P = 0.50; I2 = 0%) or procedure-related complications (OR 2.22, 95% CI: 0.80-6.13, P = 0.12; I2 = 3%) between Simpson grades I and II. Furthermore, no significant difference in postoperative neurological deficits or procedure-related complications was detected when comparing all Simpson's to each other. However, radiological tumor recurrences in Simpson I and II were significantly lower than in III and IV, with Simpson III outperforming IV (OR 0.19, 95% CI: 0.09-0.40, P < 0.01; I2 = 0%).

CONCLUSION

Simpson grade I is not more effective than grade II in any outcome, although both are superior to III and IV in tumor recurrence. Our results might suggest that dural coagulation is preferable over resection when the latter carries a higher risk of complications.

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 cordectomy for the management of thoracic malignant intraspinal tumors in paraplegic or irreversibly, severely paraparetic patients: A technical remark

BACKGROUND

Malignant Intramedullary Spinal Cord Tumor are a relatively uncommon entity affecting patients whose prognosis is quickly and relentlessly dismal. Since the '50s Spinal Cordectomy' has been advocated for the surgical management of these conditions, but to date, no standard operative protocol has been reported yet.

OBJECTIVE

Although apparently "easy", burdened by virtually no further risk for the neurological function in paraplegic or severely paraparetic patients, SCt conceals notable pitfalls and surgical problems that are to date not yet completely discussed. The objective of the present paper is therefore to report a detailed stepwise description of the surgical technique.

METHODS AND RESULTS

SCt addresses the problem of reaching a surgical radicality in patients whom neurological preoperative conditions have already irreversibly declined to a deep nonfunctional motor impairment and whose preoperative Brain MRI scan rules out intracranial seeding. The dural sac along with the radicular pouches must be considered as possible seeding and recurrence locations therefore such structure should be "en-bloc" removed. The cranial medullary end of the resection should be identified on the ground of the preoperative MRI and intraoperatively confirmed with fresh histological examinations ruling out the presence of tumor cells above the cordectomy. Due to the topographic and functional medullary arterial anatomy, no SCt should be performed above T3. The risk of postoperative sagittal imbalance is high and therefore a concurrent posterior vertebral stabilization is required.

CONCLUSION

Spinal Cordectomy is a safe and feasible "last chance" treatment to prolong survival in paraplegic or severely paraparetic patients.