Diagnosis and rehabilitation of a pregnant woman with spinal cord disorder due to spinal cord tumor

Therapeutic Strategies and Challenges in the Management of Craniospinal Tumors in Pregnancy: A Ten-Year Retrospective Tertiary-Center Study, Systematic Review, and Proposal of Treatment Algorithms

OBJECTIVE

This study aims to review therapeutic strategies in the management of craniospinal tumors in pregnant patients and the factors that may influence the management along with their influence on maternal and fetal outcomes.

METHODS

A retrospective single-center cohort study was performed at a tertiary neurosurgical referral center. Pregnant patients referred to the neuro-oncology multidisciplinary meeting (MDM) with craniospinal tumor were included. Ten-year patient data were collected from hospital records and neuro-oncology MDM outcomes. A systematic review was performed of the available literature as per PRISMA guidelines.

RESULTS

Twenty-five patients were identified, with a mean age of 31 years. Of these patients, 88% (n = 22) had cranial lesions and 12% (n = 3) had spinal lesions. Most of the patients had World Health Organization grade I/II tumors. Of the patients, 44% underwent surgery when pregnant, whereas in 40%, this was deferred until after the due date. Of patients, 16% did not require surgical intervention and were followed up with serial imaging in the MDM. The left lateral/park bench position was the preferred position for the spinal and posterior fossa lesions. Systematic review and retrospective data led to proposal of treatment algorithms addressing the therapeutic strategy for management of craniospinal tumors during pregnancy. Factors that may influence maternal and fetal outcomes during management of these tumors were identified, including aggressiveness of the tumor and stage of pregnancy.

CONCLUSIONS

Craniospinal tumors presenting in pregnancy are challenging. The surgical management needs to be tailored individually and as part of a multidisciplinary team approach. Factors influencing maternal and fetal outcomes are to be considered during management and patient counseling.

Fatal holocord recurrence of a pregnancy-related, low-grade spinal ependymoma: case report and review of an unusual clinical phenomenon

INTRODUCTION

Pregnancy-related spinal tumors (PRSTs) are unusual tumors that present during pregnancy or within a year after delivery. We describe a fatal holocord recurrence of a spinal ependymoma, which, to the best of our knowledge, is one of the most extensive PRSTs reported thus far.

CASE PRESENTATION

A 21-year-old primigravida presented at 6 months of gestation with urinary incontinence for 2 months and spastic paraparesis for 1 month. MRI showed a conus intramedullary lesion from T10 to 12. Near-total resection of the lesion was performed. The histopathological diagnosis was that of a cellular ependymoma (WHO grade II). The patient presented 6 months later with progressive quadriparesis and breathing difficulty. MRI demonstrated holocord recurrence of the tumor with edema extending to the pontomedullary junction. The patient succumbed to respiratory failure before decompression of the tumor could be performed.

DISCUSSION

This case highlights an unusual clinical course of a pregnancy-related, low-grade spinal ependymoma. The possible hormonal and genetic mechanisms underlying the aggressive involvement of the entire spinal cord by the recurrent tumor are discussed in the light of a literature review. Future studies may shed light on the possibility of utilizing these mechanisms as therapeutic targets to alter the clinical course of aggressive spinal ependymomas.

Cauda equina syndrome in an obese pregnant patient secondary to double level lumbar disc herniation - A case report and review of literature

Introduction

Lumbar disc herniation during pregnancy poses a significant challenge to the spine surgeon towards achieving good clinical, maternal, and fetal outcomes. Surgical intervention is warranted in patients with significant neural deficits, and cauda equina syndrome and needs to be performed at the earliest in order to avoid irreversible neurological sequelae.

Case presentation

We report a 29-year-old primigravida in her 21st week of gestational period, who was diagnosed with cauda equina syndrome secondary to two level lumbar disc herniations. The lengthier surgical duration in performing double level disc herniations in an obese patient raises concerns in anesthetic dosing of drugs and surgical positioning which may result in fetal distress. A double level decompression and discectomy in prone position was done under general anesthesia. Despite the surgical challenges, the postoperative period was uneventful resulting in immediate pain relief and complete neurological recovery, followed by the delivery of a 2.7-kg healthy male child.

Discussion

Surgical intervention can be performed in pregnancy, to avoid irreversible neurological deficits, even in an obese individual with double level lumbar pathology. However, it is essential that the surgeon appraises the situation and involves an integrated multidisciplinary team comprising anesthetist, spine surgeon, obstetrician, and psychologist, and inculcates certain precautions in the perioperative management to achieve good surgical and fetal outcomes.