Radical excision of intramedullary spinal cord tumors: surgical morbidity and long-term follow-up evaluation in 164 children and young adults

Intraoperative Neurophysiologic Monitoring and Mapping During Surgery on Intramedullary Spinal Cord Tumors in Children and Adolescents

SUMMARY

Surgical resection of intramedullary spinal cord tumors carries significant risks of neurologic deficits, especially in cases of infiltrative tumors. In pediatric patients, this type of surgery may be associated with a high risk of poor neurologic outcome. Intraoperative neurophysiologic monitoring has been adopted as part of the clinical routine by many centers as a useful adjunct for intraoperative assessment of neurologic integrity. To what extent intraoperative neurophysiologic mapping strategies may further support intraoperative decision-making is still a matter of debate. Here, we report on a small cohort of five pediatric patients in whom mapping with the double-train paradigm was used to identify the dorsal column and corticospinal tract and to guide the surgical resection. We also discuss the possible benefits and challenges regarding the available literature.

What Factors Predict the Development of Neurologic Deficits Following Resection of Intramedullary Spinal Cord Tumors: A Multi-Center Study

BACKGROUND

Intramedullary spinal cord tumors are challenging to resect, and their postoperative neurological outcomes are often difficult to predict, with few studies assessing this outcome.

METHODS

We reviewed the medical records of all patients surgically treated for Intramedullary spinal cord tumors at our multisite tertiary care institution (Mayo Clinic Arizona, Mayo Clinic Florida, Mayo Clinic Rochester) between June 2002 and May 2020. Variables that were significant in the univariate analyses were included in a multivariate logistic regression. "MissForest" operating on the Random Forest algorithm, was used for data imputation, and K-prototype was used for data clustering. Heatmaps were added to show correlations between postoperative neurological deficit and all other included variables. Shapley Additive exPlanations were implemented to understand each feature's importance.

RESULTS

Our query resulted in 315 patients, with 160 meeting the inclusion criteria. There were 53 patients with astrocytoma, 66 with ependymoma, and 41 with hemangioblastoma. The mean age (standard deviation) was 42.3 (17.5), and 48.1% of patients were women (n = 77/160). Multivariate analysis revealed that pathologic grade >3 (OR = 1.55; CI = [0.67, 3.58], P = 0.046 predicted a new neurological deficit. Random Forest algorithm (supervised machine learning) found age, use of neuromonitoring, histology of the tumor, performing a midline myelotomy, and tumor location to be the most important predictors of new postoperative neurological deficits.

CONCLUSIONS

Tumor grade/histology, age, use of neuromonitoring, and myelotomy type appeared to be most predictive of postoperative neurological deficits. These results can be used to better inform patients of perioperative risk.

The role of intraoperative extensor digitorum brevis muscle MEPs in spinal surgery

PURPOSE

Intraoperative muscle motor evoked potentials (m-MEPs) are widely used in spinal surgery with the aim of identifying a damage to spinal cord at a reversible stage. Generally, lower limb m-MEPs are recorded from abductor hallucis [AH] and the tibialis anterior [TA]. The purpose of this work is to study an unselected population by recording the m-MEPs from TA, AH and extensor digitorum brevis (EDB), with the aim of identifying the most adjustable and stable muscles responses intraoperatively.

METHODS

Transcranially electrically induced m-MEPs were intraoperative recorded in a total of 107 surgical procedures. m-MEPs were recorded by a needle electrode placed in the muscle from TA, AH and EDB muscles in the lower extremities.

RESULTS

Overall monitorability (i.e., at least 1 Lower Limb m-MEP recordable) was 100/107 (93.5%). In the remaining 100 surgeries in 3 cases, the only muscle that could be recorded at baseline was one AH, and in other 2 the EDB. Persistence (i.e., the recordability of m-MEP from baseline to the end of surgery) was 88.7% for TA, 89.8% for AH and 93.8% for EDB.

CONCLUSION

In our series, EDB m-MEPs have demonstrated a recordability superior to TA and a stability similar to AH. The explanations may be different and range from changes in the excitability of the cortical motor neuron to the different sensitivity to ischemia of the spinal motor neuron. EDB can be used alternatively or can be added to TA and AH as a target muscle of the lower limb in spinal surgery.

Clinical Characteristics and Treatment Outcomes of Long-Level Intramedullary Spinal Cord Tumors: A Consecutive Series of 43 Cases

Objective: Long-level intramedullary spinal cord tumors (LIMSCTs) cause complex treatment issues. However, LIMSCTs have rarely been analyzed separately. The authors reported a large case series of LIMSCTs and analyzed the clinical characteristics and treatment outcomes.Methods: The medical data of patients with LIMSCTs at our institution between January 2015 and December 2019 were retrospectively reviewed. Demographics, tumor size and location, pathology, extent of resection, and neurological functional status were collected.Results: A total of 43 consecutive cases were included. Twenty-three cases (53.5%) of LIMSCTs were ependymal tumors. All patients with ependymal tumors achieved gross total resection (GTR). In ependymal tumor cases, 3 cases (13%) of ependymal tumors experienced postoperative neurological deterioration, and 66% of them showed an improvement at follow-up; 25.6% were low-grade astrocytic tumors. The rates of GTR, subtotal resection (STR) and partial resection (PR) were 63.6%, 27.3%, and 9.1%, respectively. Twenty-seven percent cases showed postoperative neurological worsening, and 33% of them had an improvement at follow-up; 20.9% were high-grade astrocytic tumors. The excision rates were 44.4% for GTR, 44.4% for STR, and 11% for PR, respectively. Fifty-five percent cases showed postoperative neurological worsening, and none of them had an improvement at follow-up.Conclusion: In this series, all LIMSCTs were gliomas. Aggressive tumor resection did not increase the risk of long-term functional deterioration in ependymal tumors and low-grade astrocytic tumors, but in high-grade astrocytic tumors, patients had a higher risk of neurological deterioration and difficulty in recovery. In ependymal tumors and low-grade astrocytic tumors, patients can achieve long-time survival after performing aggressive tumor resection.

Long-term quality of life and functional outcomes in adults surgically treated for intramedullary spinal cord tumor

Introduction

Intramedullary spinal cord tumors (IMSCTs) are rare but clinically significant entities that may cause severe neurological decline with progressive pain and motor or sensory deterioration. Beyond the beneficial effects of surgical treatment and the long-term progression-free survival, neurological deficits may still persist after surgery, and information about the long-term patients' health-related quality of life (QoL) is still lacking. In this study, we investigate the patients' health perception 15 years after the surgery in an overall patients' wellbeing framework.

Methods

Patients surgically treated for IMSCT over a period from 1996 to 2011 were selected. After a mean of 15 years from the surgery, patient's self-administered questionnaire on disability, pain, sleep quality, and QoL was collected and neurological postoperative evaluation at the chronic stage was reexamined.

Results

Neurological deficits are reported in half of the patients in the postoperative chronic phase. After 15 years of surgery, half of the patients still report mild or severe disability grades associated with significantly higher pain and poor sleep and QoL. In accordance, the neurological condition measured at the chronic stage is significantly related not only to disease-specific symptoms (i.e., pain) but even to sleep quality complaints and poor QoL, measured at 15 years follow-up.

Conclusions

Health-related QoL is an important secondary outcome in patients. Although the progression-free survival, worse postoperative neurological conditions could predict long-term sequelae reflecting patients' poor health perception. It suggests the importance of preserving patients' functional status and globally evaluating patients' wellbeing to handle disease-specific symptoms but even more general aspects of QoL.

Primary Spinal Cord Astrocytomas: Two-Center Clinical Experience of Low- and High-Grade Lesions

OBJECTIVE

Primary spinal cord astrocytomas are rare, fatal, and poorly studied.

METHODS

This study included a 2-center, retrospective analysis of primary spinal cord astrocytoma patients from 1997 to 2020. Patients with drop metastases or without at least one follow-up were excluded.

RESULTS

Seven World Health Organization grade I, 6 grade II, 7 grade III, and 4 grade IV astrocytoma patients were included. Older patients had higher grades (median 20 years in grade I vs. 36.5 in grade IV). The median follow-up was 15 months. Thirteen patients were discharged to rehabilitation. Eight patients demonstrated radiographic progression. Adjuvant therapy was utilized more in higher grades (5 of 13 grades III vs. all 11 grades IIIIV). Six patients died (1 death in grades III vs. 5 in grades IIIIV). Ten patients had worsened symptoms at the last follow-up. The median progression-free survival in grade I, II, III, and IV tumors was 116, 36, 8, and 8.5 months, respectively. The median overall survival in grade I, II, III, and IV tumors was 142, 69, 19, and 12 months, respectively. Thrombotic complications occurred in 2 patients, one with isocitrate dehydrogenasewild type glioblastoma.

CONCLUSIONS

Outcomes worsen with higher grades and lead to difficult postoperative periods. Clinicians should be vigilant for thromboembolic complications. Further research is needed to understand these rare tumors.

Integrated genomic analysis reveals actionable targets in pediatric spinal cord low-grade gliomas

Gliomas are the most common central nervous tumors in children and adolescents. However, spinal cord low-grade gliomas (sLGGs) are rare, with scarce information on tumor genomics and epigenomics. To define the molecular landscape of sLGGs, we integrated clinical data, histology, and multi-level genetic and epigenetic analyses on a consecutive cohort of 26 pediatric patients. Driver molecular alteration was found in 92% of patients (24/26). A novel variant of KIAA1549:BRAF fusion (ex10:ex9) was identified using RNA-seq in four cases. Importantly, only one-third of oncogenic drivers could be revealed using standard diagnostic methods, and two-thirds of pediatric patients with sLGGs required extensive molecular examination. The majority (23/24) of detected alterations were potentially druggable targets. Four patients in our cohort received targeted therapy with MEK or NTRK inhibitors. Three of those exhibited clinical improvement (two with trametinib, one with larotrectinib), and two patients achieved partial response. Methylation profiling was implemented to further refine the diagnosis and revealed intertumoral heterogeneity in sLGGs. Although 55% of tumors clustered with pilocytic astrocytoma, other rare entities were identified in this patient population. In particular, diffuse leptomeningeal glioneuronal tumors (n = 3) and high-grade astrocytoma with piloid features (n = 1) and pleomorphic xanthoastrocytoma (n = 1) were present. A proportion of tumors (14%) had no match with the current version of the classifier. Complex molecular genetic sLGGs characterization was invaluable to refine diagnosis, which has proven to be essential in such a rare tumor entity. Moreover, identifying a high proportion of drugable targets in sLGGs opened an opportunity for new treatment modalities.

Current Trends in the Surgical Management of Intramedullary Tumors: A Multicenter Study of 1,033 Patients by the Neurospinal Society of Japan

OBJECTIVE

We performed a retrospective observational study to demonstrate the surgical risks and long-term prognoses of intramedullary tumors in Japan using a multicenter registry authorized by the Neurospinal Society of Japan.

METHODS

Data from 1,033 consecutive patients with intramedullary tumors, treated between 2009 and 2020, were collected from 58 centers. Patients with spinal lipomas or myxopapillary ependymomas were excluded. Patient characteristics, clinical presentations, imaging characteristics, treatments, and outcomes were analyzed. The modified McCormick scale was used to classify functional status. Survival was described using Kaplan-Meier curves, and multivariable logistic regression analyses were performed.

RESULTS

The mean age of the patients was 48.4 years. Data of 361 ependymomas, 196 hemangioblastomas, 168 astrocytic tumors, 160 cavernous malformations, and the remaining 126 cases including subependymomas, metastases, schwannomas, capillary hemangiomas, and intravascular B-cell lymphomas were analyzed. Twenty-two patients were undiagnosed. The mean follow-up duration was 46.1 ± 38.5 months. Gross total tumor removal was achieved in 672 tumors (65.1%). On the modified McCormick scale, 234 patients (22.7%) had worse postoperative grades at the time of discharge. However, neurological status gradually improved. At 6 months postoperatively, 251 (27.5%), 500 (54.9%), and 160 patients (17.6%) had improved, unchanged, and worsened grades, respectively. Preoperative functional status, gross total tumor removal, and histopathological type were significantly associated with mortality and functional outcomes.

CONCLUSION

Our findings demonstrate better postoperative functional outcomes in patients with fewer preoperative neurological deficits. Degree of resection, postoperative treatments, and prognoses are closely related to the histology of intramedullary tumors.

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.

Paediatric spinal cord low-grade gliomas-evaluation and management of post-surgical residual disease

PURPOSE

To assess the evaluation and management of post-surgical residual disease for low-grade intramedullary spinal cord tumours (IMSCT) in childhood.

METHODS

A single-centre retrospective review of low-grade IMSCTs treated between 2000 and 2019. All surgeries were performed with intent of safe maximal resection guided by intra-operative neurophysiological monitoring (IONM). Pre- and post-operative MRIs were reviewed to assess the extent of resection (EOR), recorded as follows: gross total resection (GTR), near total resection (NTR), sub-total resection (STR) and partial resection (PR). Outcome measures were time to recurrence, need for and modality of additional therapy and ambulatory status at last follow-up.

RESULTS

Thirty patients underwent surgery for IMSCT (median age 6.9 years). EOR was GTR = 8, NTR = 4, STR = 9, PR = 9. All patients were alive at last follow-up (median follow-up 73 months [IQR 93 months]). Eighteen patients (60%) remained radiologically stable. Twelve patients (40%) developed recurrence during surveillance. Progression free survival was significantly better in cases with GTR + NTR in comparison to either STR or PR (p = 0.039). 10/30 (33%) patients were treated with additional therapy. At last follow-up, 26/30 patients were independently mobile.

CONCLUSION

Survival rates for low-grade IMSCT are excellent. Radical micro-surgical resection, guided by IONM provides effective means of balancing the objectives of maximal safe resection, functional outcome and tumour control. Whilst evidence of 'residual disease' was identified in over 2/3 of immediate post-operative MRI scans, additional treatment was required in only 1/3 of cases. Critical appraisal of post-operative imaging findings is required to better define 'residual disease'. Small volume residual disease (< 5%) does not compromise progression-free survival.

Postoperative Cervicothoracic Kyphosis Following Infantile Intramedullary Tumor Resection Accelerates Neurological Deterioration

Intramedullary spinal cord tumors are rare in children. Regardless of the type of tumor, surgical removal is thought to improve progression-free survival. However, postoperative kyphosis is a serious problem in children, who can expect long-term survival. We present a pediatric case of neurofibromatosis type 2-related spinal ependymoma at the cervicothoracic regions where acute neurological deterioration was developed due to a combination of tumor recurrence and postoperative kyphotic deformity. In the first surgery, subtotal tumor resection was performed via osteoplastic laminotomy. Postoperative radiological evaluation at several months showed cervicothoracic junctional kyphosis, which subsequently made a significant improvement by lifestyle instructions. However, 22 months after the surgery, he exhibited rapid neurological deterioration caused by the regrowth of the recurrent tumor and re-emergence of kyphotic deformity, which led to the fixed laminar flap sank into the spinal canal. Therefore, a second surgery was performed 23 months after the first surgery, and gross total removal was achieved. Osteoplastic laminotomy is presumed to reduce the occurrence of postoperative kyphosis compared with laminectomy, but there have been no reports on the spinal cord compression by plunging of the re-fixed laminar flap into the spinal canal. The kyphosis deformity increases the chance of re-fixed laminar flap coming off, thereby accelerating neurological injury on top of the neural damage by tumor recurrence itself. Therefore, pediatric patients with spinal cord tumors should be carefully managed in terms of recurrent tumors and postoperative kyphosis, and timely surgical intervention is necessary before kyphotic deformity becomes evident.

Intraoperative neurophysiology in intramedullary spinal cord tumor surgery

Intramedullary spinal cord tumor (ISCT) surgery is challenged by a significant risk of neurological injury. Indeed, while most ISCT patients arrive to surgery in good neurological condition due to early diagnosis, many experience some degree of postoperative sensorimotor deficit. Thus, intraoperative neuromonitoring (IONM) is invaluable for providing functional information that helps neurosurgeons tailor the surgical strategy to maximize resection while minimizing morbidity. Somatosensory evoked potential (SEP), muscle motor evoked potential (mMEP), and D-wave monitoring are routinely used to continuously assess the functional integrity of the long pathways within the spinal cord. More recently, mapping techniques have been introduced to identify the dorsal columns and the corticospinal tracts. Intraoperative SEP decline is not a sufficient reason to abandon surgery, since SEPs are very sensitive to anesthesia and surgical maneuvers. Yet, a severe proprioceptive deficit may adversely impact daily life, and the value of SEPs should be reconsidered. While mMEPs are good predictors of short-term motor outcome, the D-wave is the strongest predictor of long-term motor outcome, and its preservation during surgery is essential. Mapping techniques are promising but still need validation in large cohorts of patients to determine their impact on clinical outcome. The therapeutic rather than merely diagnostic value of IONM in spine surgery is still debated, but there is emerging evidence that IONM provides an essential adjunct in ISCT surgery.

[Intraoperative ultrasound-assisted surgery of spinal tumors]

OBJECTIVE

To improve technique of intraoperative ultrasound-assisted microsurgery of spinal tumors.

MATERIAL AND METHODS

There were 68 patients with 70 spinal tumors who underwent intraoperative ultrasound-assisted resection between 2007 and 2018. Age of patients varied from 21 to 80 (mean 48.5±14.3). Intradural tumors were diagnosed in 54 (79.4%) patients (of them intramedullary in 16 (23.5%) and extramedullary in 38 (55.9%) cases). Fourteen patients (20.6%) had extradural tumors. Intraoperative ultrasound was used to determine localization, margins and structure of tumors, interrelations with neural structures, zones of dura opening and myelotomy. We also assessed quality of resection and spinal decompression.

RESULTS

In surgery of spinal tumors, intraoperative ultrasound allows to localize the tumor with 95.3% sensitivity, determine the character of its growth, shape, size and internal structure. One can also differentiate the margins of neoplasm, control accuracy of approach, select the optimal zone for dura opening and myelotomy, objectively assess spinal cord and nerve roots decompression in real-time mode. Quality of intraoperative ultrasonography images is comparable to preoperative MRI, and even exceed resolution of MR scans in some cases.

CONCLUSION

In our study, intraoperative ultrasound has proven to be a method complementing preoperative CT and MRI. This approach provides additional data in real-time mode to form a complete picture of surgical area, increase accuracy of manipulations and reduce surgical trauma.

Surgical Causes of Significant Intraoperative Neuromonitoring Signal Changes in Three-Column Spinal Surgery

Study Design

Retrospective case series.

Purpose

To evaluate the risks and causes of neurologic complications in three-column spinal surgery by analyzing intraoperative neurophysiological monitoring (IONM) data.

Overview of Literature

Three-column spinal surgery, which may be required to correct complex spinal deformities or resection of spinal tumors, is known to carry a high risk of neurologic complications. However, few studies reported a specific surgical procedure related to a significant IONM signal change during surgery.

Methods

Multimodality IONM data, including somatosensory-evoked potentials (SSEP) and motor-evoked potentials (MEP), were reviewed in 64 patients who underwent three-column spinal surgery from 2011 to 2015. Surgical procedures included posterior vertebral column resection, pedicle subtraction osteotomy, total en bloc spondylectomy, piecemeal spondylectomy, and corpectomy with laminectomy (n=27) in three cervical, 34 thoracic, and 31 lumbar procedures.

Results

Significant IONM signal changes occurred in 11 of 64 (17.1%) patients. SSEP and MEP were changed in 11 patients. Postoperative neurologic deterioration occurred in 54.5% (6 of 11) of the patients, and two of them were permanent. There was no postoperative neurologic deterioration in patients without significant signal change. Suspected causes of IONM data changes are as follows: adhesion/tethering, translation, contusion, and perfusion.

Conclusions

Based on the results of this study, to enhance neurologic safety in three-column spinal surgery, surgeons should pay attention to protect the spinal cord from mechanical insult, especially when the spinal column was totally destabilized during surgery, and not to compromise perfusion to the spinal cord in close cooperation with a neurologist and anesthesiologist.

Clinically aggressive pediatric spinal ependymoma with novel MYC amplification demonstrates molecular and histopathologic similarity to newly described MYCN-amplified spinal ependymomas

Primary spinal cord tumors contribute to ≤ 10% of central nervous system tumors in individuals of pediatric or adolescent age. Among intramedullary tumors, spinal ependymomas make up ~ 30% of this rare tumor population. A twelve-year-old male presented with an intradural, extramedullary mass occupying the dorsal spinal canal from C6 through T2. Gross total resection and histopathology revealed a World Health Organization (WHO) grade 2 ependymoma. He recurred eleven months later with extension from C2 through T1-T2. Subtotal resection was achieved followed by focal proton beam irradiation and chemotherapy. Histopathology was consistent with WHO grade 3 ependymoma. Molecular profiling of the primary and recurrent tumors revealed a novel amplification of the MYC (8q24) gene, which was confirmed by fluorescence in situ hybridization studies. Although MYC amplification in spinal ependymoma is exceedingly rare, a newly described classification of spinal ependymoma harboring MYCN (2p24) amplification (SP-MYCN) has been defined by DNA methylation-array based profiling. These individuals typically present with a malignant progression and dismal outcomes, contrary to the universally excellent survival outcomes seen in other spinal ependymomas. DNA methylation array-based classification confidently classified this tumor as SP-MYCN ependymoma. Notably, among the cohort of 52 tumors comprising the SP-MYCN methylation class, none harbor MYC amplification, highlighting the rarity of this genomic amplification in spinal ependymoma. A literature review comparing our individual to reported SP-MYCN tumors (n = 26) revealed similarities in clinical, histopathologic, and molecular features. Thus, we provide evidence from a single case to support the inclusion of MYC amplified spinal ependymoma within the molecular subgroup of SP-MYCN.

Clinical Prediction Modeling in Intramedullary Spinal Tumor Surgery

Artificial intelligence is poised to influence various aspects of patient care, and neurosurgery is one of the most uprising fields where machine learning is being applied to provide surgeons with greater insight about the pathophysiology and prognosis of neurological conditions. This chapter provides a guide for clinicians on relevant aspects of machine learning and reviews selected application of these methods in intramedullary spinal cord tumors. The potential areas of application of machine learning extend far beyond the analyses of clinical data to include several areas of artificial intelligence, such as genomics and computer vision. Integration of various sources of data and application of advanced analytical approaches could improve risk assessment for intramedullary tumors.

Clinicopathological Features of Primary Solitary Spinal Cord Tumors in Pediatric Patients : A 32-Year Single Institution Experience

OBJECTIVE

Few studies exist on primary spinal cord tumors (PSCTs) in pediatric patients. The purpose of this study was to perform descriptive analysis and detailed survival analysis for PSCTs.

METHODS

Between 1985 and 2017, 126 pediatric patients (male : female, 56 : 70) with PSCTs underwent surgery in a single institution. We retrospectively analyzed data regarding demographics, tumor characteristics, outcomes, and survival statistics. Subgroup analysis was performed for the intramedullary (IM) tumors and extradural (ED) tumors separately.

RESULTS

The mean age of the participants was 6.4±5.04 years, and the mean follow-up time was 69.5±46.30 months. The most common compartment was the ED compartment (n=57, 45.2%), followed by the IM (n=43, 34.1%) and intradural extramedullary (IDEM; n=16, 12.7%) compartments. Approximately half of PSCTs were malignant (n=69, 54.8%). The most common pathologies were schwannomas (n=14) and neuroblastomas (n=14). Twenty-two patients (17.5%) died from the disease, with a mean disease duration of 15.8±15.85 months. Thirty-six patients (28.6%) suffered from progression, with a mean period of 22.6±30.81 months. The 10-year overall survival (OS) rates and progression-free survival (PFS) rates were 81% and 66%, respectively. Regarding IM tumors, the 10-year OS rates and PFS rates were 79% and 57%, respectively. In ED tumors, the 10-year OS rates and PFS rates were 80% and 81%, respectively. Pathology and the extent of resection showed beneficial effects on OS for total PSCTs, IM tumors, and ED tumors. PFS was affected by both the extent of removal and pathology in total PSCTs and ED tumors; however, pathology was a main determinant of PFS rather than the extent of removal in IM tumors. The degree of improvement in the modified McCormick scale showed a trend towards improvement in patients with IM tumors who achieved gross total removal (p=0.447).

CONCLUSION

Approximately half of PSCTs were malignant, and ED tumors were most common. The most common pathologies were schwannomas and neuroblastomas. Both the pathology and extent of resection had a decisive effect on OS. For IM tumors, pathology was a main determinant of PFS rather than the extent of removal. Radical excision of IM tumors could be a viable option for better survival without an increased risk of worse functional outcomes.

Spinal Dermoid and Epidermoid Cyst: An Institutional Experience and Clinical Insight into the Neural Tube Closure Models

Objectives  The spinal dermoid and epidermoid cysts (SDECs) are rare entities comprising less than 1% of pediatric intraspinal tumors. The present study aims to extrapolate the clinicoradiological data, in order to identify the most plausible neural tube closure model in human and provide a retrospective representation from our clinical experience.

Materials and Methods  We collected the details of all histologically proven, newly diagnosed primary SDECs who underwent excision over the past 20 years. Secondary or recurrent lesions and other spinal cord tumors were excluded. Surgical and follow-up details of these patients as well as those with associated spinal dysraphism were reviewed. Clinical and radiological follow-up revealed the recurrence in these inborn spinal cord disorders.

Results  A total of 73 patients were included retrospectively, having a mean age of 22.4 ± 13.3 years, and 41 (56.2%) cases fell in the first two decades of life. Twenty-four (32.9%) dermoid and 49 (67.1%) epidermoid cysts comprised the study population and 20 of them had associated spinal dysraphism. The distribution of SDECs was the most common in lumbosacral region ( n = 30) which was 10 times more common than in the sacral region ( n = 3). Bladder dysfunction 50 (68.5%) and pain 48 (65.7%) were the most common presenting complaints. During follow-up visits, 40/48 (83.3%) cases showed sensory improvement while 11/16 (68.7%) regained normal bowel function. There was no surgical mortality with recurrence seen in eight till the last follow-up.

Conclusions  The protracted clinical course of the spinal inclusion cysts mandates a long-term follow-up. The results of our study support the multisite closure model and attempt to provide a retrospective reflection of neural tube closure model in humans by using SDECs as the surrogate marker of neural tube closure defect.

Surgical and Radiologic Prognostic Factors in Intramedullary Spinal Cord Lesions

OBJECTIVE

The present study aimed to perform a comprehensive data analysis of 47 consecutive patients treated in 8 years and to observe how clinical, radiologic, and surgical factors affect early and long-term outcomes, recurrence rate, and survival.

METHODS

Clinical, radiologic, and surgical data were collected retrospectively from the review of a prospectively collected database. The neurologic disability was evaluated according to the modified Rankin Scale (mRS). Radiologic data were obtained by direct measurement performed on magnetic resonance imaging (MRI). Univariate and multivariate statistical analysis was performed.

RESULTS

From 2008 to 2016, 47 consecutive patients underwent microsurgical resection of intramedullary lesions (28 males and 19 females; mean age, 41.2 years). Ependymoma (53.2%), astrocytoma (14.9%), hemangioblastoma (14.9%), and cavernous angioma (6.4%) were the most frequent tumor histology. The mean follow-up duration was 69.3 months. Gross total tumor resection was performed in 80.8% of cases. Forty-two patients (89.4%) were alive at last follow-up. Five-year overall survival and recurrence-free survival were 92% and 82%, respectively.

CONCLUSIONS

Among the examined variables, age seemed to strongly correlate with outcomes; better chances of recovery and a good postoperative outcome were observed in younger patients. Surfacing lesions had a better early functional outcome than did intramedullary located lesions. Patients' preoperative neurologic and functional status (mRS score ≤2) had a significant impact on late neurologic outcome. Progression-free survival correlated with the extent of tumor resection. Surgery should probably be performed before patients' neurologic decline, aiming to achieve maximal resection without compromising patients' quality of life.

Pediatric primary high-grade spinal glioma: a National Cancer Database analysis of current patterns in treatment and outcomes

PURPOSE

Pediatric primary high-grade spinal glioma (p-HGSG) is an extremely rare disease process, with little data within the current literature. Akin to primary high-grade gliomas, this cancer has been exemplified by dismal prognosis and poor response to modern treatment paradigms. This study seeks to investigate the current trends affecting overall survival using the National Cancer Database (NCDB).

METHODS

The NCDB was queried for p-HGSG between 2004 and 2016, by utilizing the designated diagnosis codes. Kaplan-Meier curves were generated, and log-rank testing was performed to analyze factors affecting overall survival. In addition, a Cox proportional-hazards model was used to perform multivariate regression analysis of survival outcomes.

RESULTS

A cohort of 97 patients was identified with a histologically confirmed p-HGSG. The overall incidence of p-HGSG in all pediatric spinal cord tumors is 7.5%, with a mean survival time of 25.3 months (SD, 21.0) and 5-year overall survival of 17.0%. The majority of patients underwent surgery (n = 87, 89.7%), radiotherapy (n = 73, 75.3%), and chemotherapy (n = 60, 61.9%). Univariate, multivariate, and Kaplan-Meier log-rank testing failed to demonstrate an association between performing surgery, extent of resection, radiotherapy, or chemotherapy with improved survival outcomes.

CONCLUSIONS

The current study constitutes the largest retrospective analysis of p-HGSGs to date, finding that current treatment options of surgery, radiotherapy, and chemotherapy have unclear benefit. This disease process has a poor prognosis without a current modality of treatment that conclusively alters survival. The risks and side effects of these treatment modalities must be carefully considered in such a highly aggressive disease process, especially given potentially limited survival benefits.

Spinal manifestations of Neurofibromatosis type 1

BACKGROUND

Neurofibromatosis type 1 (NF1) patients may present a wide spectrum of spinal pathologies. Osseous changes may lead to severe deformities with significant implications on growth and quality of life. Neurogenic tumors and soft tissue abnormalities may cause neuropathic pain and dysfunction ranging from minor paresthesias to profound motor and sensory deficits. Advanced imaging such as whole-body MRI, and volumetric tumor burden assessment have an evolving role in the evaluation and follow-up of patients with high spinal tumor load. Novel biological agents that target the hyperactivated ras pathway are currently under investigation and are reshaping current and future treatment paradigms. Surgical interventions for benign and malignant tumors, as well as deformity correction remain pivotal in treatment frameworks and require careful assessment by a dedicated multidisciplinary team.

PURPOSE

In this manuscript we review the various spinal manifestations of NF1 patients, indication for surgical intervention and oncological treatments.

Intramedullary spinal cord tumours - a single Centre, 10-year review of clinical and pathological outcomes

BACKGROUND

Intramedullary spinal cord tumours are relatively rare tumours of the central nervous system. Surgical outcomes are affected by many variables, including pre-operative neurological function, tumour histology and extent of resection. Emphasis remains on surgical treatment due to limited adjunctive therapeutic options and poor drug penetration.

OBJECTIVE

To identify clinically relevant predictors of progression free survival by retrospectively analysing the extent of resection, pre- and post-operative neurological function and histology in intramedullary spinal cord tumours from a single neurosurgical centre over 10 years.

METHODS

Forty-three adult cases were identified from a surgical database. Variables collected included pre-and post-operative Frankel Grade and Modified McCormick Scale assessments, tumour histology, extent of resection and length of follow up. Chi-Squared, Kaplan-Mier Survival and Mann-Whitney U-tests were completed.

RESULTS

Ependymoma (41.9%) and haemangioblastoma (14.0%) were the commonest tumour histologies. In total, 17 different histological tumours were identified in the series. There was a statistically significant relationship between identification of the tumour plane and extent of resection (p < 0.01), along with the extent of resection and recurrence (p = 0.04). Compared to the other histological subtypes, ependymoma's demonstrated a significantly greater extent of resection (p = 0.01). There was a significant relationship between the grade of tumour and progression-free survival (p < 0.01).

CONCLUSION

Tumour plane and the extent of tumour resection are significant determinants of progression-free survival. Ependymoma, whilst being the commonest histology in our series were also the most resectable. Whilst complete resection reduces the rate of recurrence, tumour grade is the most important predictor of outcome. Given the importance of the extent of resection, and following a similar trend to other low volume pathologies, these tumours should only be tackled by neurosurgeons with experience in their resection.

Long-Term Surgical Resection Outcomes of Pediatric Myxopapillary Ependymoma: Experience of Two Centers and Brief Literature Review

BACKGROUND

Myxopapillary ependymoma (MPE) is a rarely reported lesion of the spinal cord in the pediatric population. Based on their low mitotic index and slow-growth, MPEs are classified as low-grade glial tumors. However, MPEs have malignant characteristics, such as distant neural axis and extraneural axis dissemination. We present the long-term surgical resection outcomes of 5 consecutive pediatric MPE cases and the results of a literature search for reported cases of pediatric spinal MPE.

METHODS

We retrospectively reviewed the medical records of 38 primary spinal MPE cases who underwent surgery at 2 neurosurgical centers over a 16-year period from January 2004 to January 2019. All pediatric cases (age <18 years; n = 5) who were diagnosed with MPE composed the core sample for this study.

RESULTS

This series comprised 5 patients (3 females and 2 males), with a mean age at first presentation of 13.6 ± 2.3 years. The mean preoperative course was 8.2 ± 9.3 months. The predominant location was the lumbar spine, for 4 tumors. Gross total resection (GTR) was achieved in 4 patients. All patients were diagnosed histopathologically as MPE, World Health Organization grade I. No adjuvant treatment was provided after the first surgery. Three patients experienced spinal drop metastasis. The mean interval between the first diagnosis and diagnosis of neural dissemination was 44.0 ± 31.5 months. The location of neural dissemination in all patients was the sacral spine; 1 patient experienced distant metastasis in the brain along with her sacral metastasis. The mean duration of follow-up was 75.0 ± 37.6 months.

CONCLUSIONS

Even with GTR, pediatric MPE has a high propensity for neural axis dissemination. We recommend close clinical and radiologic follow-up for pediatric patients with MPE.

Pediatric Brain Tumors

Pediatric central nervous system (CNS) tumors are the most common solid tumors in children and comprise 15% to 20% of all malignancies in children. Presentation, symptoms, and signs depend on tumor location and age of the patient at the time of diagnosis. This article summarizes the common childhood CNS tumors, presentations, classification, and recent updates in treatment approaches due to the increased understanding of the molecular pathogenesis of pediatric brain tumors.

Reduced field of view echo-planar imaging diffusion tensor MRI for pediatric spinal tumors

OBJECTIVE

Spine MRI is a diagnostic modality for evaluating pediatric CNS tumors. Applying diffusion-weighted MRI (DWI) or diffusion tensor imaging (DTI) to the spine poses challenges due to intrinsic spinal anatomy that exacerbates various image-related artifacts, such as signal dropouts or pileups, geometrical distortions, and incomplete fat suppression. The zonal oblique multislice (ZOOM)-echo-planar imaging (EPI) technique reduces geometric distortion and image blurring by reducing the field of view (FOV) without signal aliasing into the FOV. The authors hypothesized that the ZOOM-EPI method for spine DTI in concert with conventional spinal MRI is an efficient method for augmenting the evaluation of pediatric spinal tumors.

METHODS

Thirty-eight consecutive patients (mean age 8 years) who underwent ZOOM-EPI spine DTI for CNS tumor workup were retrospectively identified. Patients underwent conventional spine MRI and ZOOM-EPI DTI spine MRI. Two blinded radiologists independently reviewed two sets of randomized images: conventional spine MRI without ZOOM-EPI DTI, and conventional spine MRI with ZOOM-EPI DTI. For both image sets, the reviewers scored the findings based on lesion conspicuity and diagnostic confidence using a 5-point Likert scale. The reviewers also recorded presence of tumors. Quantitative apparent diffusion coefficient (ADC) measurements of various spinal tumors were extracted. Tractography was performed in a subset of patients undergoing presurgical evaluation.

RESULTS

Sixteen patients demonstrated spinal tumor lesions. The readers were in moderate agreement (kappa = 0.61, 95% CI 0.30-0.91). The mean scores for conventional MRI and combined conventional MRI and DTI were as follows, respectively: 3.0 and 4.0 for lesion conspicuity (p = 0.0039), and 2.8 and 3.9 for diagnostic confidence (p < 0.001). ZOOM-EPI DTI identified new lesions in 3 patients. In 3 patients, tractography used for neurosurgical planning showed characteristic fiber tract projections. The mean weighted ADCs of low- and high-grade tumors were 1201 × 10-6 and 865 × 10-6 mm2/sec (p = 0.002), respectively; the mean minimum weighted ADCs were 823 × 10-6 and 474 × 10-6 mm2/sec (p = 0.0003), respectively.

CONCLUSIONS

Diffusion MRI with ZOOM-EPI can improve the detection of spinal lesions while providing quantitative diffusion information that helps distinguish low- from high-grade tumors. By adding a 2-minute DTI scan, quantitative diffusion information and tract profiles can reliably be obtained and serve as a useful adjunct to presurgical planning for pediatric spinal tumors.

Xenografting for disease modeling of intramedullary spinal cord tumors: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVES

The overall incidence of intramedullary spinal cord tumors (IMSCT) remains low and clinical trials or standardized treatment strategies are missing. Therefore, multiple animal-based xenograft models (AXM) have been developed to foster preclinical research efforts on IMSCT. We constructed a systematic literature review to summarize and compare all AXM for IMSCT, published until April 16, 2018.

METHODS

The review was conducted using 4 independent research databases following the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. Studies were included, if they reported on surgical transplantation of tumor cells or tumor tissue to the spinal cord. Methodological study quality was assessed according to the SYRCLE (systematic review center for laboratory animal experimentation) risk of Bias tool.

RESULTS

Systematic search yielded 20 publications dealing with AXM for IMSCT. In summary, 4 tumor entities were analyzed in 23 experiments using ~337 animals, mainly investigating glioblastoma or gliosarcoma biology. Studies varied regarding the use of engrafted animals, surgical techniques and tumor burden. Most commonly authors used heterotopic, transdural injection of immortalized brain tumor cell lines (1 × 10⁵ in 5 µl) into the thoracic spinal cord of immunocompromised rats. Quality assessment demonstrated an unclear risk of bias in most cases.

CONCLUSION

Although different AXM for IMSCT have been described so far, one rat model is technically feasible, enables robust experiments and demonstrates reproducible results. However, there is a need for new AXM using orthotopic engraftment of patient-derived tumor cells and for genetically engineered animal models.

Fluorescence Guided Surgery with 5-Aminolevulinic Acid for Resection of Spinal Cord Ependymomas

STUDY DESIGN

A retrospective study.

PURPOSE

We report our experience with 5-aminolevulinic acid (5-ALA)-assisted resection of spinal cord ependymomas in adults.

OVERVIEW OF LITERATURE

Ependymoma is the most frequent primary spinal cord tumor in adults. Surgery is the treatment of choice in most cases. However, while complete resection is achieved in approximately 80% of cases, clinical improvement is achieved in 15% only. Five-ALA fluorescence-guided surgery seems to be useful for this tumor type.

METHODS

We studied 14 patients undergoing 5-ALA fluorescence-guided surgery for spinal cord ependymomas in our service. The modified McCormick classification was used to determine clinical status and the degree of resection was assessed with magnetic resonance imaging.

RESULTS

Of the 14 patients, the tumor showed an intense emission of fluorescence in 12 and the fluorescence was weak and nonuniform in two. Complete resection was achieved in 11 cases. According to the McCormick classification, 10 patients improved, two remained the same, and two deteriorated.

CONCLUSIONS

Our results confirm that 5-ALA fluorescence-guided resection is useful in spinal cord ependymoma resection. Although the rate of complete resections is similar to that in published series without 5-ALA, clinical results are better when using 5-ALA with a lower percentage of clinical deterioration.

Pediatric Spinal Ependymomas

Background

The aim of this study was to assess the clinical and radiological outcomes of surgical treatment for primary spinal ependymoma in children.

Material/Methods

Medical records of 46 primary spinal ependymoma patients who underwent surgery in BRSHH hospital during a 12-year period from 2004 to 2015 were retrospectively reviewed. All pediatric patients (patient age <18 years) were selected as the core sample used for this study.

Results

This series included 1 female and 2 male patients between the ages of 9 and 17 years with mean age 13.3±3.9 years. The mean preoperative course was 9.1±10.5 months. The most common location was the lumbar spinal cord (n=2). The most common presenting symptoms was lower-limb weakness and numbness. Two tumors were located intradural-intramedullary and 1 was located intradural-extramedullary. Gross-total resection (GTR) was achieved in 2 patients, and a near-total resection was performed in 1 patient. No adjuvant treatment was received. The mean follow-up duration was 51.3±37.6 (17–98) months. No complications were recorded. Functional assessment of all patients by the latest follow-up evaluation showed good progress even though the patient is not fully recovered. At 6.3 years after the first operation, 1 patient presented with drop-seeding metastasis. No patients had neurofibromatosis type 2.

Conclusions

Laminoplasty and intraoperative neurophysiological monitorization are essential in surgical treatment of pediatric spinal ependymomas. GTR and recovery in pediatric spinal ependymoma are more likely than in adults. Despite the GTR, the risk of drop metastasis remains. Therefore, close clinical and radiological follow-up is recommended.

Adult Spinal Ependymomas: An Epidemiologic Study

OBJECTIVE

In adults, spinal ependymomas constitute only 3% to 6% of central nervous system tumors. Because of their rarity and poor prognosis, large population-based studies are needed to assess the epidemiology and survival risk factors associated with these tumors in the hope of improving outcome. The authors undertook this retrospective study to explore factors that may influence survival in adult patients with spinal ependymomas.

METHODS

Using the Surveillance, Epidemiology, and End Results database, a prospective cancer registry, the authors retrospectively assessed survival in histologically confirmed spinal ependymomas in patients 18 years of age and older. Survival was described with Kaplan-Meier curves, and a multivariate regression analysis was used to assess the association of several variables with survival while controlling for confounding variables.

RESULTS

Overall survival at 1 year, 3 years, and 5 years after diagnosis was 97.0%, 94.3%, and 93.3%, respectively. Patient age at diagnosis (hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.04-1.07, P < 0.001), tumor grade IV (HR 11.11, 95% CI 1.27-97.02, P = 0.032), and the use of radiation therapy during the course of treatment (HR 4.42, 95% CI 1.69-11.57, P = 0.003) were each associated with decreased survival. Gross total resection (HR 0.42, 95% CI 0.20-1.10, P = 0.026) was associated with improved overall survival. Gender, tumor size, and tumor extension were not found to impact survival.

CONCLUSIONS

High-grade ependymomas occurring in the spine have a much worse prognosis than do those with lower grades. Early diagnosis and surgery appear to be associated with improved survival and outcomes, whereas radiation therapy has an unclear role.

Expression of CD133 as a Putative Prognostic Biomarker to Predict Intracranial Dissemination of Primary Spinal Cord Astrocytoma

OBJECTIVE

Spinal cord astrocytoma with intracranial dissemination carries a poor prognosis. The mechanisms leading to dissemination remain to be elucidated. A stem cell marker, CD133, was reported to predict recurrence patterns in intracranial glioblastoma. We evaluated the significance of CD133 as a putative prognostic biomarker to predict intracranial dissemination in spinal cord astrocytoma.

METHODS

This study included 14 consecutive patients with primary spinal cord astrocytoma treated from 1998 to 2014. Six of the patients were women and the patients' ages ranged from 12 to 75 years. Seven and 6 patients underwent open biopsy and partial resection of the tumors, respectively. After confirmation of the histologic diagnoses, all patients were treated with postoperative radiotherapy, chemotherapy, or a combination of both. To identify factors predictive of intracranial dissemination, we analyzed their clinical data including Ki-67 labeling index, and CD133 expression.

RESULTS

Intracranial dissemination was observed in 6 of 14 patients. All 6 patients died during the follow-up period. Of the 8 patients without intracranial dissemination, 5 survived (P = 0.02). Median survival for the patients with intracranial dissemination was 22.7 months. CD133 expression was significantly higher in patients with intracranial dissemination (P = 0.04), whereas other variables did not indicate the dissemination.

CONCLUSIONS

The expression of CD133 can be an efficient biomarker to predict intracranial dissemination in spinal cord astrocytoma. Recognition of high CD133 expression in surgical specimens and early detection of intracranial dissemination is important for the clinical management of spinal cord astrocytoma.

Spinal ependymomas in NF2: a surgical disease?

The management of spinal cord ependymomas in Neurofibromatosis Type 2 (NF2) has traditionally been conservative, in contrast to the management of sporadic cases; the assumption being that, in the context of NF2, they did not cause morbidity. With modern management and improved outcome of other NF2 tumours, this assumption, and therefore the lack of role for surgery, has been questioned. To compare the outcome of conservative treatment of spinal ependymomas in NF2 with surgical intervention in selected patients. Retrospective review at two NF2 centers, Manchester, UK and Paris/Lille, France. In Manchester patients were managed conservatively. In France surgery was a treatment option. Inclusion in the study was based on tumor length of greater than 1.5 cm. The primary parameter assessed was acquired neurological deficit measured by the Modified McCormick Outcome Score. 24 patients from Manchester and 46 patients from France were analyzed. From Manchester, 27% of these patients deteriorated during the course of follow-up. This effectively represents the natural history of ependymomas in NF2. Of the surgical cases, 23% deteriorated postoperatively, but only 2/18 (11%) of those operated on in the NF2 specialist centers. Comparison of the two specialist centers Manchester/France showed a significantly improved outcome (P = 0.012, χ² test) in the actively surgical center. Spinal ependymomas produce morbidity. Surgery can prevent or improve this in selected cases but can itself can produce morbidity. Surgery should be considered in growing/symptomatic ependymomas, particularly in the absence of overwhelming tumor load where bevacizumab is the preferred option.

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

BACKGROUND

A considerable number of patients suffer delayed neurologic deficits, even after a successful removal of intramedullary spinal cord ependymoma. The underlying pathology remains unknown. Radiologic findings could provide an explanation for poor outcome after surgery.

METHODS

We conducted a retrospective study of all cases treated from 1980 to 2016 in our department. The cohort included all patients with intramedullary spinal cord ependymoma treated with microsurgical excision. The cross-sectional area of the spinal cord at the level of the former performed surgery was compared using magnetic resonance imaging (MRI), follow-up MRI, adjacent unaffected levels, and the control group.

RESULTS

Fifty-four patients with an intramedullary spinal cord lesion were treated in this period. Ependymoma was the predominant tumor (n = 28) followed by intramedullary gliomas and vascular lesions. Mean age (±SD) was 48.2 ± 10.5 years with a female predominance (16 women, 12 men). An unfavorable outcome was observed in 53% of the patients after an initially uneventful postoperative course. The follow-up cross-sectional area of the spinal cord was significantly reduced in these patients compared to adjacent unoperated levels and the control group. Sagittal and axial spinal MRI showed spinal cord narrowing owing to atrophic changes in the area of the performed surgery in 53% of patients with resected ependymoma after a mean follow-up time of 9 years. Functional outcome in ependymoma was significantly associated with spinal cord atrophy (P < 0.05).

CONCLUSIONS

Spinal cord atrophy seems to be a predicting factor in long-term outcome after surgical removal of intramedullary spinal cord ependymoma.

A very rare spinal cord tumor primary spinal oligodendroglioma: A review of sixty cases in the literature

LITERATURE REVIEW

In this study, we evaluated a case of primary spinal oligodendroglioma (PSO) with a rare localization between L3 and S2, and also examined sixty cases in the literature in terms of demographic characteristics, clinical, radiological, and histopathological characteristics, and treatment planning. A case of PSO has been presented, and the relevant literature between 1931 and 2016 was reviewed. A total of 57 papers regarding PSO were found and utilized in this review. The main treatment options include radical surgical excision with neuromonitoring, followed by radiotherapy. Despite these treatment protocols, the relapse rate is high, and treatment does not significantly prolong survival. Oligodendrogliomas are rare among the primary spinal cord tumors. Oligodendrogliomas are predominantly found in the cervical spinal cord, thoracic spinal cord, or junctions during childhood and adulthood. Extension to the sacral region, inferior to the Conus, is very rare. Furthermore, of the sixty cases in the literature, the case we present here is the first to be reported in this particular age group. These localizations usually occur in the pediatric age group and after relapses. While for a limited number of cases the oligodendroglioma initiates in the thoracic region and reaches as far as L2, we encountered a case of an oligodendroglioma within the range of L3 to S2. Clinical findings are observed in accordance with location, and magnetic resonance imaging is the gold standard for diagnosis.

Extent of resection and postoperative functional declination of Klekamp's type A intramedullary tumors in adult patients

BACKGROUND

The most commonly primary intramedullary spinal cord tumors (ISCT) in adults are the noninfiltrative lesions, corresponding to Klekamp's type A classification. There are few reports exclusively considering this type of lesions, their resectability and postoperative functional declination risk, and to our knowledge, none from Latin America. This led us to evaluate our results to provide information that might contribute to the decision making process in our region.

METHODS

A retrospective observational study was conducted comprising a cohort of 21 adults having primary Klekamp's type A ISCT. Diagnosis was made by magnetic resonance imaging (MRI), along with diffusion tensor/tractography in the last 7 cases. Preoperative functional status was assessed using the McCormick's modified scale (mMs), which was also used for the postoperative assessment within postoperative 90 days period. MRI was used to confirm the extent of resection.

RESULTS

Radical resection was obtained in 20/21 cases. The postoperative functional status was stable in 42.8% of the cases, and in 57.4% was even better than in the preoperative period. Temporary declination was observed in 2 cases in the early postoperative period. There were 2 cases with complications; one patient had cerebrospinal fluid fistula with meningitis, which was conservatively resolved, and another patient died from pulmonary embolism.

CONCLUSION

Although the number of patients in this series does not allow to conclude from a statistical point of view, the outcomes showed that the modern surgery of Klekamp's type A ISCT permits a complete resection with low functional declination risk.

Management and outcomes of intramedullary spinal cord tumors: A single center experience from a developing country

Background:

Intraoperative neurophysiology, high magnification microscopes, and ultrasonic aspirators are considered essential aid for the safe resection of intramedullary spinal cord tumors (IMSCTs). Most centers in developing countries such as Pakistan still lack these facilities. The purpose of this study was to review the management of IMSCTs at our hospital and to determine factors associated with the outcomes of surgery.

Methods:

This was a retrospective review of medical records of adult patients undergoing surgery for IMSCT over 12 years. The institutional ethical review committee approved this study. Data were collected regarding demographics, clinical and radiological features, and surgical details. Modified McCormick Scale was used to grade patients’ neurological status at admission, discharge, and follow-up. Statistical analysis was performed using the Statistical Package for Social Sciences version 22.

Results:

Forty three cases were reviewed. Mean age was 33.8 ± 15.1 years whereas median follow-up was 5 months (range: 0.25–96 months). Most patients had ependymoma (n = 16; 73%). Cervical region was the most commonly involved (n = 15; 34.9%). Gross total resection (GTR) was achieved in 30 cases (69.8%). The preoperative McCormick grade was significantly associated with follow-up McCormick grade (P value = 0.002). Eight patients (18.6%) underwent intraoperative electrophysiological monitoring, out of which GTR was achieved in all cases, and none had disease progression or recurrence. Ten patients received postoperative radiotherapy. Thirty five patients (81.4%) had progression free survival at last follow-up.

Conclusions:

We achieved a GTR rate of 68.9% for IMSCTs with limited resources. In few cases, where intraoperative electrophysiology was used, the rate of GTR was 100%. Preoperative neurological status was associated with better postoperative McCormick score.

Clinical Factors for Prognosis and Treatment Guidance of Spinal Cord Astrocytoma

Study Design

Retrospective study.

Purpose

To obtain information useful in establishing treatment guidelines by evaluating baseline clinical features and treatment outcomes of patients with spinal cord astrocytoma (SCA).

Overview of Literature

The optimal management of SCA remains controversial, and there are no standard guidelines.

Methods

The study included 20 patients with low-grade and 13 with high-grade SCA surgically treated between 1989 and 2014. Patients were classified according to the extent of surgical resection. Survival was assessed using Kaplan–Meier plots and compared between groups by log-rank tests. Neurological status was defined by the modified McCormick scale and compared between groups by Mann–Whitney U tests.

Results

Surgical resection was performed for 19 of 20 low-grade (95%) and 10 of 13 high-grade (76.9%) SCA patients. Only nine patients (27.3%) underwent gross total resection, all of whom had low-grade SCA. Of all patients, 51.5% showed deteriorated neurological status compared to preoperative baseline. Median overall survival was significantly longer for low-grade SCA than that (91 months, 78% at 5 years vs. 15 months, 31% at 5 years; p=0.007). Low-grade SCA patients benefited from more aggressive resection, whereas high-grade SCA patients did not. Multivariate analysis revealed histology status (hazard ratio [HR], 0.30; 95% confidence interval [CI], 0.09–0.98; p<0.05) and postoperative neurological status (HR, 0.12; CI, 0.02–0.95; p<0.05) as independent predictors of longer overall survival. Adjuvant radiotherapy had no significant impact on survival rate. However, a trend for increased survival was observed with radiation cordotomy (RCT) in high-grade SCA patients.

Conclusions

Aggressive resection for low-grade and RCT may prolong survival. Preservation of neurological status is an important treatment goal. Given the low incidence of SCA, establishing strong collaborative, interdisciplinary, and multi-institutional study groups is necessary to define optimal treatments.

A case of an anaplastic meningioma metastasizing to the mediastinal lymph nodes

CONTEXT

Grade II and III (World Health Organization classification) meningiomas rarely develop in the spinal cord. However, we experienced a case with an anaplastic meningioma that developed in the spinal cord at the cervicothoracic junction and metastasized to the mediastinal lymph nodes. No such cases have previously been reported.

FINDINGS

The patient was a 68-year-old man who developed back pain that did not affect his daily living. He developed left lower limb paralysis, and was admitted after magnetic resonance imaging (MRI) revealed an intramedullary tumor at the level of cervical vertebra 7 and thoracic vertebra 1. Positron emission tomography revealed tracer uptake in the intramedullary tumor and the mediastinal lymph nodes, suggesting a metastatic spinal cord tumor or malignant lymphoma. A lymph node biopsy was then performed. Although the tumor was highly malignant, its primary site was not identified. Detailed examinations by several other departments revealed no abnormalities. On hospital day 30, his left lower limb paralysis deteriorated, and MRI revealed that the tumor had grown. Thus, laminaplasty, laminectomy, and tumor resection were performed. The tumor was an anaplastic meningioma that resembled mediastinal lymph node tissue, and other tumor lesions were not found. These findings suggested that an anaplastic meningioma had metastasized to the mediastinal lymph nodes. The patient did not respond to radiotherapy, and he was transferred to another hospital.

CONCLUSION

In cases of intramedullary spinal tumors with metastasis without other potential primary tumor lesions, early diagnosis and treatment should be performed while considering anaplastic meningioma.

Pediatric Emergency Magnetic Resonance Imaging: Current Indications, Techniques, and Clinical Applications

MR imaging plays an important role in the detection and characterization of several pediatric disease entities that can occur in the emergent setting because of its cross-sectional imaging capability, lack of ionizing radiation exposure, and superior soft tissue contrast. In the age of as low as reasonably achievable, these advantages have made MR imaging an increasingly preferred modality for diagnostic evaluations even in time-sensitive settings. In this article, the authors discuss the current indications, techniques, and clinical applications of MR imaging in the evaluation of pediatric emergencies.

Molecular and clinical prognostic factors for favorable outcome following surgical resection of adult intramedullary spinal cord astrocytomas

OBJECTIVE

Intramedullary spinal cord astrocytomas are uncommon but important entities. Aggressive surgical resection is believed to be critical to prevent subsequent neurological deterioration; however, the prognostic significance of numerous patient and molecular variables remains unclear. We sought to investigate the clinical and molecular factors associated with outcomes following surgical resection of adult spinal cord astrocytomas.

METHODS

A consecutive retrospective chart review of all patients who underwent intramedullary spinal cord astrocytoma resection at a single tertiary-care institution between January 1996 and December 2011 was conducted. Molecular data collected included p53 mutation status, proliferative activity (Ki-67), 1p/19q chromosome loss, and EGFR amplification. Multivariable logistic and Cox proportional hazards regression were used to identify variable associated with postoperative outcomes.

RESULTS

Among 13 patients undergoing surgical resection followed for a median of 54 months, 54% experienced improvement in neurological status, while 15% remained unchanged and 31% deteriorated. Following resection, the 5-year local control (LC), progression-free survival (PFS), and overall survival (OS) rates were 83%, 63%, and 83%. Median PFS time was found to be 5.6 years. Multivariable regression revealed limited characteristics associated with postoperative outcomes, though no molecular characteristics were found to be prognostic. Older age at surgery predicted decreased probability of PFS (HR 0.91, 95% CI 0.81-0.99, p=0.03) and trended towards predicting lack of neurological improvement (OR 0.94, 95% CI 0.83-1.02, p=0.21) and decreased OS (HR 0.93, 95% CI 0.81, 1.03, p=0.15). Preoperative motor symptoms (OR 0.12, 95% CI <0.01-1.91, p=0.14) and adjuvant chemotherapy (OR 0.07, 95% CI <0.01-1.82, p=0.12) also trended towards predicting lack of neurological improvement.

CONCLUSION

Age was the only patient variable found to have a statistically significant association with profession-free survival and no other factors were significantly associated with postoperative outcomes. These findings were limited by a relatively small sample size; thus, future studies with increased power investigating the prognostic effects of molecular characteristics could provide further clarity in identifying patients most likely to benefit from surgical resection.

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 Outcomes of High-Grade Spinal Cord Gliomas

Study Design

A retrospective study.

Purpose

The purpose of this study was to obtain useful information for establishing the guidelines for treating high-grade spinal cord gliomas.

Overview of Literature

The optimal management of high-grade spinal cord gliomas remains controversial. We report the outcomes of the surgical management of 14 high-grade spinal glioma.

Methods

We analyzed the outcomes of 14 patients with high-grade spinal cord gliomas who were surgically treated between 1989 and 2012. Survival was charted with the Kaplan-Meier plots and comparisons were made with the log-rank test.

Results

None of the patients with high-grade spinal cord gliomas underwent total resection. Subtotal resection was performed in two patients, partial resection was performed in nine patients, and open biopsy was performed in three patients. All patients underwent postoperative radiotherapy and six patients further underwent radiation cordotomy. The median survival time for patients with high-grade spinal cord gliomas was 15 months, with a 5-year survival rate of 22.2%. The median survival time for patients with World Health Organization grade III tumors was 25.5 months, whereas the median survival time for patients with glioblastoma multiforme was 12.5 months. Both univariate and multivariate Cox proportional hazards models demonstrated a significant effect only in the group that did not include cervical cord lesion as a factor associated with survival (p=0.04 and 0.03).

Conclusions

The surgical outcome of patients diagnosed with high-grade spinal cord gliomas remains poor. Notably, only the model which excluded cervical cord lesions as a factor significantly predicted survival.

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.

Pediatric intramedullary spinal cord lesions: Pathological spectrum and outcome of surgery

Background:

Pediatric intramedullary spinal cord lesions are not only rare but also different from adults in a number of aspects. We aimed to study the incidence and the frequencies of various pediatric intramedullary mass lesions, their outcome to treatment and the factors determining their outcome of treatment.

Materials and Methods:

Thirty-one consecutive children (aged 1–18 years, mean 11.1 years, male: female = 1.8:1) with pathologically proven intramedullary spinal cord lesions treated at our center were studied. Clinico-radiological, histopathological, operative, and outcome data were reviewed retrospectively. The functional status was assessed using the modified McCormick grading system.

Results:

Gross total tumor excision was performed in 19 patients (61.3%), subtotal in 9 patients (29%), partial excision was performed in 2 (6.5%) patient, and only biopsy was performed in 1 patient (6.5%). There was one peroperative death, 2 patients died at follow-up. Complications included wound related complications (n = 4), transient deterioration in the motor power, and respiratory complication requiring a tracheostomy. Six patients showed recurrence at a mean follow-up of 16.4 months. Developmental tumors, high-grade ependymomas, and incompletely excised grade 2 ependymomas showed a tendency to recur.

Conclusions:

Children constituted nearly 1/5^th (17.4%) of intramedullary spinal cord tumors. Astrocytomas and ependymomas taken together constituted the most common intramedullary spinal lesions in children; however, developmental tumors predominated in the first decade. Children usually presented in good functional grades preoperatively and maintained good grades after surgery. Functional outcome was dependent on the preoperative neurological status and histopathology of the lesions.

Management and functional outcome of intramedullary spinal cord tumors: A prospective clinical study

AIM

Intramedullary spinal cord tumors (IMSCT) are rare neoplasms of central nervous system but require proper evaluation and management to ensure a good outcome. This study was carried out to evaluate the functional outcome of IMSCT following surgery and to decipher the factors affecting optimal outcome of these cases.

MATERIALS AND METHODS

A prospective clinical study was carried out at a tertiary care center from 2003 to 2012. Forty three patients with intramedullary tumors diagnosed on magnetic resonance imaging were included. Their clinical details, neurological findings and demographic data were recorded. The patients were then subjected to surgery and adjuvant radiotherapy. The patients were followedup clinically and radiologically, and all parameters examined and recorded.

RESULTS

Sensory and motor impairment was present preoperatively in majority of patients (n = 39 and n = 38, 90.7% and 88.4%, respectively). Gross total excision was performed in 30 cases (69.76%). The most common histological diagnosis was ependymoma (n = 21, 48.8%). Postoperatively 32 patients (74.4%) were in McCormick functional Grade I or II improving from 13 cases (30.2%) in Grade I or II preoperatively. Fifteen of 17 patients in Medical Research Council (MRC) Grade III and 10 out of 12 patients in Grade MRC IV improved. No mortality was recorded during the entire period of follow-up (mean: 22, range: 3-96 months). Eight patients (18.6%) had recurrence till the last follow-up visit.

CONCLUSIONS

Preoperative neurological grade was the most important predictor of functional outcome. Gross tumor excision was the best surgical modality to improve event free survival. High-grade tumors had higher rates of recurrence but no effect on functional outcome.

Pediatric intramedullary spinal cord tumors: a single center experience

AIM

To evaluate clinical and radiological findings, pathological features and treatment modalities in pediatric patients with intramedullary spinal cord tumors.

PATIENTS AND METHODS

The medical records of 36 patients with intramedullary spinal tumors were reviewed for clinical, radiological and histopathological data, chemotherapy, radiotherapy, surgical resection, treatment responses, events, and final outcome. Survival analyses were performed.

RESULTS

The median age was 7.9 years (range: 1-16 years; male/female ratio:1.4). Majority of the tumors were histopathologically diagnosed as astrocytomas (n = 16, 44.4%) and ependymomas (n = 19, 52.8%); whereas one was unclassified glioma. Overall, 94% of the astrocytomas and 84% of the ependymomas were low-grade, only three tumors were high-grade. In one patient with ependymoma, histopathological grade was undetermined. The primary tumor was commonly located in thoracic (47%) and cervical segments (28%). All patients had undergone surgery (gross-total resection, 33%; subtotal resection, 45%; biopsy, 22%). Radiotherapy was administered to 26 patients (72%) and chemotherapy to 15 patients (42%). The 3-, 5- and 10-year overall survival rates were 72%, 63% and 56%, respectively; and event-free survival rates were 43%, 40% and 40%. Survival did not significantly differ with gender, age groups, lag-time, neurologic status, histopathological tumor type, tumor location, extent of resection, treatment, or treatment responses in univariate survival analyses. Survival rates were significantly higher in patients with low-grade tumors and in ependymoma patients with resected tumors.

CONCLUSIONS

Patients with low-grade tumors and those who underwent gross-total tumor resection had better prognosis. Surgery remains the main treatment in intramedullary spinal tumors. The role of radiotherapy and chemotherapy is limited and even controversial in low-grade tumors.

Neurological outcome after surgical treatment of intramedullary spinal cord tumors

Objective

Recently, surgical outcomes of patients with intramedullary spinal cord tumors (IMSCT) have been improved due to advances of medicine. The purposes of our study were to evaluate the recent neurological outcomes after surgical treatment of IMSCTs.

Methods

We retrospectively reviewed 69 patients who underwent surgical treatment for IMSCT in our hospital between 1998 and 2013. Patient's age, sex, histological origin and grade, tumor location, tumor extension, preoperative neurological state, initial presenting symptom, and extend of tumor resection were analyzed to evaluate predictive factors that affect postoperative functional outcome.

Results

The neurological states at last follow-up were improved in 16 patients (23.2%), unchanged in 47 (68.1%), aggravated in 6 (8.7%). In all patients, the functional outcomes were good in 52 patients (75.4%), fair in 10 (14.5%), poor in 7 (10.1%). Preoperative good neurological state was the strongest positive predictor of good functional outcome (p<0.05). In tumor location, functional outcomes of thoracic tumors were poor than those in cervical and conus medullaris region (p=0.011). High-grade tumor shows poor outcome compare to low-grade tumor (p=0.03).

Conclusion

The most reliable predicting factor of surgical outcome was the preoperative neurological state. In addition, IMSCTs in thoracic region and high-grade tumor showed relatively bad outcome and had a risk of postoperative morbidity.