Intradural spinal tumors: 10 - years surgical experience in a single institution

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Indications for Fusion With Intradural Spine Tumor Resection in Adults: A Systematic Review and Meta-analysis

BACKGROUND

The evidence for instrumented fusion in the setting of degenerative, traumatic, or congenital deformity is well established. Data on fusion indications in intradural spinal tumors (IDST) are scarce and reduced to retrospective studies. The objective of this work is to systematically review the published literature since 2015 and analyze the change of practice patterns for stabilization and fusion after intradural tumor resection in adults.

METHODS

A systematic literature review was performed via PubMed with the terms: "intradural spinal tumors", "intramedullary spinal tumors", and "intraspinal tumors". The analysis was limited to adult patients with IDST and studies with more than 10 patients. Data on the proportion of patients who underwent instrumentation and had postoperative deformity was pooled in a meta-analysis.

RESULTS

A total of 1073 articles were identified and 47 papers were selected. All the studies were retrospective series and a total of 2473 patients were included. The follow-up ranged from 1 to 96 months, the pooled spinal fixation rate was 6% (95% CI 4.5%-7.6%), the pooled laminoplasty rate was 14.4% (95% CI 5.9%-23%), the pooled rate of postoperative deformity or malalignment in patients with a follow up of at least 6 months was 2.1% (95% CI 1.2%-3%) and just 7 patients were reoperated due to progressive deformity.

CONCLUSIONS

Based on existing evidence, the rate of fusion during resection of intradural spinal tumors is low. Prophylactic fixation is often unnecessary and only indicated in unique cases that require extensive bony resection.

Clinical Effect of Laminectomy with Lateral Mass Screw Fixation in Treating Cervical Schwannoma: A Retrospective Study

Background

The objective of this study was to evaluate the clinical effectiveness and safety of laminectomy combined with lateral mass screw fixation in treating cervical intradural extramedullary schwannoma.

Methods

We retrospectively collected and analyzed medical records of 38 patients who underwent resection of cervical intraspinal schwannoma between January 2012 and April 2019. Based on different surgical procedures, two groups were divided among all participants: laminectomy-only (n = 21) and laminectomy with instrumented fixation (n = 17); the minimum follow-up time was 1 year. The visual analogue scale (VAS) score and neck disability index (NDI) were utilized for pain assessment; the Japanese Orthopedic Association (JOA) score was carried out for the assessment of neurological impairment. Radiographic changes of Cobb angle were compared before and after the surgery.

Results

Consequently, demographics were well matched in both groups, without any statistical difference (P > 0.05). Compared with preoperation, both surgical procedures significantly improved VAS, NDI, and JOA scores (P < 0.001), but no differences between them (P > 0.05). In terms of postoperative spinal instability/deformity, laminectomy-only caused more events than instrumented fixation, which is statistically significant (P < 0.001).

Conclusions

In summary, laminectomy with lateral mass screw fixation is an effective and safe approach to treat cervical intraspinal schwannoma, which is likely to be a better choice than the laminectomy-only approach.

Evaluation of Surgically Treated Primary Spinal Cord Tumors in a Single Brazilian Institution: A Case Series Study of 104 Patients

Background: Primary spinal cord tumors are rare and heterogeneous, and their prevalence varies among the studies. Few articles have evaluated the prevalence, characteristics, and histological types of spinal cord tumors in Latin American populations. This study aimed to analyze the histological types and clinical aspects of a series of consecutive patients diagnosed with primary spinal cord tumors who underwent surgical treatment in a single Brazilian institution and to compare them with the literature.

Methods: This is a case series study, with retrospective analysis of all consecutive adult patients who underwent surgical treatment for primary spinal cord tumors in a single center between January 1997 and April 2021. Data analyzed included age at surgery, sex, anatomical location, histopathological diagnosis, clinical presentation, and neurological status at discharge.

Results: A total of 104 patients (53 women [51.0%]; mean age, 49.0 ± 16.7 years [range, 19-87 years]) were included in the analysis. Among the tumors, 83.7% were benign, and 36.5% involved the thoracic spine; intradural extramedullary lesions comprised 52.9% of the tumors, and the most prevalent were schwannomas (26.9%) and meningiomas (18.3%). Among the patients, 55% and 50% presented with pain and motor deficit, respectively, and the deficit improvement rate was greater than the worsening rate at the immediate postoperative period and discharge.

Conclusions: Our series highlights the heterogeneity of primary spinal cord tumors compared to other studies. Further large population studies are necessary to elucidate the epidemiology of this disease.

Minimally Invasive Surgical Technique for the Management of Giant Dumbbell Spinal Schwannoma

BACKGROUND

 Completely extradural spinal schwannomas have a unique morphology (dumbbell tumors) with an intra- and extraspinal component. When they compromise two contiguous vertebral bodies or have an extraspinal extension >2.5 cm, they are classified as giant spinal schwannomas. The aim of this study is to present our experience in the surgical management of completely extradural giant spinal schwannomas with a minimally invasive approach.

METHODS

 This study is a case series of patients treated at the Neurosurgery Department of the University Clinical and Provincial Hospital of Barcelona, Spain, between January 2016 and December 2019.

RESULTS

 Fifteen patients met the inclusion criteria, with thoracic and lumbar spines being the most frequent locations. All patients underwent surgical treatment, with a mini-open interlaminar and far-lateral technique. Total gross resection was accomplished in all patients and spine instrumentation was not necessary.

CONCLUSIONS

 Microsurgery is the treatment of choice for spinal schwannomas, and gross total resection with low morbidity must be the surgical goal. Mini-open interlaminar and far-lateral access is a valid surgical option, with low morbidity in experienced hands, and there is no need for spinal instrumentation.

Surgical treatment of solitary intradural extramedullary spinal cord metastases from solid cancers of non-neurogenic origin. A multicenter study

PURPOSE

Intradural extramedullary spinal metastases (IESM) represent an extremely rare manifestation of systemic cancer. We evaluated the surgical indications, complications and outcome in a series of 43 patients with solitary intradural extramedullary metastases originating from solid cancer of non-neurogenic origin.

METHODS

Patients' age, histopathological diagnoses of primary cancer, tumor size, spinal location, and extramedullary tumor dissemination were collected. Preoperative functional status, pre- and post-operative neurological status, extent of the tumor resection were also analyzed.

RESULTS

The majority of IEMS occurred in the thoracic area, with the most common presenting symptoms ranging from motor (76.7%) to sensory (72%) deficits. Gross total resection was achieved in 55.8% of cases, while In 44.2% of patients a subtotal resection was performed due to strong adherence between the tumor and neural tissue. After surgery, 72.1% of patients exhibited improvement of symptoms in terms of pain relief and partial recovery of motor and/or sensory deficits, while neurologic functional status was severely affected postoperatively in 3 patients.

CONCLUSION

Although there was no statistical significance between the different parameters and overall survival, KPS and the presence of other metastases were the strongest prognostic factors for overall survival and postoperative neurologic outcome.

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.

A Rare Presentation of Spinal Schwannoma Causing Conus Medullaris Syndrome: A Case Series on Surgical Outcome

Introduction

Spinal schwannoma can occur anywhere along the spinal cord but is predominantly seen in the cervical and thoracic region.It composes mainly of well-differentiated schwann cell and is benign in nature. It is typically seen in the peripheral nerves and is commonly associated with neurofibromatosis. Up to 80% of cases, spinal schwannoma is reported to be intradural in location and 15% of cases have both intradural and extradural components. Spinal schwannoma rarely causes conus medullaris syndrome.

Case Report

In this case series, all three female patients in their 4th and 5th decades of life presented with conus medullaris syndrome. Lower back pain, radiculopathy, lower limb weakness, and urinary incontinence are their main clinical presentation. Magnetic resonance imaging shows a well-defined intradural, extramedullary mass compressing onto the conus medullary region. These patients undergone microscopic assisted excision of the tumor and had remarkably good early outcome despite the advanced presentation of neurological deficit.

Conclusion

Despite the late presentation with significant neurological deficit, surgical excision of spinal schwannomas carries a good prognosis postoperatively due to their benign nature and extramedullary location.

Clinical Efficacy of Laminectomy with Instrumented Fixation in Treating Thoracolumbar Intradural Extramedullary Schwannomas: A Comparative Study

Background

This study investigated the clinical effect of laminectomy plus pedicle screw fixation in treating thoracolumbar intradural extramedullary schwannomas.

Material/Methods

Between October 2011 and May 2017, 57 patients undergoing resection of thoracolumbar schwannomas were retrospectively identified and included in the study. Based on the surgical procedures used, all participants were assigned to either the laminectomy-only group (n=33) or the combination group (laminectomy plus pedicle screw fixation, n=24). All participants were followed up for over 2 years. In the laminectomy, the spinal process, vertebral laminae, and bilateral upper articular processes of the surgical segments were completely resected and the lower articular processes were reserved. For further analysis, we evaluated the pain levels using visual analogue scale (VAS) score. The assessment of neurological function was performed with Japanese Orthopaedic Association (JOA) score and Oswestry disability index (ODI). The comparisons of Cobb angle changes were carried out pre-surgery and post-surgery.

Results

The demographic data were well matched between the laminectomy-only group and combination group, without significant differences (P>0.05). After surgery, both surgical procedures achieved significant improvement in VAS score, ODI, and JOA score (P<0.001), but no significant differences were found between these 2 surgical procedures (P>0.05). The postoperative change in Cobb angle indicated a significant difference in the laminectomy-only group, but not in the combination group (P<0.05). In addition, postoperative spinal instability/deformity was found in the laminectomy-only group (P<0.05).

Conclusions

In conclusion, the combination of laminectomy and pedicle screw fixation is a safe and effective surgical procedure when used to treat thoracolumbar schwannoma, and appears to be superior to the laminectomy-only procedure.