Long-level intramedullary spinal cord astrocytoma complicated with spine scoliosis: Report of two cases

A comprehensive evaluation of imaging features in pediatric spinal gliomas and their value in predicting tumor grade and histology

PURPOSE

Pediatric spinal cord gliomas (PSGs) are rare in children and few reports detail their imaging features. We tested the association of tumoral grade with imaging features and proposed a novel approach to categorize post-contrast enhancement patterns in PSGs.

METHODS

This single-center, retrospective study included patients <21 years of age with preoperative spinal MRI and confirmed pathological diagnosis of PSG from 2000-2022. Tumors were classified using the 5th edition of the WHO CNS Tumors Classification. Two radiologists reviewed multiple imaging features, and classified enhancement patterns using a novel approach. Fisher's exact test determined associations between imaging and histological features.

RESULTS

Forty-one PSGs were reviewed. Thirty-four were intramedullary, and seven were extramedullary. Pilocytic astrocytoma was the most common tumor (39.02%). Pain and weakness were the most prevalent symptoms. Seven patients (17.07%) died. Cyst, syringomyelia, and leptomeningeal enhancement were associated with tumor grade. Widening of the spinal canal was observed only in low-grade astrocytomas. There was a significant association between tumor grade and contrast enhancement pattern. Specifically, low-grade PSGs were more likely to exhibit type 1A enhancement (mass-like, with well-defined enhancing margins) and less likely to exhibit type 1B enhancement (mass-like, with ill-defined enhancing margins).

CONCLUSION

PSGs display overlapping imaging features, making grade differentiation challenging based solely on imaging. The correlation between tumor grade and contrast enhancement patterns suggests a potential diagnostic avenue, requiring further validation with larger, multicenter studies. Furthermore, Low-grade PSGs display cysts and syringomyelia more frequently, and leptomeningeal enhancement is less common.

Clinical features and pathogenesis of scoliosis due to spinal astrocytoma

The aetiology of scoliosis remains unclear. Some studies have focused on the theory of possible muscular imbalance. The role of the spinal cord, which directly innervates the paraspinal muscles, in muscular imbalance has not yet been studied. Spinal astrocytomas often grow on one side of the spinal cord, destroying it asymmetrically. Asymmetrical damage to the spinal cord can lead to asymmetrical changes in paraspinal muscles. The present study investigated the effect of muscular imbalance on scoliosis by observing scoliosis caused by spinal astrocytomas. Patients diagnosed with spinal astrocytomas in a single centre were analysed, and the type and side of the symptoms, sagittal tumour position, scoliosis, end vertebrae and apical vertebrae of scoliosis were recorded. The tumour side was assumed from symptom type and side, and the cross-sectional area of the paraspinal muscles on both sides of the end vertebra was outlined and compared. The incidence of astrocytoma-induced scoliosis was significantly higher in patients with unilateral symptoms. The inferred tumour side was highly consistent with the convex side of scoliosis. The distal vertebral segments of scoliosis were consistent with the spinal cord segments involved in the astrocytomas. The apical vertebrae were more caudal in astrocytoma-induced scoliosis. The cross-sectional area of the multifidus muscle on the convex side of apical-level scoliosis was significantly smaller than that on the concave side. However, no significant differences were observed in the erector spinae muscles. Overall, spinal astrocytomas can cause asymmetric destruction of the corresponding spinal cord segment, resulting in asymmetric atrophy and weakness of the multifidus muscle innervated by the spinal cord segment, thereby causing scoliosis that is convex to the weaker side. This mechanism involves asymmetric lower neuron paralysis of the multifidus muscle. This is a type of scoliosis with several differences from idiopathic scoliosis.

Approaches to Incidental Intradural Tumors of the Spine in the Pediatric Population

BACKGROUND

Incidental intradural tumors of the spine in the pediatric population are rare lesions whose management remains unclear. Surgeons must balance the risks of iatrogenic deficits and complications after surgical resection against the risks from progressive growth of the tumor. Moreover, the natural history of an incidental finding can be difficult to predict. Here, we review the literature on incidental intradural tumors of the spine and present considerations for their management.

SUMMARY

Growth of the tumor or changes in radiographic features are usually indications for resection. Asymptomatic lesions can be found in patients with genetic syndromes that predispose to tumor formation, such as neurofibromatosis type 1 and 2, schwannomatosis, and Von-Hippel-Lindau syndrome, and careful workup of a genetic cause is warranted in any patient presenting with multiple tumors and/or cutaneous features. Close follow-up is generally favored given the heavy tumor burden; however, some recommend pre-emptive resection to prevent permanent neurological deficits. Incidental intradural tumors can also occur in association with hydrocephalus, significant syringomyelia, and cord compression, and surgical treatment is usually warranted. Tumors may also be discovered as part of the workup for scoliosis, where they are not truly incidental to the scoliosis but rather are contributing to curve deformation.

KEY MESSAGES

Thorough workup of patients for associated genetic syndromes or comorbidities should be undertaken in pediatric patients with incidental intradural tumors. Further research is needed into the natural history of these incidental lesions. Incidental tumors can often be managed conservatively with close follow-up, with surgical intervention warranted for expanding tumors or new-onset symptoms.

Massive Intramedullary Ependymoma: A Case Report

Introduction: Intramedullary ependymoma (IE) is adults' most common intramedullary spinal tumor. Tumors usually extend one to eight segments in the cervical region. In this case report, we reported a patient with massive IE spanning from the fourth ventricle to the T4 segment of the spinal cord, which surgically treated with laminectomy from occiput to T4 Case Presentation: A 42-year-old man who is a known case of IE with progressive upper extremities paraesthesia and gait disturbance. Four years ago he refused surgery and presented with dysphagia. The patient's MRI demonstrated an intramedullary spinal cord tumor extending from the fourth ventricle to T4. Conclusions: massive spinal ependymoma is a rare, benign, slow-growing tumor, and patients present symptoms years before diagnosis. Upon confirmation of the diagnosis, the tumor must be surgically removed.

Carbon fibre instrumentation for scoliosis surgery in children with spinal cord intramedullary tumours: a novel technical note

INTRODUCTION

Scoliosis in children is the most common spinal deformity seen by general practitioners, paediatricians and spinal surgeons. Progressive scoliosis can result in the development of a worsening deformity and cosmesis. Patients usually present with aesthetic concerns. Progressive scoliosis that fails conservative management may require or be offered surgical intervention. Intramedullary tumours may be associated with scoliosis. Management of patients with these dual pathologies can be challenging. Classical scoliosis instrumentation utilising titanium implants impairs post-operative MRI evaluation with metal artefacts. Carbon fibre instrumentations has the potential to reduce the imaging metal artefacts but has not been described in scoliosis correction.

METHODS

Surgical technical note describing correction of scoliosis in two adolescents' with intradural tumours utilising carbon fibre implants.

RESULTS

We developed a hybrid approach where we initially used titanium implants to manipulate the deformity then replaced the construct with carbon fibre implants in the same setting to maintain the deformity correction with good follow up outlook.

CONCLUSION

Our technique is robust, safe and replicable. It enabled appropriate post-operative MRI evaluation of the neural structures with a reduced risk of metal artefacts.

Surgical management of a huge intramedullary ependymoma from oblongata to T4: A case report

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A huge ependymoma from oblongata to T4, was en bloc gross total resected.

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Total resection of ependymoma should be suggested, regardless of its extension.

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Long level laminoplasty is an effective option to maintain a proper spine alignment.

Introduction and importance

Huge intramedullary tumor is a rare condition. Surgical management of such huge ependymoma is technically challenging. We reported one case of 300 mm long intramedullary spinal cord ependymoma from oblongata to T4, which was satisfactorily en bloc gross total resected and the cervical spine alignment was successfully maintained by laminoplasty.

Case presentation

A 30-year-old man presented to our service with two-year progressive neck pain combined with bilateral sense disorders of both the upper and lower extremities. The neurological grade was ASIA D. Repeat MRI imaging demonstrated a “medulla oblongata to T4” intramedullary spinal cord tumor complicated with cervical physiological curvature loss.

Clinical discussion

Laminectomies were made at the C1-T4 level by a milling cutter. The tumor was gently separated bilaterally. The ventral part of the tumor was separated from the cranial and the caudal ends until reaching the middle site of the tumor. The whole tumor was isolated en bloc. Titanium miniplates were used bilaterally to fix both sides of the laminoplasty section on each level. At the 2-year postoperative follow-up, the muscle strength of both the upper and lower limbs were grade Ⅳ. No tumor recurrence was detected.

Conclusion

The total removal of an intramedullary ependymoma should be recommended as soon as the diagnosis is made, regardless of its extension. Long-level laminoplasty could be an effective alternative option to maintain the proper spine alignment.