Spinal cord tumours in the elderly

Minimally invasive surgery for benign intradural extramedullary spinal meningiomas: experience of a single institution in a cohort of elderly patients and review of the literature

Meningiomas of the spine are the most common benign intradural extramedullary lesions and account for 25%–46% of all spinal cord tumors in adults. The goal of treatment is complete surgical resection while preserving spinal stability. Usually, these lesions occur in the thoracic region and in middle-aged women. Clinical presentation is usually nonspecific and the symptoms could precede the diagnosis by several months to years, especially in older people, in whom associated age-related diseases can mask the tumor for a long time. We report a series of 30 patients, aged 70 years or more, harboring intradural extramedullary spinal meningiomas. No subjects had major contraindications to surgery. A minimally invasive approach ( hemilaminectomy and preservation of the outer dural layer) was used to remove the tumor, while preserving spinal stability and improving the watertight dural closure. We retrospectively compared the outcomes in these patients with those in a control group subjected to laminectomy or laminotomy with different dural management. In our experience, the minimally invasive approach allows the same chances of complete tumor removal, while providing a better postoperative course than in a control group.

Results in the operative treatment of elderly patients with spinal meningiomas

STUDY DESIGN

Thirty consecutive patients over 70 years of age who were operated on for spinal meningiomas are presented to assess surgical criteria and postoperative outcome.

OBJECTIVES

To assess the outcome of surgically treated spinal meningiomas in patients in their eighth or ninth decade of life and to analyze the possible role of some prognostic factors.

SUMMARY OF BACKGROUND DATA

The ageing of the population in the industrial nations has led to increased findings of benign spinal tumors, namely meningiomas, in the elderly. These slow-growing tumors may prevent these patients from leading an autonomous life. Little is known about the outcome of spinal meningioma surgery in patients of 70 years or older because the number of these patients, although increasing, is still small.

METHODS

Thirty consecutive patients over 70 years of age (mean age, 77.1 years) were operated on for spinal meningiomas between 1986 and 2001. The preoperative neurologic status of the patients was graded with the Solero score, and the general health conditions were staged according to the American Society of Anesthesiology classification. Total tumor removal was achieved in 27 patients. The follow-up period ranged from 17 to 173 months (mean, 62.7 months).

RESULTS

There was no operative mortality, and morbidity was not significant. Although not significant, neurologic outcome was better in patients with a low preoperative Solero score than those with a high one (P = 0.06). Clinical outcome was not influenced by the duration of symptoms before surgery or preoperative American Society of Anesthesiology classification. No recurrence was observed during the follow-up period.

CONCLUSIONS

Neurologic outcome following surgery was favorable in the vast majority of patients, with no mortality or significant morbidity. Surgery is the only treatment in elderly patients with symptomatic spinal meningiomas, even those with a poor preoperative neurologic condition, whenever there is an acceptable risk from an anesthesiological point of view.

Intramedullary spinal cord metastasis: report of three cases and review of the literature

BACKGROUND

Intramedullary spinal cord metastasis is rare; but it is being encountered with increasing frequency. Optimal treatment after diagnosis remains controversial.

METHODS

In the last 3 years, we have encountered three cases of intramedullary metastasis presenting as focal mass lesions with minimal systemic evidence of cancer. We present our results in these patients and review the literature in an effort to more optimally define both the natural course of this disease, as well as a potential subset of patients who might benefit from more aggressive treatment.

RESULTS

With the availability of more sensitive imaging techniques, these tumors are being diagnosed with increasing frequency. Magnetic resonance imaging is sensitive, but nonspecific, in distinguishing intramedullary spinal cord metastases from primary cord tumors. Urgent biopsy is often necessary prior to definitive treatment. Radiation with chemotherapy significantly prolongs survival. Radical subtotal resection may offer additional quality survival, especially in cases of metastatic melanoma with an occult primary.

CONCLUSIONS

Regardless of treatment, many patients survive less than 1 year. Intramedullary spinal cord metastasis is a devastating condition, but with appropriate diagnosis and aggressive treatment, selected patients may have substantially increased survival.

Extradural malignant lymphoma associated with spinal cord compression

Cord compression was noted in 26 patients with extradural malignant lymphoma. There were 19 cases of nonHodgkin's lymphoma and seven cases of Hodgkin's disease. Eighteen cases of non-Hodgkin's lymphoma had intermediate or high grade malignancy types according to the Working Formulation Lymphoma Classification. These patients represented 28% of all extradural malignant tumours seen at the Royal Adelaide Hospital (RAH) and 2.5% of all patients with malignant lymphoma, during an 11 year period. The patients were classified in three presenting groups: Group A, six patients with primary extranodal extradural lymphoma; Group B, nine patients with both extradural lymphoma and disseminated disease at initial presentation; and Group C, 11 patients who developed extradural lymphoma during the course of established disease. Only classification by groups appeared to affect survival time. Group A had the most favourable prognosis, with a 5 year survival of 83%. Five of the Group A patients had a relapse of lymphoma; four at distant sites and one in the retroperitoneum. Laminectomy was essential to provide a diagnosis in Group A patients. The most useful warning symptom of impending spinal cord compression was back and/or radicular pain, which preceded neurological deficit either by days or by up to 5 years. Plain spinal X-rays were abnormal in 64% of cases, emphasizing the value of this simple procedure.

Relative incidence of spinal canal tumors

By a retrospective study, the relative incidence of various histopathological types of one hundred and seventy-nine biopsy proven tumors of the spinal canal from a general hospital in Iran is presented and compared with the statistics reported from several eastern countries and the west. Nerve sheath cell tumors are more frequent in the east especially in far eastern countries whereas meningiomas and neuroepithelial tumors have a lower percentage in most eastern reports. With the available data no conclusion can be drawn as to the geographic difference in the frequency of occurrence of other histopathological types appearing in the spinal canal; some statistical features in this latter group are pointed out.

Paraganglioma of the cauda equina. Report of a rare tumor

The rare occurrence of a paraganglioma of the cauda equina is described. The correct diagnosis was made only retrospectively after examination of a recurrence nine years after initial surgery. Paragangliomas have not been mentioned in large tabulations of spinal cord tumors, perhaps reflecting the fact that it is only within the last decade that such tumors have been recognized in this unusual location. A literature review has revealed six cases of paraganglioma of the cauda equina reported since 1970. An awareness of the possibility of a paraganglioma intimately associated with the spinal cord as well as the histopathologic appearance are the bases of a correct diagnosis. These tumors are histopathologically similar to paragangliomas in conventional locations, exhibit ultrastructural granules and may, as in the current case, also demonstrate argyrophilic granules.

Peripheral neuropathy in the elderly: a clinical and electrophysiologic study

Fifty-nine elderly patients with clinical and neurophysiologic evidence of peripheral neuropathy were reviewed. Diabetes, alcoholism and malignancy were the important etiologic factors, but other causes of acquired neuropathy such as drugs, autoimmune disease, and acute or chronic demyelinating neuropathy continue to warrant attention. Postural hypotension associated with neuropathy occurred in three patients with diabetes and one patient with lymphoma. Prognosis for the neuropathies did not seem to be adversely affected by age.