Anatomical location dictating major surgical complications for intradural extramedullary spinal tumors: a 10-year single-institutional experience

Systematic Review Comparing Open Versus Minimally Invasive Surgical Management of Intradural Extramedullary Tumours (IDEM)

Background/Objectives: Intradural extramedullary (IDEM) spinal tumours are relatively rare and predominantly benign. Gross total resection (GTR) has been demonstrated as an effective treatment, with increasing evidence supporting the use of minimally invasive techniques to achieve GTR. This study reviews the current surgical management options for IDEM tumours and their outcomes. Methods: A systematic literature search without meta-analysis was conducted by two independent reviewers in December 2024. The population of interest comprised patients who underwent surgical treatment for IDEM tumours. Outcomes assessed included the extent of resection, postoperative neurological function, and complications. Results: Fifty-seven articles met the inclusion criteria, providing data on 4695 IDEM cases, of which 3495 were managed through open surgery and 750 via minimally invasive surgery. The extent of resection was high, with a mean GTR > 90% across studies. Open laminectomy and unilateral minimally invasive hemilaminectomy were the most common surgical approaches. Complications, such as cerebrospinal fluid leaks, were less frequent following minimally invasive procedures vs. open surgery (11.1% vs. 14.3%). Minimally invasive surgery also led to improved postoperative functional outcomes (mean McCormick score change -1.30 vs. -0.64) and a lower recurrence rate (1.4% vs. 10.0%). Conclusions: Whilst open surgery yields acceptable rates of resection and neurological improvement, there is growing evidence that minimally invasive surgery can achieve comparable, if not superior, rates of resection with fewer complications, leading to lower costs and shorter hospital stays.

Minimally Invasive Far-Lateral Hybrid Exoscopic-Endoscopic Lateral Rolling Technique for T1-2 Anterior Intradural Extramedullary Meningioma

Anterior intradural extramedullary meningiomas are intimidating, especially in the thoracic spine due to the spinal cord impeding conventional surgical corridor, restricted space, and precarious cord vascularity.1,2 This is possibly the first report in the literature of a minimally invasive surgery: far-lateral hybrid exoscopic and angled endoscopic approach for an anterior thoracic spine meningioma. A 60-year-old woman presented with an anterior T1-2 meningioma with a flattened cord draping over the tumor more toward the right, leaving a potential corridor on the left lateral aspect (Video 1). Under a three-dimensional exoscope, a minimally invasive retractor was placed through the left paramedian incision centered on the lamina-transverse process junction; lateral fenestration and T1-2 facetectomy were carried out with a high-speed drill and rongeurs, meticulously preserving C7-T1 articulations.3,4 Following coagulation of the anterolateral dura over the tumor, a lateral longitudinal durotomy with a T-shaped anterolateral extension was performed around the tumor. Following devascularization, disconnection, and extra-arachnoidal dissection, a unique lateral rolling technique was employed, wherein the tumor was bimanually rolled onto the bony gutter created earlier without disturbing the spinal cord. This was followed by coagulation and excision of the dural tail. A 45° endoscope was then inserted to look for any residual tumor or dural tail.5 As the durotomy was lateral with excision of the dural tail, a multilayered soft tissue closure without dead space was sufficient to prevent cerebrospinal fluid leak.3 Fixation was not needed as only a single thoracic spine facet was disrupted.4 The patient recovered fully with radiology confirming total excision. This minimally invasive lateral rolling technique is safe and effective for anterior meningioma with the ergonomics of exoscope & the angled optics of endoscope complementing each other.

Epidemiology study on the prognostic factors of intradural extramedullary spinal tumors

Introduction

Intradural extramedullary (IDEM) tumors are rare tumors of the spinal cord. Currently, there is no evidence on the factors that predict poor outcomes in the patients. The objective of this study was to determine the prognostic factors that are associated with poor outcomes in IDEM tumors.

Materials and Methods

Patients 18 years and older with IDEM tumors who underwent surgery at our institute were identified and retrospectively reviewed. The patient's demographic data, risk factors, and modified McCormick Scale score were collected.

Results

A total of 129 patients with IDEM were included in this study. The age ranged from 19 to 79 years (mean 51.3 years), with a predominantly female population (85 patients, 65.9%). Eighty-nine (68.9%) patients had a good outcome, while 40 (31.0%) patients had a poor outcome. The significant factors for poor outcomes included the number of vertebral levels removed for tumor access (adjusted odds ratio [OR] = 3.80, 95% confidence interval [CI] =1.30-11.08, P = 0.013); pathology other than meningioma, schwannoma, and neurofibroma (adjusted OR = 18.86, 95% CI = 2.16-164.49, P = 0.007); and bowel/bladder involvement (adjusted OR = 3.47, 95% CI = 1.15-10.39, P = 0.027).

Conclusion

We found that the factors for poor outcomes included bowel/bladder involvement, number of vertebral levels removed for tumor access, and pathology other than meningioma, schwannoma, and neurofibroma.

A Novel and Reproducible Classification of Cervical Dumbbell Tumors to Inform Surgical Approach and Reconstruction Techniques

STUDY DESIGN

A retrospective case series.

OBJECTIVE

This study developed a novel classification system based on imaging and anatomy to select optimal surgical approaches and reconstruction strategies to achieve total resection of cervical dumbbell tumors and restore spinal stability.

SUMMARY OF BACKGROUND DATA

Total resection is necessary to decrease the recurrence rate of cervical dumbbell tumors. Previous cervical dumbbell tumor classifications are insufficient for determining surgical strategies; therefore, a practical classification is needed.

MATERIALS AND METHODS

This study included 295 consecutive patients with cervical dumbbell tumors who underwent total surgical resection. A novel classification of cervical dumbbell tumors was developed based on magnetic resonance imaging and computed tomography. Continuous variables were expressed as mean±SD and were compared using an unpaired two-tailed Student t test. The χ 2 test or the Fisher exact test was used for categorical variables. Kendall's W test assessed three independent raters' inter-rater and intrarater reliabilities on 140 cervical dumbbell tumors.

RESULTS

The inter-rater and intrarater consistency coefficient was 0.969 (χ 2 =404.3, P <0.001) and 0.984 (χ 2 =273.7, P <0.001). All patients with type I and II tumors underwent single-posterior surgeries to achieve total resection. Of the patients in this study, 86.1%, 25.9%, 75.9%, and 76.9% underwent posterior surgeries for types IIIa, IIIb, IVa, and V tumors, respectively. All patients with type IVb tumors underwent a combined anterior and posterior approach. Posterior internal fixation was used for all patients in posterior surgery. Anterior reconstruction was applied for patients with type IVb tumors (20/20, 100%) and some with type V tumors (3/13, 23.1%). The mean follow-up duration was 93.6±2.6 months. A recurrence was observed in 19 (6.4%) patients.

CONCLUSION

The authors describe a novel classification system that is of practical use for planning the complete resection of cervical dumbbell tumors.

Primary intradural extramedullary lesions: a longitudinal study of 212 patients and analysis of predictors of functional outcome

BACKGROUND

Primary intradural extramedullary (IDEM) lesions are rare, with an incidence of about 1/100,000 person-years. The aim of this study was to investigate their demographic, clinical, imaging, management, histopathological and outcome parameters. Another objective was to evaluate the various predicting factors leading to long-term favorable outcomes, thereby answering the controversial question: when to operate?

METHODS

This study observed 212 patients of primary IDEM lesions and followed-up for a mean of 53.80 months. The patient's outcome using McCormick grade at follow-up was correlated with age, sex, duration of symptoms, preoperative McCormick grade, tumor location and extent, extradural spread, extent of excision, vascularity, WHO grade and histopathological tumor type.

RESULTS

Benign nerve sheath tumors were the commonest lesions (47.17% schwannoma, 4.72% Neurofibroma), followed in incidence by meningioma (19.34%). There was predominance of males (57.08%), except in meningiomas (male: female ratio 1:2.15). Pain was the commonest initial symptom (51.88%). Limb weakness was the most common presenting complaint (88.68%). Gross total excision was achieved in 81.60% of cases and 70.75% of patients improved following surgery. The significant factors predicting favorable outcome included preoperative McCormick grade (P=0.001), the vertical extent of the tumor (P=0.027), histopathological tumor type (P=0.023) and WHO grading (P=0.015); and extent of excision had an odds ratio of 1: 2.5.

CONCLUSIONS

Significant predictors of functional outcome following surgery in IDEM lesions included preoperative McCormick grade, extent of the tumor, tumor type, WHO grading and extent of resection. The authors recommend surgery with the intent of complete tumor excision, before the onset of substantial symptoms, for better outcome.

Does the degree of preoperative gait disturbance remain after tumor resection in patients with intradural extramedullary spinal cord tumors?

STUDY DESIGN

Retrospective comparative study.

OBJECTIVE

This study aimed to determine whether the degree of preoperative gait disturbance remains following surgical resection in patients with intradural extramedullary spinal cord tumors (IDEMSCTs), and to investigate any factors that may influence poor improvement in postoperative gait disturbance.

SETTING

The single institution in Japan.

METHODS

In total, 78 IDEMSCTs patients who required surgical excision between 2010 and 2019 were included. According to the degree of preoperative gait disturbance using modified McCormick scale (MMCS) grade, they were divided into the Mild and Severe groups. The mean postoperative follow-up period was 50.7 ± 17.9 months. Data on demographic and surgical characteristics were compared between the two groups.

RESULTS

There was no significant difference in terms of age at surgery, sex, tumor size, surgical time, estimated blood loss, tumor histopathology, and postoperative follow-up period between the Mild and Severe groups. At the final follow-up, 84.6% of IDEMSCTs patients were able to walk without support. Gait disturbance improved after surgery in most of the patients with preoperative MMCS grades II-IV, but remained in approximately half of patients with preoperative MMCS grade V. Age at surgery was correlated with poor improvement in postoperative gait disturbance in the Severe group.

CONCLUSIONS

Regardless of the degree of preoperative gait disturbance, it improved after tumor resection in most of the IDEMSCTs patients. However, in the preoperative MMCS grade III-V cases, older age at surgery would be an important factor associated with poor improvement in postoperative gait disturbance.

Postoperative neurological complications in intradural extramedullary tumors: A 10-year experience of a single center

BACKGROUND

Intradural extramedullary spinal cord tumors (IDEMs) cause neurological symptoms due to compression of the spinal cord and caudal nerves. The purpose of this study was to investigate the incidence of postoperative neurological complications after surgical resection of IDEM and to identify factors associated with such postoperative neurological complications.

METHODS

We retrospectively analyzed 85 patients who underwent tumor resection for IDEM between 2010 and 2020. We investigated the postoperative worsening of neurological disorders. The patients were divided into two groups: those with and without postoperative neurological complications. Patient demographic characteristics, tumor level, histological type, and surgery-related factors were also compared.

RESULTS

The mean age at the time of surgery was 57.4 years, and histological analysis revealed 45 cases of schwannoma, 34 cases of meningioma, three cases of myxopapillary ependymoma, one case of ependymoma, one case of hemangioblastoma and one case of lipoma. There were five cases (5.8%) of postoperative neurological complications, and four patients improved within 6 months after surgery, and one patient had residual worsening. There were no statistically significant differences in age, sex, tumor location, preoperative modified McCormick Scale grade, histology, tumor occupancy, or whether fixation was performed in the presence or absence of postoperative neurological complications. All four cases of meningioma with postoperative neurological complications had preoperative neuropathy and meningiomas were located in the anterior or lateral thoracic spine.

CONCLUSIONS

Neurological complications after surgical resection for IDEM occurred in 5.8% of patients. Meningiomas with postoperative neurological complications located anteriorly or laterally in the thoracic spine.

Intradural extramedullary tumors. Retrospective cohort study assessing prognostic factors for functional outcome in adult patients

OBJECTIVE

The purpose of this study is to analyze a series of patients with intradural extramedullary tumors (IDEM) and assess factors that may modify or determine the final long term outcome and management.

MATERIALS AND METHODS

Single Center, retrospective study of a series of surgical patients with IDEM lesions from our Institution operated between 2010 and 2021. Patients with less than 6 months of follow up were excluded. Several preoperative demographics, clinical, imaging and surgical features, as well as histopathology, recurrence and adjuvancy were assessed. Patients' final clinical outcome was categorized using the McCormick scale.

RESULTS

A total of 203 patients with a mean follow-up of 30.50 months (range 6-130) were included. 57.64% of the analyzed population was female and the mean age was 50.51 years. The most frequent location of the tumors was dorsal (34.98%) followed by the lumbar region (32.02%). Total resection was achieved in 84.24% of cases, and the most frequent histopathology was Schwannoma (36.45%), followed by Meningioma (30.05%). Pain was the most usual initial symptom (63.05%). In our analysis, functional outcome after surgery was associated with statistical significance with preoperative McCormick grade, tumor type, EOR and postoperative complications such as hematoma and sphincter involvement.

CONCLUSION

The management of these lesions depends on many factors. It is worthy of mention that clinical presentation, EOR, histopathology and postoperative complications have shown significant prognostic value for the final outcome. Early treatment with the intention of achieving GTR when possible, using carefully tailored approaches, should be considered before the onset of significant symptoms.

Malignant Spinal Tumors

Malignant spinal tumors constitute around 22% of all primary spinal tumors. The most common location of metastases to the spinal region is the extradural compartment. The molecular and genetic characterization of these tumors was the basis for the updated WHO classification of CNS tumors in 2016, where many CNS tumors are now diagnosed according to their genetic profile rather than relying solely on the histopathological appearance. Magnetic resonance imaging (MRI) is the current gold standard for the initial evaluation and subsequent follow-up on intradural spinal cord tumors, and the imaging sequences must include T2-weighted images (WI), short time inversion recovery (STIR), and pre- and post-contrast T1-WI in the axial, sagittal, and coronal planes. The clinical presentation is highly variable and depends on the tumor size, growth rate, type, infiltrative, necrotic and hemorrhagic potential as well as the exact location within the spinal compartment. Surgical intervention remains the mainstay of management of symptomatic and radiographically enlarging spinal tumors, where the goal is to achieve maximal safe resection. Tumor recurrences are managed with repeat surgical resection (preferred whenever possible and safe), radiotherapy, chemotherapy, or any combination of these therapies.

Microsurgical Tubular Resection of Intradural Extramedullary Spinal Tumors With 3-Dimensional-Navigated Localization

BACKGROUND

The safety and efficacy of minimally invasive spine surgical (MISS) approaches have stimulated interest in adapting MISS principles for more complex pathology including intradural extramedullary (IDEM) tumors. No study has characterized a repeatable approach integrating the MISS surgical technique and 3-dimensional intraoperative navigated localization for the treatment of IDEM tumors.

OBJECTIVE

To describe a safe and reproducible technical guide for the navigated MISS technique for the treatment of benign intradural and extradural spinal tumors.

METHODS

Retrospective review of prospectively collected data on 20 patients who underwent navigated microsurgical tubular resection of intradural extramedullary tumors over a 5-year period. We review our approach to patient selection and report demographic and outcomes data for the cohort.

RESULTS

Our experience demonstrates technical feasibility and safety with a 100% rate of gross total resection with no patients demonstrating recurrence during an average follow-up of 20.2 months and no instances of perioperative complications. We demonstrate favorable outcomes regarding blood loss, operative duration, and hospital length of stay.

CONCLUSION

Navigated localization and microsurgical tubular resection of IDEM tumors is safe and effective. Adherence to MISS principles and thoughtful patient selection facilitate successful management of these patients.

Severe High Cervical Cord Compression Due to Large Bilateral Neurofibromas in a Patient With Neurofibromatosis Type 1: A Case Report and Review of Literature

Spinal neurofibromas are rare benign lesions associated with neurofibromatosis Type 1. They can often cause compression on nerve roots and the spinal cord. In this rare case, there are bilateral large neurofibromas with severe cord compression presenting as progressive myelopathy. We illustrate the surgical management as well as post-operative care along with a detailed literature review of similar cases. To our knowledge, this is the first report, in English literature, of spinal neurofibroma with large size, bilateral high cervical cord compression.

Transtubular image-guided surgery for spinal intradural lesions: techniques, results, and complications in a consecutive series of 60 patients

OBJECTIVE

The authors previously described the image merge tailored access resection (IMTAR) technique for resection of spinal intradural lesions (SIDLs). The authors reported their updated experience with the IMTAR technique and compared surgical results between patients who underwent operations with 2D or 3D fluoroscopic guidance.

METHODS

The authors reviewed 60 patients who underwent SIDL resection with transtubular techniques over a 14-year period. The earlier patients in the series underwent operations with 2D fluoroscopic image guidance. The latter patients underwent operations with the IMTAR technique based on 3D image guidance. The results of both techniques were analyzed.

RESULTS

Sixty patients were included: 27 females (45%) and 33 males (55%). The median (range) age was 50.5 (19-92) years. Gross-total resection (GTR) was achieved in 52 patients (86.7%). Subtotal resection was accomplished in 5 patients (8.3%). Neurological complications occurred in 3 patients (5%), and tumor recurrence occurred in 1 patient (1.7%). The non-IMTAR and IMTAR cohorts showed similar postoperative Nurick scale scores and rates of neurological complications and GTR. The median (interquartile range) bone resection surface area at the index level was 89.5 (51-147) mm2 in the non-IMTAR cohort and 35.5 (11-71) mm2 in the IMTAR cohort, with a statistically significant difference (p = 0.0112).

CONCLUSIONS

Surgery for SIDLs may be challenging, and meticulous surgical planning is crucial to optimize tumor access, maximize resection, and minimize risk of complications. Image-guided transtubular resection is an additional surgical technique for SIDLs and facilitates microsurgical tumor removal of ventrally located lesions with a posterolateral approach, without requiring potentially destabilizing bone resection.

Laminectomy Versus Laminectomy with Fusion for Intradural Extramedullary Tumors: A Systematic Review and Meta-Analysis

OBJECTIVE

The primary objective of our systematic review and meta-analysis was to systematically compare the reported outcomes between laminectomy and laminectomy with fixation/fusion (LF) for the treatment of intradural extramedullary tumors (IDEMTs). Our secondary objective was to compare the outcomes between different laminectomy exposure techniques.

METHODS

PubMed and Embase were queried for literature on laminectomy and LF for IDEMTs. Reports of transforaminal approaches, interlaminar approaches, corpectomy, pediatrics patients, intramedullary tumors, technical studies, animal or cadaver studies, and literature reviews were excluded. The outcome measures recorded were pain, neurologic function, functional independence, cerebrospinal fluid leak, and wound infection. Where possible, the laminectomy technique (partial laminectomy [PL] vs. total laminectomy [TL]) was specified. Stata, version 17, was used for the fixed effects inverse variance meta-analysis.

RESULTS

Of 1849 reports assessed, 17 were included. The meta-analysis revealed that laminectomy (PL or TL) resulted in higher rates of postoperative sagittal instability compared with LF (odds ratio, 1.81; P < 0.001). No differences in any other postoperative outcome were observed between laminectomy and LF (P = 0.44). The systematic review also revealed no differences in postoperative pain, neurologic function, or functional independence or disability between PL and TL. Some evidence suggested that TL might result in greater rates of sagittal instability compared with PL.

CONCLUSIONS

No differences between LF, PL, or TL in pain, neurologic deficit, functional independence, cerebrospinal fluid leak, or wound infection were reported. Laminectomy had greater odds of sagittal instability compared with LF. Patients with preoperative sagittal instability requiring extensive removal of the posterior spinal column to achieve adequate resection of large tumors might benefit from LF.

Minimally Invasive Removal of Extra- and Intradural Spinal Tumors Using Full Endoscopic Visualization

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate the clinical efficacy of minimally invasive endoscopic surgery in patients with spinal extradural and intradural-extramedullary tumors.

METHODS

This was a study of 15 consecutive patients with spinal extradural or intradural-extramedullary tumors up to 2 levels treated by minimal invasive surgery using a full endoscopic visualization and Caspar's retraction system (for cervical, thoracic, and lumbar tumors) over a 4-year period between January 2015 to April 2019 at a tertiary center.

RESULTS

A gross total remove was achieved in all patients (100%), determined by postoperative contrast computed tomography scans and magnetic resonance imaging. There was no postoperative spinal instability. All patients had equal or better neurologic functions after surgery at follow-up. The average preoperative Nurick's grade mean was 1.9 and the postoperative was 1.1. The average preoperative McCormick's grade mean was 2.9 versus 1.3 in the postoperative period.

CONCLUSIONS

Selective extradural or intradural-extramedullary tumors well localized and up to 2 levels can be safely and effectively treated by minimally invasive surgery using a full endoscopic visualization and the Caspar's retractor. However, there is insufficient evidence to recommend this approach over the classical or other microsurgical approach described.

Analysis of Factors Influencing the Long-term Outcome in Primary Spinal Cord Tumors: Review of Literature

Introduction Primary spinal cord tumors are amenable to total surgical excision but the outcomes are still diverse.

Objective The purpose of this study is to identify the significant factors which influence the long-term outcome of spinal cord tumors.

Materials and Methods A total of 84 consecutive spinal cord tumor patients who underwent microsurgical excision during April 2003 to 2014 were retrospectively studied. Patients operated after April 2014 were not considered. Ten factors were taken and correlated with the outcome. Multiple regression analysis was used. Patients were periodically evaluated at 1, 6 months, 1, 2, and 5 years. In 72 cases, postoperative MRI scans were performed. The follow-up period ranged between 5 to 15 years.

Results In our study, we had 64 extramedullary tumors and 21 intramedullary tumors with varied pathology. Axial location of the tumour (20.294/0.000), extent of the resection of the tumour (13.827/0.001), preoperative Nurick grade (11.349/0.023), and location of the tumour in the spine with respect to vertebral segments (8.151/0.017) were significant predictive factors. We had good outcomes in 65 cases and poor outcomes in 19 cases.

Conclusion Our results show location of the tumor with respect to axial plane and vertebral segments were the main contributing factors. They influence the extent of excision of the spinal cord tumor. Preoperative neurological status is the fourth factor which independently determines the long-term outcome. It is one of the few papers where patients have been followed-up for a long period ranging from 5 to 15 years.

Thoracic spine schwannoma presenting with traumatic spinal cord injury: A case report

Background:

The presentation of a thoracic spinal tumor due to high-impact trauma is quite rare and we found no other case reported.

Case Description:

This is a case report and literature review. A patient presented with severe paraparesis on day 4 after trauma. Thoracic MRI showed an oval image centered to T4-T5 suggestive of hemorrhage. The patient underwent a bilateral T4 and T5 laminectomy and microsurgically assisted intradural exploration. After laminectomy, we found no extradural lesions, so we proceeded to dural opening, after which we found a large extramedullary lesion which was completely removed. Pathology revealed a schwannoma. The patient had a very good recovery after surgery and motor rehabilitation. At 6 months after surgery, inferior limbs muscle strength was completely normal. We found no other case reported.

Conclusion:

Thoracic spine schwannomas are difficult to early diagnose unless there is a clinical suspicion. Initial presentation as bleeding after trauma was not described before. This presentation should be kept in the differential diagnosis of any patient with an acute neurological deficit without trauma signs on admission imaging.

Tumor Occupancy Ratio-An Imaging Characteristic Prognosticating the Surgical Outcome of Benign Intradural Extramedullary Spinal Cord Tumors

BACKGROUND

Intradural extramedullary (IDEM) spinal cord tumors are two thirds of all spinal tumors. We have prospectively analyzed the importance of the tumor occupancy ratio as a factor for predicting the course of the disease and in prognosticating the surgical outcome in patients with IDEM tumors.

METHODS

We prospectively analyzed 44 consecutive cases of IDEM tumors, diagnosed as cervical, thoracic, and lumbar IDEM tumors (excluding conus/cauda equina lesion) by magnetic resonance imaging (MRI), that were operated on at our institution between 2014 and 2016. We measured the tumor occupancy ratio and noted the sagittal and axial location of the tumor in the preoperative MRI and performed the laminectomy and unilateral medial facetectomy. A primary outcome has been noted according to the gait disability score in the preoperative period and in the follow-up period of 1 year. In the statistical analysis, categorical variables were compared using a chi-square test, and an analysis of variance and student t tests were used for the continuous variables. P < .05 was considered statistically significant.

RESULTS

The tumor occupancy ratio showed a significant association to the preoperative gait disability score (P < .001) and also predicted that the surgical outcome is much better in patients with tumors with a low tumor occupancy ratio than in patients with tumors with a high occupancy ratio (P < .001). No difference in the tumor occupancy ratio was noted in 2 different pathological tumors, and there was also no difference in the tumor occupancy ratio at different sagittal and axial locations of the tumor.

CONCLUSION

Tumor occupancy ratio has shown a significant impact on the preoperative course and also predicts the surgical outcome in patients with IDEM tumors. Hence, it is an important imaging characteristic to prognosticate the outcome in IDEM tumors and should be noted in each case.

A transpedicular approach to complex ventrally situated thoracic intradural extramedullary tumors: technique, indications, and multiinstitutional case series

OBJECTIVE

Ventrally situated thoracic intradural extramedullary tumors are surgically challenging and difficult to access, and they may be complicated by extensive adhesions and calcifications. Selecting an approach for adequate ventral access is key to complete resection and optimization of outcomes. The authors present a case series of patients who underwent resection of ventral thoracic intradural extramedullary tumors and discuss indications and considerations for this technique. Additionally, they describe the use of a posterolateral transpedicular approach for resection of ventral thoracic intradural extramedullary tumors compared with other techniques, and they summarize the literature supporting its application.

METHODS

From May 2017 to August 2020, 5 patients with ventral thoracic intradural extramedullary tumors underwent resection at one of the two academic institutions.

RESULTS

Patient ages ranged from 47 to 75 (mean 63.4) years. All tumors were diagnosed as meningiomas or schwannomas by histological examination. Three of the 5 patients had evidence of partial or extensive tumor calcification. Four of the 5 patients underwent an initial posterolateral transpedicular approach for resection, with positive radiographic and clinical outcomes from surgery. One patient initially underwent an unsuccessful traditional direct posterior approach and required additional resection 2 years later after interval disease progression. There were no postoperative wound infections, CSF leaks, or other complications related to the transpedicular approach.

CONCLUSIONS

Posterolateral transpedicular tumor resection is a safe technique for the treatment of complex ventrally situated thoracic intradural extramedullary tumors compared with the direct posterior approach. Anecdotally, this approach appears to be particularly beneficial in patients with calcified tumors.

Paraplegia due to spinal meningioma during the third trimester of pregnancy: case report and literature review

INTRODUCTION

Spinal meningiomas represent 25-45% of intradural spinal tumors and ~2% of meningiomas of the central nervous system (CNS), and their occurrence during pregnancy is unusual. We present an updated literature review.

CASE REPORT

A 36-year-old woman, at 32.6 weeks of gestation, was hospitalized for urinary tract infection and urinary retention. One month earlier, she had decreased strength in lower limbs, and this weakness rapidly progressed to flaccid paraplegia without sphincters control. Magnetic resonance imaging (MRI) revealed a well-defined intradural extramedullary lesion in T3-T4. Using a posterolateral approach, the tumor was completely removed; however, there was no clinical improvement, and the patient was discharged with an impairment scale (AIS) grade A. Histopathology examination indicated a psammomatous meningioma.

DISCUSSION

Meningiomas are benign tumors that are slowly progressive; however, the hemodynamic and hormonal changes of pregnancy are related to their accelerated growth. Reports show that the onset of the symptoms during the third trimester of pregnancy, including early neurological symptoms or signs of spinal cord compression, can be easily attributed to those of pregnancy by both the patient and the doctor. The time to diagnosis and medulla compression time are thus prolonged, which can be further compounded in middle-high income countries due to limitations in obtaining images for evaluation. Although rare, spinal meningiomas should be considered in the differential diagnosis of patients with neurological symptoms during pregnancy. Their early recognition is important to avoid irreversible neurological damage.

Clinical outcome of intradural extramedullary spinal cord tumors: A single-center retrospective analytical study

Background:

Intradural extramedullary spinal cord tumors (IESCT) account for approximately two-thirds of largely benign intraspinal neoplasms. They occasionally present with acute neurological deterioration warranting emergent surgical intervention.

Methods:

Here, we reviewed a series of 31 patients with intradural extramedullary spinal tumors who underwent surgery from 2012 to 2019. Patients averaged 50.8 years of age, and there were 16 males and 15 females. Patients were followed for a minimum of 1 year. Multiple clinical outcome variables were studied (e.g., Karnofsky Performance Score [KPS], visual analog scale (VAS), and Frankel grade).

Results:

The majority of IESCT tumors were found in the thoracic spine 18 (58.06%) followed by the lumbar 8 (25.80%), cervical 1 (3.22%), and combined junctional tumors 4 (12.90%) (cervicothoracic-02 and thoracolumbar-02). Histopathological diagnoses included schwannomas-16 (51.61%), meningiomas-11 (35.48%), lipomas-2 (6.45%), hemangiomas-1 (3.22), and ependymomas-01 (03.22%). The VAS score was reduced in all cases, while KPS and Frankel grades were significantly improved. Complications included cerebrospinal fluid leakage, new/residual paresthesias, and tumor recurrence (12.50%).

Conclusion:

Most intradural extramedullary tumors are benign and are readily diagnosed utilizing MRI scans. Notably, good functional outcomes follow surgical intervention.

Nine-segment laminectomy is safe for the resection of a schwannoma extending from C-2 to T-3: a rare case report

Cervical spine schwannoma, which is long and entirely intracanal, is rare to be found. Its rarity and atypical feature leads to difficulty in diagnosing and managing cases because of the scarcity of available literature. The surgical removal of this type of schwannomas via multisegment laminectomy is a great challenge because of various risks of postoperative complications. This report describes cervical spine schwannoma that was initially was not suspected as schwannoma and was subject to surgical removal via nine-segment laminectomy. In one year after surgery, motor function returned to normal strength, no new neurological deficits occurred, and no kyphotic deformity, which is a common complication of multisegment laminectomy.

Healthcare Resource Utilization and Patient-Reported Outcomes Following Elective Surgery for Intradural Extramedullary Spinal Tumors

BACKGROUND

Healthcare resource utilization and patient-reported outcomes (PROs) for intradural extramedullary (IDEM) spine tumors are not well reported.

OBJECTIVE

To analyze the PROs, costs, and resource utilization 1 year following surgical resection of IDEM tumors.

METHODS

Patients undergoing elective spine surgery for IDEM tumors and enrolled in a single-center, prospective, longitudinal registry were analyzed. Baseline and postoperative 1-year PROs were recorded. One-year spine-related direct and indirect healthcare resource utilization was assessed. One-year resource use was multiplied by unit costs based on Medicare national payment amounts (direct cost). Patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost).

RESULTS

A total of 38 IDEM tumor patients were included in this analysis. There was significant improvement in quality of life (EuroQol-5D), disability (Oswestry and Neck Disability Indices), pain (Numeric rating scale pain scores for back/neck pain and leg/arm pain), and general physical and mental health (Short-form-12 health survey, physical and mental component scores) in both groups 1 year after surgery (P < .0001). Eighty-seven percent (n = 33) of patients were satisfied with surgery. The 1-year postdischarge resource utilization including healthcare visits, medication, and diagnostic cost was $4111 ± $3596. The mean total direct cost was $23 717 ± $7412 and indirect cost was $5544 ± $4336, resulting in total 1-year cost $29 177 ± $9314.

CONCLUSION

Surgical resection of the IDEM provides improvement in patient-reported quality of life, disability, pain, general health, and satisfaction at 1 year following surgery. Furthermore, we report the granular costs of surgical resection and healthcare resource utilization in this population.

CSF-Related Complications After Intradural Spinal Tumor Surgery: Utility of an Autologous Fat Graft

Object:

The incidence of cerebrospinal fluid (CSF)-related complications after intradural spinal tumor (IST) surgery is high and reported in up to 18% of patients. However, no efficient way to prevent those complications has been reported so far. Treating these complications may require prolonged bed rest, re-exploration, external lumbar drain, use of antibiotics, and possible precipitation of other complications. To alleviate the risk of CSF-related complications, we prospectively adopted the intraoperative use of autologous fat grafting after IST surgery.

Methods:

This is a perspective analysis of 37 cases (out of 40 cases series) that a prospective use of abdominal fat autograft was applied during dural closure. After the tumor was resected and the dura closed, we used the Valsalva maneuver to ensure watertight closure. CSF leak was prevented with the enforcement of suture with a fat autograft as necessary. In addition a thin layer of fat tissue was then placed over the dura to obliterate any dead space. Fibrin glue was then applied over the graft. Filling the dead space with the fat graft prevented a low-pressure space in which CSF could pool and form a pseudomeningocele.

Results:

After adopting the fat autograft technique, we did not observe any post-surgery CSF-related complications in any of these patients.

Conclusions:

The prospective use of autologous fat grafting can ensure watertight dural closure and obliterate the dead space created during surgical exposure and bone removal. This technique significantly reduces, and may completely eliminate, postoperative CSF-related complications in patients with ISTs.

Intradural spinal tumors in adults-update on management and outcome

Among spinal tumors that occur intradurally, meningiomas, nerve sheath tumors, ependymomas, and astrocytomas are the most common. While a spinal MRI is the state of the art to diagnose intradural spinal tumors, in some cases CT scans, angiography, CSF analyses, and neurophysiological examination can be valuable. The management of these lesions depends not only on the histopathological diagnosis but also on the clinical presentation and the anatomical location, allowing either radical resection as with most extramedullary lesions or less invasive strategies as with intramedullary lesions. Although intramedullary lesions are rare and sometimes difficult to manage, well-planned treatment can achieve excellent outcome without treatment-related deficits. Technical advances in imaging, neuromonitoring, minimally invasive approaches, and radiotherapy have improved the outcome of intradural spinal tumors. However, the outcome in malignant intramedullary tumors remains poor. While surgery is the mainstay treatment for many of these lesions, radiation and chemotherapy are of growing importance in recurrent and multilocular disease. We reviewed the literature on this topic to provide an overview of spinal cord tumors, treatment strategies, and outcomes. Typical cases of extra- and intramedullary tumors are presented to illustrate management options and outcomes.

[Surgical treatment of intradural extramedullary lesions by hemilaminectomy]

OBJECTIVE

To evaluate the usefulness of hemilaminectomy as a surgical approach in patients with intradural-extramedullary tumors.

METHODS

Retrospective analysis of patients in which hemilaminectomy was as surgical approach in intradural-extramedullary tumors between June 2006 and December 2015. Demographics, preoperative symptoms, imaging characteristics, intraoperative findings, histological lineage, and postsurgical complications were analyzed. The average follow-up was 48.9 months (6-120 months).

RESULTS

Fifty-three patients underwent hemilaminectomy. Tumor was located in the cervical level in 5 cases, in the dorsal level in 24, and in the lumbar region in 24 cases. Histological analysis revealed 28 neuromas, 11 meningiomas, 7 ependymomas, and 7 "multiple injuries." Total resection without postsurgical neurologic deficit was possible in 96% of the patients. There were no recurrences on follow-up.

CONCLUSION

Hemilaminectomy is an effective approach for the resection of lateralized cervicodorsal intradural-extramedullary tumors. It can also be used to treat midline lesions located in the lumbar level.

Surgical Resection of Intradural Extramedullary Spinal Tumors: Patient Reported Outcomes and Minimum Clinically Important Difference

STUDY DESIGN

Analysis of prospectively collected longitudinal web-based registry data.

OBJECTIVE

To determine relative validity, responsiveness, and minimum clinically important difference (MCID) thresholds in patients undergoing surgery for intradural extramedullary (IDEM) spinal tumors.

SUMMARY OF BACKGROUND DATA

Patient-reported outcomes (PROs) are vital in establishing the value of care in spinal pathology. There is limited availability of prospective, quality studies reporting PROs for IDEM spine tumors.

METHODS

. A total of 40 patients were analyzed. Baseline, postoperative 3-month, and 12-month PROs were recorded: Oswestry Disability Index or Neck disability Index (ODI/NDI), Quality of life EuroQol-5D (EQ-5D), Short Form-12 (SF-12), Numeric Rating Scale (NRS)-pain scores. Responders were defined as those who achieved a level of improvement one or two, after surgery, on health transition index (HTI) of SF-36. Receiver-operating characteristic curves were generated to assess the validity of PROs, and the difference between standardized response means (SRMs) in responders versus nonresponders was utilized to determine the relative responsiveness of each PRO measure. MCID thresholds were derived using previously reported minimal detectable change approach.

RESULTS

A significant improvement across all PROs at 3-months and 12-months follow up was noted. The derived MCID thresholds were 13.9 points: ODI/NDI, 0.14 quality adjusted life years: EQ-5D, 2.8 points: SF-12PCS and 10.7 points: SF-12MCS, 1.9 points: NRS-back/neck pain, and 1.8 points: NRS-leg/arm pain. SF-12PCS was most accurate discriminator of meaningful improvement (area under the curve, AUC-0.83) and most responsive (SRM-1.36) to postoperative improvement. EQ-5D, ODI/NDI, NRS-pain scores were all accurate discriminator (AUC-0.7-0.8) and responsive measures (0.97-0.67) of meaningful postoperative improvement. SF-12MCS was neither a valid discriminator (AUC-0.48) nor a responsive measure (SRM: -1.5) of outcome.

CONCLUSION

Surgical resection of IDEM spinal tumors provides significant and sustained improvement in quality of life, general health, disability, and pain at 12-month after surgery. The surgically resected IDEM-specific clinically meaningful thresholds are reported. All the PROs reported in this study can accurately discriminate responders and nonresponder based on SF-36 HTI index except for SF-12 MCS.

LEVEL OF EVIDENCE

3.

Improved patient quality of life following intradural extramedullary spinal tumor resection

OBJECTIVE Resection significantly improves the clinical symptoms and functional outcomes of patients with intradural extramedullary tumors. However, patient quality of life following resection has not been adequately investigated. The aim in this retrospective analysis of prospectively collected quality of life outcomes is to analyze the efficacy of resection of intradural extramedullary spinal tumors in terms of quality of life markers. METHODS A retrospective review of a single institutional neurosurgical administrative database was conducted to analyze clinical data. The Oswestry Disability Index (ODI), visual analog scale (VAS) for pain, and the EQ-5D-3 L descriptive system were used to analyze quality of life preoperatively, less than 1 month postoperatively, 1-3 months postoperatively, 3-12 months postoperatively, and more than 12 months postoperatively. RESULTS The ODI scores increased perioperatively at the < 1-month follow-up from 36 preoperatively to 47. Relative to preoperative values, the ODI score decreased significantly at 1-3, 3-12, and > 12 months to 23, 17, and 20, respectively. VAS scores significantly decreased from 6.1 to 3.5, 2.4, 2.0, and 2.9 at the < 1-month, 1- to 3-, 3- to 12-, and > 12-month follow-ups, respectively. EQ-5D mobility significantly worsened at the < 1-month follow-up but improved at the 3- to 12-and > 12-month follow-ups. EQ-5D self-care significantly worsened at the < 1-month follow-up but significantly improved by the 3- to 12-month follow-up. EQ-5D usual activities improved at the 1- to 3-, 3- to 12-, and > 12-month follow-ups. EQ-5D pain and discomfort significantly improved at all follow-up points. EQ-5D anxiety and depression significantly improved at 1- to 3-month and 3- to 12-month follow-ups. CONCLUSIONS Resection of intradural extramedullary spine tumors appears to significantly improve patient quality of life by decreasing patient disability and pain and by improving each of the EQ-5D domains.

Minimally invasive removal of lumbar intradural extramedullary lesions using the interlaminar approach

OBJECT Posterior midline laminectomy or hemilaminectomy has been successfully applied as the standard microsurgical technique for the treatment of spinal intradural pathologies. However, the associated risks of postoperative spinal instability increase the need for subsequent fusion surgery to prevent potential long-term spinal deformity. Continuous efforts have been made to minimize injuries to the surrounding tissue resulting from surgical manipulations. The authors report here their experiences with a novel minimally invasive surgical approach, namely the interlaminar approach, for the treatment of lumbar intraspinal tumors. METHODS A retrospective review was conducted of patients at the Second Affiliated Hospital of Zhejiang University School of Medicine who underwent minimally invasive resection of lumbar intradural-extramedullary tumors. By using an operative microscope, in addition to an endoscope when necessary, the authors were able to treat all patients with a unilateral, paramedian, bone-sparing interlaminar technique. Data including preoperative neurological status, tumor location, size, pathological diagnosis, extension of resections, intraoperative blood loss, length of hospital stay, and clinical outcomes were obtained through clinical and radiological examinations. RESULTS Eighteen patients diagnosed with lumbar intradural-extramedullary tumors were treated from October 2013 to March 2015 by this interlaminar technique. A microscope was used in 15 cases, and the remaining 3 cases were treated using a microscope as well as an endoscope. There were 14 schwannomas, 2 ependymomas, 1 epidermoid cyst, and 1 enterogenous cyst. Postoperative radiological follow-up revealed complete removal of all the lesions and no signs of bone defects in the lamina. At clinical follow-up, 14 of the 18 patients had less pain, and patients' motor/sensory functions improved or remained normal in all cases except 1. CONClUSIONS When meeting certain selection criteria, intradural-extramedullary lumbar tumors, especially schwannomas, can be completely and safely resected through a less-invasive interlaminar approach using a microscope, or a microscope in addition to an endoscope when necessary. This approach was advantageous because it caused even less bone destruction, resulting in better postoperative spinal stability, no need for facetectomy and fusion, and quicker functional recovery for the patients. Individualized surgical planning according to preoperative radiological findings is key to a successful microsurgical resection of these lesions through the interlaminar space.

Occipito-cervical fusion following gross total resection for the treatment of spinal extramedullary tumors in craniocervical junction: a retrospective case series

Background

Previous studies found that the facet joint of the C1 vertebra were removed (C1 facetectomy) before extirpation from the extramedullary tumor in craniocervical junction, leading to postoperative upper cervical instability or deformity. Occipito-cervical fusion (OCF) is a demanding and morbid surgical procedure, which can be used in such patients. This study is to analyze the clinical manifestation and surgical outcome of patients with craniocervical extramedullary tumor undergoing an extirpation of spinal tumors and OCF by one-stage posterior approach.

Methods

The surgical and clinical databases were searched for operative procedures that had been performed for patients with spinal extramedullary tumors in craniocervical junction at a single institution from January 2008 to July 2011. The following inclusion criteria were applied: (1) initial surgery for craniocervical extramedullary tumor, (2) gross total resection and occipito-cervical fusion had been performed, (3) minimum 2-year follow-up, and (4) no previous cervical spine surgery. Medical records included demographic characteristics, clinical assessment, and radiographic studies. Clinical outcomes before and after the surgery were assessed using Frankel grade and the Japanese Orthopaedic Association (JOA) score. Cervical sagittal alignment was evaluated by C0-2 angle and C2-7 angle based on X-ray.

Results

Nine patients were included in the study. Five patients had schwannoma, three patients had meningioma, and only one patient had neurofibroma. All cases were followed up for 24–42 months (average, 34.2 months). At the last follow-up, three patients improved from Frankel grade C to grade D, two patients from Frankel grade C to grade E, and one patient from Frankel grade D to grade E, while two patients remained stationary at the Frankel grade D. The JOA score of the eight patients were 9.0 (range, 6–17) before surgery and were 14.6 (range, 12–17) at the most recent follow-up (p < 0.05). The mean C0-2 angle and the mean C2-7 angle before surgery were 26.2 ± 5.3° and 17.4 ± 13.1°, respectively. At the end of follow-up, the mean C0-2 angle was 25.6 ± 4.8°, and the mean C2-7 angle decreased to 12.7 ± 10.9°. However, this trend did not reach statistical significance (p < 0.05). Two patients suffered from cerebrospinal fluid leaks postoperatively. All patients had a satisfactory fusion and did not exhibit a tumor recurrence during the follow-up period.

Conclusions

OCF following gross total resection appears to be a useful surgical procedure for the craniocervical extramedullary tumors requiring C1 facetectomy and does not cause postoperative kyphosis of the upper cervical spine.

Comparison of open and minimally invasive surgery for intradural-extramedullary spine tumors

OBJECT

Patients with symptomatic intradural-extramedullary (ID-EM) tumors may be successfully treated with resection of the lesion and decompression of associated neural structures. Studies of patients undergoing open resection of these tumors have reported high rates of gross-total resection (GTR) with minimal long-term neurological deficit. Case reports and small case series have suggested that these patients may be successfully treated with minimally invasive surgery (MIS). These studies have been limited by small patient populations. Moreover, there are no studies directly comparing perioperative outcomes between patients treated with open resection and MIS. The objective of this study was to compare perioperative outcomes in patients with ID-EM tumors treated using open resection or MIS.

METHODS

A retrospective review was performed using data collected from 45 consecutive patients treated by open resection or MIS for ID-EM spine tumors. These patients were treated over a 9-year period between April 2003 and October 2012 at Northwestern University and the University of Chicago. Statistical analysis was performed to compare perioperative outcomes between the two groups.

RESULTS

Of the 45 patients in the study, 27 were treated with the MIS approach and 18 were treated with the open approach. Operative time was similar between the two groups: 256.3 minutes in the MIS group versus 241.1 minutes in the open group (p = 0.55). Estimated blood loss was significantly lower in the MIS group (133.7 ml) compared with the open group (558.8 ml) (p < 0.01). A GTR was achieved in 94.4% of the open cases and 92.6% of the MIS cases (p = 0.81).

The mean hospital stay was significantly shorter in the MIS group (3.9 days) compared with the open group (6.1 days) (p < 0.01). There was no significant difference between the complication rates (p = 0.32) and reoperation rates (p = 0.33) between the two groups. Multivariate analysis demonstrated an increased rate of complications in cervical spine tumors (OR 15, p = 0.05).

CONCLUSIONS

Thoracolumbar ID-EM tumors may be safely and effectively treated with either the open approach or an MIS approach, with an equivalent rate of GTR, perioperative complication rate, and operative time. Patients treated with an MIS approach may benefit from a decrease in operative blood loss and shorter hospital stays.

Hemilaminectomy approach for intradural extramedullary spinal tumors: an analysis of 164 patients

OBJECT

The authors report their experience with the use of a minimally invasive hemilaminectomy approach for the excision of intradural extramedullary (IDEM) tumors of the spinal cord.

METHODS

Included were 164 consecutive patients (167 tumors in total), treated between January 2004 and December 2014, in whom the hemilaminectomy approach for IDEM spinal cord tumors was planned. The clinicoradiological data of patients presenting to Christian Medical College were analyzed retrospectively using a computerized chart-review method. Preoperative MRI localization was used in 51 cases.

RESULTS

The mean age (± SD) of the patients was 42.6 ± 16.6 years, and the mean duration of symptoms was 20.8 ± 27.8 months. The average tumor size was 2.4 ± 1.7 cm. Forty-four tumors were cervical, 5 were cervicothoracic, 72 were thoracic, 7 were thoracolumbar, and 39 were lumbar. Forty-two tumors were ventrally located, whereas 11 were ventrolateral; the rest were either dorsal or dorsolateral. The most common pathologies were schwannoma (110 cases) and meningioma (31 cases). Total excision was achieved for 93% of the tumors. The average duration of surgery was 1.6 ± 0.6 hours.

CONCLUSIONS

The hemilaminectomy approach to the removal of intradural tumors was quick and safe and resulted in minimal morbidity and no mortality. Preoperative MRI localization improved accuracy and reduced operating time by eliminating the need for intraoperative fluoroscopy.

Surgery of Intradural Extramedullary Tumors

BACKGROUND:

Intradural extramedullary tumors (IDEMTs) are uncommon lesions that cause pain and neurological deficits.

OBJECTIVE:

To evaluate the effects of surgery for IDEMTs.

METHODS:

This cohort study recruited all patients operated on for IDEMTs at the Department of Neurology and Psychiatry of Sapienza University of Rome from January 2003 to January 2013. The analysis was conducted on clinical records evaluation over a 1-year follow-up. The Graphic Rating Scale was used to assess pain. Neurological deficits were detected through neurological examination. Quality of life was evaluated with the EuroQol (EQ-5D). Statistical interpretation of the data was performed with SPSS version 19 software.

RESULTS:

One hundred seven patients were recruited. Three were lost to follow-up. Patients reported lower level of pain 1 year after surgery (before surgery, 6.05; after surgery, 3.65). Mean comparison showed a significant decrease of −2.400 (P &lt; .001). Ninety-two patients (88.5%) were neurologically asymptomatic 1 year after surgery. Only 12 patients (11.5%) presented with a deficit, with a global decrease of 39% (χ2 = 27.6; P &lt; .005). The quality of life in patients was middle to high (mean rating of EQ-5D visual analog score, 61.78%). The lowest levels of quality of life were found in patients with sphincter dysfunctions (mean, 33.4).

CONCLUSION:

Surgery for IDEMTs has a good outcome. Patients reported lower levels of pain and a drastic reduction in neurological symptoms 1 year after surgery. The quality of life is middle to high. It is influenced mainly by the neurological outcome.