Incidence of spinal deformity after resection of intramedullary spinal cord tumors in children who underwent laminectomy compared with laminoplasty

Risk factors analysis for spinal deformity following resection of intradural spinal cord tumors from posterior approach: systematic review and meta-analysis

PURPOSE

The presented study aimed to identify risk factors for spinal deformity (SD) following resection of intradural spinal cord tumors via posterior approach.

METHODS

Articles of interest were found in accordance with PRISMA guidelines utilizing the following databases: PubMed, Web of Science, and Scopus. Keywords such as "laminoplasty","laminotomy","laminectomy","tumor","resection","spinal deformity","kyphosis","intradural","intramedullary","extramedullary" were applied. Odds ratios (OR) were estimated for dichotomous variables.

RESULTS

From eleven retrospective studies comprising 715 patients, with mean age 17.1 years, 183 developed postoperative SD. Younger age (25 years or below; OR 4.03; p < 0.0001;13 years and below; OR 3.72; p = 0.003) was associated with an elevated risk of SD development. Patients in the age group of > 5 and ≤ 21 years old showed increased risk in the non-fusion subgroup only (OR 9.36; p = 0.02). Preoperative SD was a strong predictor of postoperative SD (OR 12.19; p = 0.0007), particularly accentuated in the non-fusion subgroup (OR 22.14; p < 0.00001). In the non-fusion subgroup, intramedullary tumor location emerged as a significant risk factor for SD (OR 3.67; p = 0.04). Involvement of the thoracolumbar junction increased the risk of postoperative SD (OR 3.11; p = 0.04). In the fusion subgroup, surgery encompassing at least 3 spinal levels elevated the risk of SD (OR 9.18; p = 0.02).

CONCLUSION

Risk factors for postoperative spinal deformity include younger age, preoperative SD, thoracolumbar junction involvement, extensive decompression, and intramedullary tumor location. These findings provide insights for clinicians in strategizing optimal surgical strategies for patients with high risk of SD development. PROSPERO registration no.: CRD42024517309 ( https://www.crd.york.ac.uk/PROSPERO/ ).

Astrocytomas of the spinal cord

Tumors of astrocytic origin represent one of the most frequent entities among the overall rare group of spinal cord gliomas. Initial clinical symptoms are often unspecific, and sensorimotor signs localizing to the spinal cord occur with progressing tumor growth. On MRI, a hyperintense intrinsic spinal cord signal on T2-weighted sequences with varying degrees of contrast enhancement raises suspicion for an infiltrative neoplasm. Blood and CSF analysis serves to exclude an infectious process, nutritional deficits, or metabolic disorders. When such other differential diagnoses have been ruled out, a neuropathological tissue-based analysis is warranted to confirm the diagnosis of a spinal cord astrocytoma and guide further patient management. As such, maximal safe resection forms the basis of any treatment. Meticulous preoperative planning is necessary to weigh the potential improvement in survival against the risk of functional deterioration. Intraoperative neuromonitoring and ultrasound may aid in achieving a more extensive resection. Depending on the assigned WHO tumor grade spanning from grade 1 to grade 4, the use of radiotherapy and chemotherapy might be indicated but also wait-and-scan approaches appear reasonable in tumors of lower grade. Close imaging follow-up is necessary given that recurrence inevitably occurs in astrocytomas of grades 2-4. Prognosis is so far dictated by tumor grade and histopathological findings, but also by age and clinical performance of the patient. Targeted therapies resting upon an in-depth tissue analysis are emerging in recurrent tumors, but no prospective study is available so far given the rarity of spinal cord astrocytomas.

Intramedullary pediatric low-grade glioma of the spine

PURPOSE

Pediatric intramedullary spinal cord low-grade gliomas (pLGGs) are rare diagnoses among central nervous system (CNS) tumors in the pediatric population. The classic presentation of the patients includes some degree of neurologic deficit, although many times the symptoms are vague which leads to delayed diagnosis.

MATERIAL AND METHODS

The first step in the diagnosis includes special parameters in spinal imaging, particularly magnetic resonance imaging (MRI), and surgical resection remains the cornerstone for both diagnosis and treatment. Yet, recent years advancement in molecular and genetic understanding of CNS tumors allows for better adjustment of the treatment and follow-up regimens. Based on postoperative status, adjuvant therapy may provide additional therapeutic advantage for some types of tumors.

CONCLUSION

Ultimately, patients have a very promising prognosis when treated appropriately in most of the cases of pediatric spinal cord LGG with continued advances arising. This manuscript summarizes the most contemporary evidence regarding clinical and treatment features of intramedullary pLGGs.

Does Minimally Invasive Hemilaminectomy for Intradural Extramedullary Tumor Resection Prevent Postlaminectomy Kyphosis or Lordosis Loss?

BACKGROUND

Minimally invasive hemilaminectomy is a safe and effective alternative to open laminectomy for treating intradural extramedullary tumors. There are no reports of postoperative kyphosis after this approach. This study aims to determine whether performing minimally invasive spine surgery hemilaminectomy for intradural extramedullary tumors can prevent the development of postlaminectomy kyphosis (PLK) or lordosis loss.

MATERIAL AND METHODS

Sixty-five patients with spinal intradural extramedullary tumors who underwent minimally invasive hemilaminectomy surgery and complete pre and postoperative radiologic imaging were included. The effect of the surgical approach on the spinal sagittal axis was assessed by comparing pre- versus postoperative segmental and local Cobb angles at different spinal levels, considering anatomical localization (cervical, thoracic, lumbar, and transition segments) and functional features (mobile, semi-rigid, and transition segments), as well as the extent of the surgical approach (1, 2, or 3 levels) and follow-up.

RESULTS

None of the patients had an increase in thoracic kyphosis nor a loss of cervical or lumbar lordosis greater than or equal to 10° after undergoing the minimally invasive spine surgery hemilaminectomy approach. More than 5° of increase in kyphosis was detected on 7.4% and 11.1%, for the segmental and the local angles, respectively; meanwhile, for patients with loss of lordosis, this deviation was detected in 5.3%, for both angles. The occurrence of PLK was more common than that of lordosis loss, but mainly manifested in postoperative angle impairment of less than 5°. No significant differences were evidenced, considering the approach length.

CONCLUSIONS

Hemilaminectomy represents a promising approach for preventing PLK and postlaminectomy lordosis loss following intradural extramedullary tumor resection.

Non-Hodgkin lymphoma presenting with spinal cord compression: A population-based analysis of the NHL-BFM study group

BACKGROUND

Spinal cord compression is a rare presentation of non-Hodgkin lymphoma (NHL) in children. We aimed to describe the prevalence, histological subtypes, clinical presentation, therapy, and outcome of those children in a population-based cohort. The chemotherapy regimen remained comparable over time.

METHODS

We retrospectively identified all children and adolescents with paresis as initial manifestations of the NHL between January 1990 and December 2020 from the NHL-BFM database. Characteristics, therapy, and outcome data were gathered from the database and patient files.

RESULTS

Fifty-seven of 4779 children (1.2%) presented with initial paresis due to spinal cord compression. The median age was 10.3 years (range, 3.1-18.0 years), and 33% were female. Initial symptoms were paresis/weakness (n = 50, 88%), back pain (n = 33, 58%), paresthesia (n = 23, 40%), and bladder dysfunction and/or constipation (n = 22, 39%), persisting for a median of 14 days before diagnosis. Subtype distribution was mature B-NHL (n = 41, 72%), precursor B-lymphoblastic lymphoma (LBL) (n = 12, 21%), anaplastic large cell lymphoma (ALCL) (n = 3, 5%), and T-LBL (n = 1, 2%). Initial emergency therapy included surgery (70%) and/or chemotherapy/steroids (63%). Five-year event-free survival and overall survival (80% ± 5% and 82% ± 5%, respectively) were comparable with all other NHL patients. Neurological symptoms persisted in approximately one-third of surviving patients at the last follow-up.

CONCLUSION

1.2% of pediatric NHL patients presented with paresis from spinal cord compression mainly due to B-cell lymphomas. Neurological sequelae were observed in one-third of surviving patients.

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.

Revisiting Post-Laminectomy Kyphosis and Challenges in Its Management: A Case Report

The posterior ligamentous complex plays a pivotal role in spinal stability during complex movements, especially at the cervical vertebral level. Its disruption leads to the development of post-laminectomy kyphosis. The present case emphasizes the challenges in managing post-laminectomy kyphosis, restoring spinal alignment, and the importance of the posterior tension band as a spine stabilizer. A 19-year-old male underwent C2-C5 laminectomy for cervical C3 neurofibroma at an outside hospital. The patient remained stable for five months and then developed cervical kyphosis, leading to myelopathy. Clinical examination revealed significant neurological deficits, including spasticity, clonus, loss of hand dexterity, and sensory abnormalities. Imaging revealed C3 retrolisthesis with severe cervical kyphosis, cord compression, and myelomalacia. The management involved cervical traction with gradual increments in the weight and correction of the cervical sagittal balance. Principles of kyphotic deformity correction were applied, and C2 pedicle with C3-C5 lateral mass fixation was performed. The patient's modified Japanese Orthopaedic Association score improved from 10 to 16 at six months' follow-up. Post-laminectomy, the disruption of the posterior ligamentous complex increases the range of motion, particularly in the cervical spine, leading to instability and kyphosis. Surgical interventions such as laminoplasty, laminotomy, and laminectomy with posterior cervical fusion aim to mitigate the risk of kyphosis, with techniques such as bone-to-bone ligament-preserving laminoplasty and ultrasonic bone scalpel showing promise in further reducing the risk of kyphosis. The key determinant for the prevention of kyphosis is the integrity of the posterior ligamentous complex. The management of cervical kyphosis includes appropriate pre-operative planning, which includes the evaluation of cervical and spinopelvic parameters. For a posterior spinal approach, one may choose to consider laminotomy, laminoplasty, or laminectomy along with posterior cervical fusion.

The evolution of spinal cord surgery: history, people, instruments, and results

INTRODUCTION

Spinal cord surgery has and always will be a challenging operation with satisfying results, but also with potentially devastating results. Over the last century, there has been an evolution in the way we perceive and conduct spinal cord surgery. The phenomenal evolution in technology from the very first x-ray pictures helps to localize the spinal pathology through the use of high-resolution MRI and ultrasonography that allows for high precision surgery with relatively minimal exposure.

METHODS

The advancements in the surgical technique and the utilization of neuromonitoring allow for maximal safe resection of these delicate and intricate tumors. We also are beginning to understand the biology of spinal cord tumors and vascular lesions, as in the recent 2021 WHO classification which identifies specific entities such as spinal ependymomas, MYCN-amplified, as separate entity from the other subtypes of ependymomas. Surgeons have also accepted the importance of maximal safe resection for most of the spinal cord pathologies rather than just performing biopsy and adjuvant treatment.

CONCLUSION

There have been significant advances since the first resection of an intramedullary tumor including diagnosis, imaging, and surgical technique for children. These advances have improved the prognosis and outcome in these children.

Spinous Process-Splitting Laminectomy Approach for Tumor Excision at Conus Medullaris or Cauda Equina Level Results in Satisfactory Clinical Outcomes Without Affecting Global Spinal Sagittal Alignment

STUDY DESIGN

Retrospective comparative study.

OBJECTIVES

The present study investigated radiographical changes in global spinal sagittal alignment (GSSA) and clinical outcomes following tumor resection using spinous process-splitting laminectomy (SPSL) approach without fixation in patients with conus medullaris (CM) or cauda equina (CE) tumor.

METHODS

Forty-one patients with CM or CE tumor (19 males, 22 females, mean age at surgery of 52.9 ± 13.0 years) were included in this study. The variations of outcome variables were analyzed in various GSSA profiles using radiographic outcomes. The clinical outcomes were assessed using Japan Orthopaedic Association (JOA) score and JOA back pain evaluation questionnaire (JOABPEQ).

RESULTS

In all cases, the various GSSA parameters (sagittal vertical axis, C2-7 lordosis, T1 slope, thoracic kyphosis, T10-L2 kyphosis, lumbar lordosis [LL; upper, middle, and lower], sacral slope, pelvic incidence, and pelvic tilt) did not significantly change in the 2-years postoperative period. Moreover, age at surgery, the number of resected laminae, preoperative T12-L2 kyphosis, or LL did not affect the postoperative changes in T12-L2 kyphosis or LL, and had no statistically significant correlation among them. The scores of each postoperative JOA domain and the Visual Analogue Scale included in the JOABPEQ were significantly improved. There was no statistical significant group difference in each sagittal profile or clinical outcomes between CM and CE groups postoperatively.

CONCLUSIONS

Tumor resection using SPSL approach did not affected the various GSSA parameters examined and resulted in satisfactory clinical outcomes, indicating that SPSL approach is a suitable surgical technique for patients with CM or CE tumor.

Knowledge Review of Spinal Deformity and the Need for Fusion and Fixation following Treatment for Spinal Tumors among the Pediatric Age Group

BACKGROUND

Spinal tumors are rare pathology in the pediatric population. The tumors can be classified as extradural, intradural extramedullary, or intramedullary. Any of the spinal tumors can eventually lead to spinal deformity. The progressive spinal deformity can be part of the initial presentation or evolve on long follow-up, even years after the initial intervention and treatment.

SUMMARY

Management of spinal deformity associated with spinal tumors in children is not well defined. Patients with progressive symptoms and even neurological deficits need correction for their deformity when diagnosed. Patients that do not have pain or related neurological deficits should be evaluated for the severity of their deformity and followed long-term. Special consideration is needed for young patients who need multilevel surgery or have deformity at presentation.

KEY MESSAGES

When considering the need for instrumentation and fusion, the surgeon should consider the age of the patient, expected future growth of the spine, neurologic status, extent of initial deformity, and the number of vertebral levels involved by tumor. Providers should also consider how surgery may fix or prevent deformity, especially when instrumentation can affect imaging at follow-up.

Long-term Follow-up Results of Reconstructive Laminoplasty With L-shaped Leibinger Mini-plate for Posterior Approach in the Treatment of Intraspinal Tumor Surgery

OBJECTIVE

Laminoplasty using mini-plates is one of the most common surgical techniques in surgery for intraspinal pathologies. However, limited are present in the literature. The aim of this study was to determine its long-term clinical and radiologic outcome, specifically using an L-shaped mini-plate.

METHODS

Patients who underwent surgery for spinal intradural pathology from January 2008 to December 2019 were retrospectively reviewed. Those who received laminoplasty using the Leibinger mini-plate and were followed for more than 2 years were included. Patient demographics and clinical and radiographic data were reviewed and analyzed. A total of 117 patients (male:female = 47:70; mean age 50.9 years, range 16-92 years) were included, and mean follow-up period was 50.3 months (range 24-151 months).

RESULTS

The most common pathology was schwannoma (n = 66, 56.4%) followed by meningioma (n = 30, 25.6%). Gross total resection was achieved in 82.9% (n = 97). Clinical outcomes at last follow-up were mostly good and excellent (n = 95, 81.2%). Computed tomography at the postoperative 1-year follow-up were available in 32 patients (27.4%) and the overall fusion rate was 89.3% (50 of 56 laminae). The fusion rate was significantly lower in the cervical spine compared to other locations (50% vs. thoracic [100%], lumbar [85.7%], P < 0.002). No displacement of laminae or postoperative spinal deformity were observed throughout the follow-up.

CONCLUSIONS

Laminoplasty using L-shape Leibinger mini-plates had an 89.3% fusion rate, and no displacement of the re-attached laminae was observed. We think it is a safe and feasible option in surgeries for intraspinal pathologies.

Transverse Split Laminoplasty: A Novel Anatomy Preserving Technique

Laminoplasty is a technique often used in spine surgery as a way of restoring a patient's normal anatomy and posterior tension band (PTB). In pediatric patients, this is an important consideration given their intrinsic relative ligamentous laxity and significant potential for future growth. Conventional laminoplasty re-approximates the bone removed at each vertebral segment, relying on the lamina to heal through osteogenesis and the soft tissue of the PTB to heal from a sharp division. Ligamentous healing of the PTB constitutes the formation of a scar that is biologically and biomechanically inferior to the tissue it has replaced. Herein, the authors present two pediatric cases in which the novel technique of transverse split laminoplasty was used to approach intradural pathology and subsequently reconstruct the spine, while maximizing preservation of the PTB, with excellent post-surgical outcomes.

REVISION RECONSTRUCTION OF THE CERVICAL SPINE IN A PATIENT WITH EARLY DEEP SSI COMPLICATED BY ANGULAR KYPHOSIS: clinical case and literature review

Background. Deep surgical site infection (DSSI) is one of the most severe complications in spinal surgery. The timing and nature of DSSI are the determining criteria in the choice of treatment tactics. Aim. To present a unique clinical case of early deep SSI after ACDF in a patient with multisegmental degenerative spinal canal stenosis, complicated by epidural abscess and angular kyphotic deformity. Angular kyphosis correction, corpectomy of C4-6 and three-column cervical reconstruction were performed in one surgical session. Case presentation. A 57-year-old patient was admitted to the clinic after staged surgical interventions on the cervical spine for multilevel degenerative stenosis of the spinal canal. The primary surgical interventions were complicated by DSSI in the early period after the second surgery with formation of angular kyphosis of the cervical spine. The patient underwent revision one-stage reconstructive intervention to correct the deformity, decompress the spinal canal, and three-column reconstruction of C3-7 segments. Long-term follow-up showed persistent reduction of pain syndrome, improved quality of life and absence of recurrence of DSSI. Conclusion. The presented case illustrates the possibilities of one-stage revision three-column cervical spine reconstruction for correction of sagittal profile, decompression of intracanal neural structures and ensuring stability of operated segments. Use of DSSI treatment algorithms based on Prinz V. and Vajkoczy P. classification contributes to the selection of the optimal tactics of patient management.

Technical note-in situ laminotomy: preserving posterior tension band in surgery of pediatric multilevel spinal tumor

BACKGROUND

Laminotomy has been introduced in surgical practice to reduce complications of laminectomy after surgery of tumors in the spinal canal. However, the posterior ligament complex, which is routinely interrupted to remove the laminoplasty segment and gain access to the spinal canal, has a tendency not to heal and can lead to progressive kyphosis and collapse.

CASE PRESENTATION

A 5-month-old boy affected by a thoracolumbar extradural tumor extending along seven spinal levels was operated on. The tumor was exposed and completely resected by a one-piece laminotomy with preservation of the integrity of the posterior tension band at both extremities. After 1-year radiological examination ruled out spinal deformity.

CONCLUSION

The technique herein presented, which we named in situ laminotomy, allows to fully preserve the posterior tension band without reducing the exposure of the spinal canal in multilevel tumors. Additionally, the technique makes also the reconstruction of the spine elements very easy and rapid. However, longer follow-up is necessary to prove the effectiveness of this procedure in preventing long-term deformity and instability.

Clinical and Biomechanical Study of Laminoplasty for Thoracic and Lumbar Intradural Tumors

(1) Background: Primary intraspinal tumors account for 2-15% of all central nervous system (CNS) tumors. Most intraspinal tumors are benign, and about 40% of them occur intradurally, for which early surgery is the preferred treatment. Laminectomy with pedicle screw fixation is the conventional surgical treatment. However, laminectomy with pedicle screw fixation is likely to reduce the spinal range of motion (ROM), with many other complications, although it can maintain the stability of the spine. The aim of this study is to determine whether laminoplasty as a new surgical approach for thoracic and lumbar intradural tumors is superior to laminectomy in preserving spinal ROM, maintaining spinal stability and reducing postoperative complications. (2) Methods: We retrospectively analyzed 50 patients who received intradural tumor resection, including 23 who received traditional laminectomy with pedicle screw fixation and 27 who received new laminoplasty. Spinal ROM was evaluated by lumbar flexion/extension radiograph and biomechanical evaluation. Spinal stability was evaluated by imaging observations of the spinal Cobb angle and laminar bone fusion. Postoperative complications were evaluated according to cerebrospinal fluid (CSF) leakage and the length of hospital stay. (3) Results: Compared with the laminectomy group, patients in the laminoplasty group exhibited a better spinal ROM (31.6 ± 12.0° vs. 21.7 ± 11.8°, p = 0.013), a smaller Cobb angle (9.6 ± 4.3 vs. 12.5 ± 5.3, p = 0.034), a lower incidence of CSF leakage (4/14.8% vs. 11/47.8%, p = 0.015), and a shorter length of hospital stay (13.1 ± 1.8 vs. 15.1 ± 2.3 days, p = 0.001). Most patients in the laminoplasty group had satisfactory bone fusion. The biomechanical experiment also demonstrated that spinal ROM in laminoplasty was larger than that in the laminectomy group. (4) Conclusions: Compared with the traditional surgery, the new laminoplasty surgery can better maintain the stability of the spine, preserve spinal ROM, and reduce postoperative complications. It is a surgical method that can be clinically popularized.

Benign Spinal Tumors

Benign spinal intradural tumors are relatively rare and include intramedullary tumors with a favorable histology such as low-grade astrocytomas and ependymomas, as well as intradural extramedullary tumors such as meningiomas and schwannomas. The effect on the neural tissue is usually a combination of mass effect and neuronal involvement in cases of infiltrative tumors. The new understanding of molecular profiling of different tumors allowed us to better define central nervous system tumors and tailor treatment accordingly. The mainstay of management of many intradural spinal tumors is maximal safe surgical resection. This goal is more achievable with intradural extramedullary tumors; yet, with a meticulous surgical approach, many of the intramedullary tumors are amenable for safe gross-total or near-total resection. The nature of these tumors is benign; hence, a different way to measure outcome success is pursued and usually depends on functional rather than oncological or survival outcomes.

Spinal canal stenosis in children with achondroplasia: the role of augmentation laminoplasty-a 15-year single institution experience

PURPOSE

Achondroplasia typically results in compressive spinal canal stenosis in one-third of children, but rare under the age of 15 years. Laminectomy is the mainstay of treatment but this leads to instability and progressive deformity requiring complex fixation. In order to reduce that risk, we developed a novel modified augmented laminoplasty that increases spinal canal diameter while preserving the posterior column stability.

METHODS

All laminoplasty cases for spinal compressive achondroplasia from 2006 to 2020 were included. Ten augmentation laminoplasty procedures were performed in 7 children with regular clinical and radiological post-operative follow-up. Kyphotic deformity and clinical outcomes (neurological and urological) were evaluated.

RESULTS

At presentation, clinical features included radiculopathy, neurogenic claudication or acute cauda equina compression with sphincter dysfunction. The average age at initial surgery was 11.2 (range 5-16) with a mean follow-up of 5 (range 2-8) years. All patients demonstrated improvement in neurogenic claudication symptoms after surgery; however, bladder dysfunction persisted in some children. In one child, cervical and lumbar augmentation laminoplasties were performed for concomitant disease. Augmentation laminoplasty effectively prevented deformity progression over time in all cases except one where a further revision laminoplasty with extension was required for screw loosening. Despite this, progressive symptomatic kyphotic deformity led to a 360° fixation. Minor complications included one dural breach (repaired intraoperatively) and one superficial wound infection.

CONCLUSION

Augmentation laminoplasty is a viable surgical option following laminectomy in achondroplasia patients as an alternative to surgical fixation. Fixation can be reserved for cases where there is progressive deformity and kyphosis.

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.

Current management in the treatment of intramedullary ependymomas in children

PURPOSE

Current management of pediatric intramedullary ependymoma is extrapolated from adult series since large studies in children are unavailable. This has led us to share our experience with this rare tumor and compare it to the literature and to review and highlight important aspects of current management and point out inconsistencies.

METHODS

This is a retrospective analysis of patients with intramedullary ependymoma managed at our institution between 2004 and 2021.

RESULTS

During the study period, 5 patients were treated for intramedullary ependymoma. Cases of myxopapillary ependymoma were excluded. The mean age of our cohort was 11.2 years. We identified 4 cases of grade II ependymoma and 1 case of grade III ependymoma. Gross tumor removal (GTR) was achieved in two patients (40%) of patients. One patient was treated with radiotherapy for recurrence and two patients received chemotherapy. There were no cases of recurrence among patients treated with GTR, but in all patients treated with STR. Eighty percent of patients either improved or stayed stable neurologically. During follow-up (mean 73 months), 2 patients died of disease.

CONCLUSION

GTR and tumor grade remain the key prognostic factor of long-term tumor-free survival. Many questions prevail regarding outcomes, correct use of adjuvant therapy, and prognostic factors.

Cervical Lift-up Basket Laminoplasty after Resection of Spinal Intramedullary Tumors: A Finite Element Analysis and Clinical Image Evaluation

Although reconstructive laminoplasty is commonly performed after resection of spinal intramedullary tumors of the cervical spine, its biomechanical rigidity of laminoplasty framework remains unclear. The objective of this study was to examine the structural reliability of our unique method of cervical lift-up basket laminoplasty by using computed tomography (CT)-based finite element analysis (FEA) and clinical radiological evaluation. A finite element model of cervical laminoplasty was created based on CT images using FEA software. Cervical lift-up basket laminoplasty (Basket) was compared with the standard style of open-door basket laminoplasty (Open-door). Clinical subjects for radiological evaluation comprised 33 patients who underwent cervical lift-up basket laminoplasty after resection of spinal intramedullary tumors. An FEA-equivalent stress histogram showed that stress was moderately dispersed around the basket. Virtual displacement of the spinous process of the Basket model was equivalent to that of the Open-door model in any direction of posterior-to-anterior, right-to-left, or top-to-bottom force. In the clinical analysis, radiological data with a minimum postoperative period of 6 months were obtained in a total of 28 out of 33 patients. No patients underwent revision surgery because of implant-related complications. No significant differences in C2-C7 angle or cervical tilt angle were observed between pre- and postoperatively. The structural rigidity of cervical lift-up basket laminoplasty was equivalent to the open-door style on the FEA. Clinical radiological evaluation suggested that there were no serious adverse events associated with cervical laminoplasty, although the longer postoperative follow-up is mandatory.

Surgical approaches to intramedullary spinal cord astrocytomas in the age of genomics

Intramedullary astrocytomas represent approximately 30%–40% of all intramedullary tumors and are the most common intramedullary tumor in children. Surgical resection is considered the mainstay of treatment in symptomatic patients with neurological deficits. Gross total resection (GTR) can be difficult to achieve as astrocytomas frequently present as diffuse lesions that infiltrate the cord. Therefore, GTR carries a substantial risk of new post-operative deficits. Consequently, subtotal resection and biopsy are often the only surgical options attempted. A midline or paramedian sulcal myelotomy is frequently used for surgical resection, although a dorsal root entry zone myelotomy can be used for lateral tumors. Intra-operative neuromonitoring using D-wave integrity, somatosensory, and motor evoked potentials is critical to facilitating a safe resection. Adjuvant radiation and chemotherapy, such as temozolomide, are often administered for high-grade recurrent or progressive lesions; however, consensus is lacking on their efficacy. Biopsied tumors can be analyzed for molecular markers that inform clinicians about the tumor’s prognosis and response to conventional as well as targeted therapeutic treatments. Stratification of intramedullary tumors is increasingly based on molecular features and mutational status. The landscape of genetic and epigenetic mutations in intramedullary astrocytomas is not equivalent to their intracranial counterparts, with important difference in frequency and type of mutations. Therefore, dedicated attention is needed to cohorts of patients with intramedullary tumors. Targeted therapeutic agents can be designed and administered to patients based on their mutational status, which may be used in coordination with traditional surgical resection to improve overall survival and functional status.

Perioperative outcomes and survival after surgery for intramedullary spinal cord tumors: a single-institution series of 302 patients

OBJECTIVE

Intramedullary spinal cord tumors (IMSCTs) are rare neoplasms whose treatment is often technically challenging. Given the low volume seen at most centers, perioperative outcomes have been reported infrequently. Here, the authors present the largest single-institution series of IMSCTs, focusing on the clinical presentation, histological makeup, perioperative outcomes, and long-term survival of surgically treated patients.

METHODS

A cohort of patients operated on for primary IMSCTs at a comprehensive cancer center between June 2002 and May 2020 was retrospectively identified. Data on patient demographics, tumor histology, neuraxial location, baseline neurological status, functional deficits, and operative characteristics were collected. Perioperative outcomes of interest included length of stay, postoperative complications, readmission, reoperation, and discharge disposition. Data were compared across tumor histologies using the Kruskal-Wallis H test, chi-square test, and Fisher exact test. Pairwise comparisons were conducted using Tukey's honest significant difference test, chi-square test, and Fisher exact test. Long-term survival was assessed across tumor categories and histological subtype using the log-rank test.

RESULTS

Three hundred two patients were included in the study (mean age 34.9 ± 19 years, 77% white, 57% male). The most common tumors were ependymomas (47%), astrocytomas (31%), and hemangioblastomas (11%). Ependymomas and hemangioblastomas disproportionately localized to the cervical cord (54% and 59%, respectively), whereas astrocytomas were distributed almost equally between the cervical cord (36%) and thoracic cord (38%). Clinical presentation, extent of functional dependence, and postoperative 30-day outcomes were largely independent of underlying tumor pathology, although tumors of the thoracic cord had worse American Spinal Injury Association (ASIA) grades than cervical tumors. Rates of gross-total resection were lower for astrocytomas than for ependymomas (54% vs 84%, p < 0.01) and hemangioblastomas (54% vs 100%, p < 0.01). Additionally, 30-day readmission rates were significantly higher for astrocytomas than ependymomas (14% vs 6%, p = 0.02). Overall survival was significantly affected by the underlying pathology, with astrocytomas having poorer associated prognoses (40% at 15 years) than ependymomas (81%) and hemangioblastomas (66%; p < 0.01) and patients with high-grade ependymomas and astrocytomas having poorer long-term survival than those with low-grade lesions (p < 0.01).

CONCLUSIONS

The neuraxial location of IMSCTs, extent of resection, and postoperative survival differed significantly across tumor pathologies. However, perioperative outcomes did not vary significantly across tumor cohorts, suggesting that operative details, rather than pathology, may have a stronger influence on the short-term clinical course, whereas pathology appears to have a stronger impact on long-term survival.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Postoperative Cervicothoracic Kyphosis Following Infantile Intramedullary Tumor Resection Accelerates Neurological Deterioration

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

Surgical resection of intradural extramedullary tumors in the atlantoaxial spine via a posterior approach

BACKGROUND

The anatomical features of the atlantoaxial spine increase the difficulty of complete and safe removal of atlantoaxial intradural extramedullary (IDEM) tumors. Studies concerning surgical interventions via a posterior approach are limited.

AIM

To investigate the safety and efficacy of atlantoaxial IDEM tumor resection using a one-stage posterior approach.

METHODS

We retrospectively analyzed clinical databases for one-stage atlantoaxial IDEM tumor resection via a posterior approach between January 2008 and January 2018. The analyzed data included tumor position, histopathological type, pre- and post-operative Japanese Orthopedic Association (JOA) scores and Nurick grades, postoperative complication and recurrence status.

RESULTS

A total of 13 patients who underwent C1-C2 Laminectomy and/or unilateral facetectomy via the posterior approach were enrolled in the study. In all cases reviewed, total tumor resection and concomitant C1-C2 fusion were achieved. The average follow-up was 35.3 ± 6.9 mo (range, 26-49 mo). A statistically significant difference was noted between the preoperative JOA score (11.2 ± 1.1) and the score at the last final follow-up (15.6 ± 1.0) (P < 0.05). A statistically significant difference was noted between the preoperative Nurick grade (2.3 ± 0.9) and that at the last follow-up (1.2 ± 0.4) (P < 0.05). However, no statistically significant difference was noted between the preoperative and last follow-up C1-2 Cobb angle and C2-7 Cobb angle (P > 0.05). No mortalities, severe complications or tumor recurrence were observed during the follow-up period.

CONCLUSION

Total resection of atlantoaxial IDEM tumors is feasible and effective via a posterior approach. Surgical reconstruction should be considered to avoid iatrogenic kyphosis and improve spinal stability and overall clinical outcomes.

Spinal hemangioblastomas: analysis of surgical outcome and prognostic factors

The prognostic factors for surgically removed spinal hemangioblastomas, the impact of VHL disease on outcome, and the role of intraoperative neuromonitoring are still not completely clear. The aim of this study was to review our experience with spinal hemangioblastomas in order to assess potential predictors of neurological outcome after surgery. All cases of spinal hemangioblastomas removed at two Italian academic institutions from 1985 to 2020 were reviewed. Data about clinical presentation and symptom duration, diagnosis of VHL, surgical approach, use of IONM, duration of hospital stay, follow-up, and modified McCormick grade before and after surgery were extracted. Sixty-one patients (31 F, 30 M) underwent 69 surgeries to remove 74 spinal hemangioblastomas (37 cervical, 32 thoracic, 5 lumbar). Improvement was found in 32.3% of cases, neurological condition remained stable in 51.6% of cases, and deteriorated in 16.1% of patients. A worsening trend in VHL patients and an improvement trend in non-VHL patients were detected, despite the lack of statistical significance. Laminotomy and use of IONM were found to be associated with better outcome, although no association was found between surgery without IONM and worse outcome. In most cases, patients affected by spinal hemangioblastomas can expect a good long-term outcome. In our experience, laminotomy seems to be associated with better outcome compared to laminectomy. While its absence is not associated with worse outcome, IONM seems to be associated with a better neurological outcome. Our study suggests that the more impaired the preoperative neurological condition, the worse the outcome.

Clinical outcomes of laminoplasty for patients with lysosomal storage disease including mucopolysaccharidosis and mucolipidoses: a retrospective cohort study

Background

Although the clinical efficacy of laminoplasty in adult cervical spondylotic myelopathy or ossification of posterior longitudinal ligament has been frequently reported, there are only few reports of laminoplasty for patients with lysosome storage diseases (LSDs). Therefore, this study aimed to report the midterm clinical and radiological outcomes of patients with LSDs after cervical laminoplasty.

Methods

Six patients with LSD who underwent laminoplasty with/without C1 laminectomy for cervical myelopathy were enrolled. Clinical evaluations, including the cervical Japanese Orthopedic Association (cJOA) score and visual analog scale (VAS) scores for upper extremity numbness, and radiographic parameters, including C2–C7 lordotic angle, atlanto-dens interval (ADI), and ⊿ADI, were evaluated preoperatively, at 2 years postoperatively, and at the final follow-up.

Results

Five patients had mucopolysaccharidoses (type I: n = 1, II: n = 3, VII: n = 1) and one patient had mucolipidoses type III. The mean age of patients at surgery was 27.5 years, and the mean postoperative follow-up period was 61 months. All mucopolysaccharidoses cases required C1 posterior arch resection with C2–C7 laminoplasty. No critical complications were observed postoperatively. There were no significant differences in C2–C7 angle (p = 0.724) and ⊿ADI (p = 0.592) between the preoperative and final follow-ups. The cJOA score and VAS for numbness significantly improved at the final follow-up (p = 0.004 and p = 0.007, respectively).

Conclusions

The cervical myelopathy in patients with LSD could be safely and effectively treated with laminoplasty with/without C1 posterior arch resection after excluding patients with atlantoaxial instability. Atlantoaxial stability and symptom improvement could be maintained at an average of 5 years postoperatively.

Spinal cord compression as tumor onset: an unusual case report of Hodgkin lymphoma in a teenager

Background

Spinal cord compression (SCC) is an uncommon, severe complication of Hodgkin lymphoma (HL), occurring in 0.2% of cases at the onset and in 6% during disease progression. We present a teenager with SCC with clinical onset of HL; her pre-existing neurological abnormalities covered the presence of an epidural mass, which could have misled us.

Case presentation

A 13-year-old girl presented with a three-month history of lower back pain and degrading ability to walk. She suffered from a chronic gait disorder due to her preterm birth. A magnetic resonance imaging of the spine revealed an epidural mass causing collapse of twelfth thoracic vertebra and thus compression and displacement of the spinal cord. Histological examination with immunohistochemical analysis of the epidural mass demonstrated a classic-type Hodgkin lymphoma. Early pathology-specific treatment allowed to avoid urgent surgery, achieve survival and restore of neurological function.

Conclusions

Children and adolescents with back pain and neurological abnormalities should be prioritized to avoid diagnostic delay resulting in potential loss of neurological function. SCC requires a prompt radiological assessment and an expert multidisciplinary management.

Dural Tear During Thoracic Laminectomy Using Craniotome With Footplate Attachment

Laminectomy can be accomplished using the craniotome with a footplate attachment, and the technique has been advanced as a superior alternative to using a high-speed drill-driven burr and Kerrison rongeurs. Laminectomy can be accomplished more rapidly and with less bone destruction, an advantage when planning laminoplasty. There is, however, scant literature describing complications of dural laceration using this technique. A 48-year-old male underwent T7-10 laminectomy for resection of an intramedullary spinal cord tumor. During the upward cut of the hemi-lamina at T7-9, a dural laceration occurred that proved not amenable to direct suture closure. The dural was closed with a dural patch placed along the inner surface of the dura and a fat graft on the outer surface with adjunctive use of a lumbar drain. While the footplate laminectomy technique has merits touted in prior publications, including the ability to open the spinal canal quickly at numerous levels and an enhanced ability to achieve an osteoplastic laminoplasty, surgeons should be cognizant of the risk of associated dural laceration. We believe that it is important to emphasize that the initial placement of the lip of the footplate must be well-seated under the inferior aspect of the lowest lamina and over the ligamentum flavum and that the footplate should not be directed beyond the border of the laminae and facet, as this can result in dura and root injury.

Bone-to-bone ligament preserving laminoplasty technique for reconstruction of laminae

Introduction

Laminoplasty is a method used in spinal intradural tumor surgery to reduce the possibility of iatrogenic deformity. In classic laminoplasty, the interspinous, supraspinous, and ligamentum flavum integrity may be impaired, thereby creating a risk of deformity despite the laminoplasty. The aim of this study was to review the outcomes of bone-to-bone ligament preserving laminoplasty (BLP laminoplasty) technique.

Materials and Methods

The data of 14 cases who underwent BLP laminoplasty for intradural spinal tumor between 2017 and 2019 were reviewed. Through examination of preoperative and postoperative computed tomography images and flexion-extension lateral X-rays, the fusion and kyphotic changes were evaluated in the laminas. An axial Visual Analog Scale (VAS) was used to evaluate clinical satisfaction.

Results

The cases comprised 10 females and 4 males, with a mean age of 39.2 years (range, 16-52 years). The masses were intramedullary in six cases and extramedullary in eight. Lumbar region localization was most frequent. Ependymoma was determined in 8 cases, schwannoma in 4, and meningioma in 2. Laminoplasty was applied at 43 levels (10 thoracic and 33 lumbar). No complications were observed, and fusion was obtained in all the cases at the end of 1 year. No segmental kyphotic changes were determined. In the clinical evaluation, the VAS scores improved from 3.4 ± 2.0 preoperatively to 1.8 ± 2.1 postoperatively.

Conclusion

BLP laminoplasty is a safe technique which preserves posterior ligamentous integrity. Furthermore, the use of ultrasonic bone scalpel provides a narrower gap between laminae and other bones, preventing dislocation, and allowing for more fusion, and consequently preventing kyphosis.

Abordaje mínimamente invasivo para el tratamiento de tumores espinales intradurales extramedulares: Nota Técnica

Objetivo:

Describir la técnica de abordaje mínimamente invasiva para el tratamiento de tumores intradurales extramedulares en los diferentes segmentos espinales.

Material y Métodos:

Se detallan la planificación, posicionamiento, marcación, pasos técnicos del abordaje mínimamente invasivo, exéresis lesional y cierre de lesiones ID-EM a nivel cervical, dorsal, lumbar y sacro. Se proporcionan recomendaciones para descomplejizar maniobras quirúrgicas, acortar el tiempo operativo y evitar potenciales complicaciones.

Conclusiones:

El abordaje MISS es una opción segura y eficaz para el tratamiento quirúrgico de determinados tumores ID-EM.

T12 pedicle subtraction osteotomy for post-laminectomy kyphoscoliotic deformity following resection of a thoracolumbar astrocytoma in an adolescent with a previous paraplegic context

STUDY DESIGN

Case report.

PURPOSE

To describe a rare case of iatrogenic post-laminectomy thoracolumbar kyphoscoliosis in an adolescent, and its surgical management with pedicle subtraction osteotomy (PSO).

BACKGROUND

Kyphoscoliosis secondary to multilevel laminectomies for intradural astrocytoma resection is rare and its management can be very challenging.

METHODS

We report the case of 15-year-old boy who has been complaining of a progressively increasing hump in his back during the past 6 months. Two years prior to presentation, he underwent multilevel thoracolumbar laminectomies from T10 to L2 for resection of an intradural astrocytoma that was causing progressive paraplegia predominant on the right side. Full spine anteroposterior and lateral X-rays revealed a thoracolumbar kyphosis with an angulation of 73° between T10 and L1, with a long left thoracolumbar scoliosis of 24 degrees. CT scan confirmed the multilevel laminectomies and showed T12 anterior wedging. MRI did not show any tumor recurrence.

RESULTS

The patient underwent T12 PSO with instrumentation from T4 to L3 with the use of a one-sided domino on the convex side. Thoracolumbar kyphosis was corrected to 9°, and scoliosis was corrected to 7°, with a maintained correction at 7 years of follow-up.

CONCLUSION

Literature is sparse on the management of post-laminectomy kyphoscoliotic deformity after intradural astrocytoma resection. Despite previous paraplegia context, aggressive correction technique such as PSO can be a safe option if proper management of the scar tissues and adhesions is performed, with satisfactory clinical and radiological long-term results.

Spinal Deformities after Childhood Tumors

Simple Summary

A significant number of children surviving intra- or juxta-spinal tumors develop secondary spinal deformities and disabilities. This retrospective non-comparative study focuses on deformity analysis, age, and skeletal maturity dependent treatment options and results. Patients who developed severe scoliosis, pathological kyphosis, and/or lordosis were either treated conservatively or surgically by using growth-friendly spinal implants in younger children or definite spinal fusion during puberty. Despite severe spinal deformity, some patients were not surgically corrected in order to preserve mobility through trunk motion or malignant tumor progression. Growth-friendly spinal implants and spinal fusions were able to significantly reduce pathological curves. The first method, with bilateral rib-to-pelvis fixation, still allows spinal magnetic resonance imaging or neurosurgical intervention if needed. Severe ad hoc curve correction enhances the risk of neurological deterioration because of prior spinal cord impairment. The data of this study may help to improve the individual patient care.

Abstract

Childhood tumors of the central nervous system (CNS) and other entities affecting the spine are rare. Treatment options vary from surgical biopsy to partial, subtotal, and total resection, to radiation, to chemotherapy. The aim of this study is to investigate spinal deformity and subsequent surgical interventions in this patient cohort. A retrospective review at our institution identified children with CNS tumors, spinal tumors, and juxta-spinal tumors, as well as spinal deformities. Tumor entity, treatment, mobilization, and radiographic images were analyzed relative to the spinal deformity, using curve angles in two planes. Conservative or surgical interventions such as orthotic braces, growth-friendly spinal implants, and spinal fusions were evaluated and analyzed with respect to treatment results. Tumor entities in the 76 patients of this study included CNS tumors (n = 41), neurofibromatosis with spinal or paraspinal tumors (n = 14), bone tumors (n = 12), embryonal tumors (n = 7), and others (n = 2). The initial treatment consisted of surgical biopsy (n = 5), partial, subtotal, or total surgical resection (n = 59), or none (n = 12), followed by chemotherapy, radiotherapy, or both (n = 40). Out of 65 evaluated patients, 25 revealed a moderate or severe scoliotic deformity of 71° (range 21–116°), pathological thoracic kyphosis of 66° (range 50–130°), and lordosis of 61° (range 41–97°). Surgical treatment was performed on 21 patients with implantation of growth-friendly spinal implants (n = 9) as well as twelve dorsal spinal fusions (two with prior halo distraction). Surgical interventions significantly improved spinal deformities without additional neurological impairment. With the increasing number of children surviving rare tumors, attention should be focused on long-term problems such as spinal deformities and consequent disabilities. A significant number of children with CNS tumors, spinal tumors or juxta-spinal tumors required surgical intervention. Early information about spinal deformities and a close follow-up are mandatory for this patient group.

Incidence and predictors of kyphotic deformity following resection of cervical intradural tumors in adults: a population-based cohort study

BACKGROUND

The first line of treatment for most cervical intradural tumors is surgical resection through laminotomy or laminectomy. This may cause a loss of posterior pulling force leading to kyphosis, which is associated with decreased functional outcome. However, the incidence and predictors of kyphosis in these patients are poorly understood.

OBJECT

To assess the incidence of posterior fixation (PF), as well as predictors of radiological kyphosis, following resection of cervical intradural tumors in adults.

METHODS

A population-based cohort study was conducted on adult patients who underwent intradural tumor resection via cervical laminectomy with or without laminoplasty between 2005 and 2017. Primary outcome was kyphosis requiring PF. Secondary outcome was radiological kyphotic increase, measured by the change in the C2-C7 Cobb angle between pre- and postoperative magnetic resonance images.

RESULTS

Eighty-four patients were included. Twenty-four percent of the tumors were intramedullary, and the most common diagnosis was meningioma. The mean laminectomy range was 2.4 levels, and laminoplasty was performed in 40% of cases. No prophylactic PF was performed. During a mean follow-up of 4.4 years, two patients (2.4%) required delayed PF. The mean radiological kyphotic increase after surgery was 3.0°, which was significantly associated with laminectomy of C2 and C3. Of these, C3 laminectomy demonstrated independent risk association.

CONCLUSIONS

There was a low incidence of delayed PF following cervical intradural tumor resection, supporting the practice of not performing prophylactic PF. Kyphotic increase was associated with C2 and C3 laminectomy, which could help identify at-risk patients were targeted follow-up is indicated.

A new concept of motion preservation surgery of the cervical spine: PEEK rods for the posterior cervical region

BACKGROUND

Laminectomy may cause kyphotic postoperative deformity in the cervical region leading to segmental instability over time. Laminoplasty may be an alternative procedure to laminectomy, as it protects the spine against post-laminectomy kyphosis; however, similar to laminectomy, laminoplasty may cause sagittal plane deformities by destructing or weakening the dorsal tension band.

OBJECTIVE

Using finite element analysis (FE), we attempted to determine whether a posterior motion preservation system (PEEK posterior rod system concept) could overcome the postoperative complications of laminectomy and laminoplasty and eliminate the side effects of rigid posterior stabilization in the cervical region.

METHODS

We compared PEEK rods in four different diameters with a titanium rod for posterior cervical fixation. The present study may lead to motion preservation systems of the cervical vertebra.

RESULTS

When PEEK rod is compared with titanium rod, considerable increase in range of motion is observed.

CONCLUSIONS

PEEK rod-lateral mass screw instrumentation systems may be useful in motion preservation surgery of the posterior cervical region.

Contemporary management of pediatric spinal tumors: a single institute's experience in Taiwan in the modern era

INTRODUCTION

Pediatric spinal tumors are unique pathologies treated by pediatric neurosurgeons. Special attention is required for the preservation of neural function and bony alignment. We reported our experience in the management of these challenging lesions.

METHODS

A total of 75 pediatric patients with spinal tumors treated at the National Taiwan University Hospital from 1998 to 2018 were identified retrospectively. Clinical data, radiographic image, and pathological report were reviewed for analysis.

RESULTS

There were 37 females and 38 males. The median age was 9 years. Thirty-eight tumors (50.6%) were extradural, 20 (26.7%) intradural extramedullary, and 17 (22.6%) intramedullary. The most common pathologies were glioma, ependymoma, and neuroblastoma. The rate of total and subtotal resection was 45.3% and 21.3%. Thirty-four patients (45.3%) required post-operative adjuvant therapy. Eight patients (10.6%) with spinal deformity had simultaneous tumor excision and spinal fusion surgery. Additional six (8%) patients had subsequent spinal fixation and fusion for deformity after primary tumor operation. Eighty-four percent of patients were ambulatory 3 years after operation. For patients with intradural extramedullary and intramedullary tumors, worse survival outcome was associated with tumor derived from CSF seeding and cranial involvement of spinal tumor, while poorer functional outcome was correlated with cranial involvement and adjuvant therapy with chemotherapy or radiotherapy.

CONCLUSIONS

Pediatric spinal tumor surgery carries low surgical morbidity and mortality under current standard of neurosurgical practice. Post-operative adjuvant therapy is required for nearly half of the cases. Spinal deformity requires special attention and sometimes surgical correction. Contemporary management of pediatric spinal tumors enables effective ablation of the lesion and delivers favorable outcome for the majority of patients.

Risk factor analysis for progressive spinal deformity after resection of intracanal tumors─ a retrospective study of 272 cases

BACKGROUND

Progressive spinal deformity has become a well-recognized complication of intracanal tumors resection. However, the factors affecting post-operative spinal stability remain to be further research. Here, we described the current largest series of risk factors analysis for progressive spinal deformity following resection of intracanal tumors.

METHODS

We retrospectively analyzed the medical records of the patients with resection of intracanal tumors between January 2009 and December 2018. All patients who underwent resection of intracanal tumors performed regular postoperative follow-up were identified and included in the study. Clinical, radiological, surgical, histopathological, and follow-up data were collected. The incidence of postoperative progressive kyphosis or scoliosis was calculated. The statistical relationship between postoperative progressive spinal deformity and radiographic, clinical, and surgical variables was assessed by using univariate tests and multivariate logistic regression analysis.

RESULTS

Two hundred seventy-two patients (mean age 42.56 ± 16.18 years) with median preoperative modified McCormick score of 3 met the inclusion criteria. Among them, 7(2.6%)patients were found to have spinal deformity preoperatively, and the extent of spinal deformity in these 7 patients deteriorated after surgery. 36 (13.2%) were new cases of postoperative progressive deformity. The mean duration of follow-up was 21.8 months (median 14 months, range 6-114 months). In subsequent multivariate logistic regression analysis, age ≤ 18 years (p = 0.027), vertebral levels of tumor involvement (p = 0.019) and preoperative spinal deformity(p = 0.008) was the independent risk factors (p < 0.05), increasing the odds of postoperative progressive spinal deformity by 3.94-, 0.69- and 27.11-fold, respectively.

CONCLUSIONS

The incidence of postoperative progressive spinal deformity was 15.8%, mostly in these patients who had younger age (≤18 years), tumors involved in multiple segments and preoperative spinal deformity. The risk factors of postoperative progressive spinal deformity warrants serious reconsideration that when performing resection of spinal cord tumors in these patients with such risk factors, the surgeons should consider conducting follow-ups more closely, and when patients suffering from severe symptoms or gradually increased spinal deformity, surgical spinal fusion may be a more suitable choice to reduce the risk of reoperation and improve the prognosis of patients.

Risk factor analysis of progressive spinal deformity after resection of intramedullary spinal cord tumors in patients who underwent laminoplasty: a report of 105 consecutive cases

OBJECTIVE

Laminoplasty has been used in recent years as an alternative approach to laminectomy for preventing spinal deformity after resection of intramedullary spinal cord tumors (IMSCTs). However, controversies exist with regard to its real role in maintaining postoperative spinal alignment. The purpose of this study was to examine the incidence of progressive spinal deformity in patients who underwent laminoplasty for resection of IMSCT and identify risk factors for progressive spinal deformity.

METHODS

Data from IMSCT patients who had undergone laminoplasty at Beijing Tsinghua Changgung Hospital between January 2014 and December 2016 were retrospectively reviewed. Univariate tests and multivariate logistic regression analysis were used to assess the statistical relationship between postoperative spinal deformity and radiographic, clinical, and surgical variables.

RESULTS

One hundred five patients (mean age 37.0 ± 14.5 years) met the criteria for inclusion in the study. Gross-total resection (> 95%) was obtained in 79 cases (75.2%). Twenty-seven (25.7%) of the 105 patients were found to have spinal deformity preoperatively, and 10 (9.5%) new cases of postoperative progressive deformity were detected. The mean duration of follow-up was 27.6 months (SD 14.5 months, median 26.3 months, range 6.2-40.7 months). At last follow-up, the median functional scores of the patients who did develop progressive spinal deformity were worse than those of the patients who did not (modified McCormick Scale: 3 vs 2, and p = 0.04). In the univariate analysis, age (p = 0.01), preoperative spinal deformity (p < 0.01), extent of tumor involvement (p < 0.01), extent of abnormal tumor signal (p = 0.02), and extent of laminoplasty (p < 0.01) were identified as factors associated with postoperative progressive spinal deformity. However, in subsequent multivariate logistic regression analysis, only age ≤ 25 years and preoperative spinal deformity emerged as independent risk factors (p < 0.05), increasing the odds of postoperative progressive deformity by 4.1- and 12.4-fold, respectively (p < 0.05).

CONCLUSIONS

Progressive spinal deformity was identified in 25.7% patients who had undergone laminoplasty for IMSCT resection and was related to decreased functional status. Younger age (≤ 25 years) and preoperative spinal deformity increased the risk of postoperative progressive spinal deformity. The risk of postoperative deformity warrants serious reconsideration of providing concurrent fusion during IMSCT resection or close follow-up after laminoplasty.

Predictors of 90-Day Readmission in Children Undergoing Spinal Cord Tumor Surgery: A Nationwide Readmissions Database Analysis

OBJECTIVE

A fair number of hospital admissions occur after 30 days; thus, the true readmission rate could have been underestimated. Therefore, we hypothesized that the 90-day readmission rate might better characterize the factors contributing to readmission for pediatric patients undergoing spinal tumor resection.

METHODS

The Nationwide Readmissions Database was used to study the patient demographic data, comorbidities, admissions, hospital course, spinal tumor behavior (malignant vs. benign), complications, revisions, and 30- and 90-day readmissions.

RESULTS

Of the 397 patients included in the 30-day cohort, 43 (10.8%) had been readmitted. In comparison, the 90-day readmission rate was significantly greater; 52 of 325 patients were readmitted (16.0%; P < 0.04). Patients aged 16-20 constituted the largest subgroup. However, the highest readmission rate was observed for patients aged <5 years (30-day, 21.7%; 90-day, 26.4%). Medicaid patients were more likely to be readmitted than were private insurance patients (30-day odds ratio [OR], 3.3 [P < 0.001]; 90-day OR, 2.29 [P < 0.02]). In both cohorts, patients with malignant tumors required readmission more often than did those with benign tumors (30-day OR, 2.78 [P < 0.02]; 90-day OR, 1.92 [P = 0.08]). In the 90-day cohort, the patients had been readmitted 26.4 days after discharge versus 10.6 days in the 30-day cohort. Within the 90-day cohort, 18.6% of the readmissions were for spinal reoperation, 28.3% for chemotherapy or hematologic complications, and 25.6% for other central nervous system disorders. The median charges for each readmission were ∼$50,000 and ∼$40,000 for the 30- and 90-day cohorts, respectively. Medicaid insurance, malignant tumors, and younger age were significant predictors of readmission in the 90-day cohort.

CONCLUSIONS

The prevalence and charges associated with unplanned hospital readmissions after spinal tumor resection were remarkably high. Younger age, Medicaid insurance, malignant tumors, and complications during the initial admission were significant predictors of 90-day readmission.

Surgical outcomes of pediatric spinal cord astrocytomas: systematic review and meta-analysis

OBJECTIVE

Pediatric spinal astrocytomas are rare spinal lesions that pose unique management challenges. Therapeutic options include gross-total resection (GTR), subtotal resection (STR), and adjuvant chemotherapy or radiation therapy. With no randomized controlled trials, the optimal management approach for children with spinal astrocytomas remains unclear. The aim of this study was to conduct a systematic review and meta-analysis on pediatric spinal astrocytomas.

METHODS

The authors performed a systematic review of the PubMed/MEDLINE electronic database to investigate the impact of histological grade and extent of resection on overall survival among patients with spinal cord astrocytomas. They retained publications in which the majority of reported cases included astrocytoma histology.

RESULTS

Twenty-nine previously published studies met the eligibility criteria, totaling 578 patients with spinal cord astrocytomas. The spinal level of intramedullary spinal cord tumors was predominantly cervical (53.8%), followed by thoracic (40.8%). Overall, resection was more common than biopsy, and GTR was slightly more commonly achieved than STR (39.7% vs 37.0%). The reported rates of GTR and STR rose markedly from 1984 to 2015. Patients with high-grade astrocytomas had markedly worse 5-year overall survival than patients with low-grade tumors. Patients receiving GTR may have better 5-year overall survival than those receiving STR.

CONCLUSIONS

The authors describe trends in the management of pediatric spinal cord astrocytomas and suggest a benefit of GTR over STR for 5-year overall survival.

Pediatric intramedullary spinal cord tumor outcomes using the WeeFIM scale

PURPOSE

The Functional Independence Measure for children (WeeFIM) is a user-friendly functional outcomes tool that has been validated across other traditional functional scales. Historically, the significant neurologic and functional deficits of intramedullary spinal cord tumors (IMSCTs) have been monitored by coarse or overbearing functional outcomes tools that make it difficult to measure the slow improvement/decline seen in these patients. This study is the first to report WeeFIM outcomes on a series of IMSCTs with emphasis on an aggressive surgical strategy.

METHODS

A retrospective review from 2005 to 2014 was performed for nine patients who underwent resective surgery for intramedullary spinal cord tumors with intraoperative ultrasound and neurophysiologic monitoring. WeeFIM scales were assessed at admission and discharge to evaluate changes in severity of disability and need for assistance.

RESULTS

At the time of this submission, 7/9 patients are alive. The mean WeeFIM improvement was 27 points (8-50 points) with a mean WeeFIM efficiency of 2.0 points/day.

CONCLUSIONS

The WeeFIM scale is an appropriate and useful scale for measuring postoperative improvements in patients with IMSCTs undergoing aggressive resective surgery. Attention to intraoperative spinal cord monitoring and prevention of spinal column instability may prevent morbidity related to surgery, and functional outcomes do not appear to be compromised by an aggressive surgical approach.

Spinal meningioma and factors predictive of post-operative deterioration

PURPOSE

Spinal meningiomas are slow-growing intradural-extramedullary tumors. They are usually associated with good outcomes. However, there are few descriptions of factors predictive of impaired evolution. Our objective was to identify predictive factors of post-operative deterioration as well as outcomes at follow-up.

METHODS

Between 2009 and 2016, 87 patients had surgery for spinal meningioma in our referral center. Clinical presentation, management and outcomes were reported during the post-operative period and at 3-month follow-up. Evaluation was based on post-operative neurological deterioration defined as an increase of at least one point in the McCormick score compared to the status at admission.

RESULTS

During the study period, post-operative deterioration occurred in 17 patients (19.5%). Risk factors associated with this deterioration were the absence of pre-operative neurological signs (Relative Risk; RR = 2.38, p = 0.04), an anterior location of the meningioma and a grade 2 meningioma on WHO classification score (RR = 6, p ≤ 0.01). At 3-month follow-up, in patients who initially presented with a motor deficit, partial recovery was found in 75%, stability in 20% and a deterioration of their clinical status in 5%. After a mean follow-up of 92.4 ± 51.9 months, the recurrence rate was 8%.

CONCLUSIONS

Spinal meningiomas are usually benign tumors whose treatment is based on complete surgical resection. Progress in surgical techniques has resulted in lower morbidity rates and improvement in post-operative recovery. In this study, we observed several factors associated with clinical deterioration. Before surgery, patients should be fully informed of these predictive factors of post-operative deterioration and their association with surgical morbidity.

Instrumented fusion for spinal deformity after laminectomy or laminoplasty for resection of intramedullary spinal cord tumors in pediatric patients

OBJECTIVE Spinal deformity has become a well-recognized complication of intramedullary spinal cord tumor (IMSCT) resection. In particular, laminectomy can result in biomechanical instability caused by loss of the posterior tension band. Therefore, laminoplasty has been proposed as an alternative to laminectomy. Here, the authors describe the largest current series of pediatric patients who have undergone laminoplasty for IMSCT resection and investigate the need for surgical fusion after both laminectomy and laminoplasty. METHODS The medical records of pediatric patients who underwent resection of an IMSCT at a single institution between November 2003 and May 2014 were reviewed retrospectively. Demographic, clinical, radiological, surgical, histopathological, and follow-up data were collected. RESULTS Sixty-six consecutive patients underwent resection of an IMSCT during the study period. Forty-three (65%) patients were male. The patients had a median age of 12.9 years (interquartile range [IQR] 7.2-16.5 years) at the time of surgery. Patients typically presented with a tumor that involved the cervical and/or thoracic spine. Nineteen (29%) patients underwent laminectomy, and 47 (71%) patients underwent laminoplasty. Patients in each cohort had a similar rate of postoperative deformity. Overall, 10 (15%) patients required instrumented spinal fusion for spinal deformity. Four patients required revision of the primary fusion. CONCLUSIONS These findings show that among pediatric patients with an IMSCT, postoperative surgical fusion rates remain high, even after laminoplasty. Known risk factors, such as the age of the patient, location of the tumor, and the number of involved levels, might play a larger role than replacement of the laminae in determining the rate of surgical fusion after IMSCT resection.