PROGNOSTIC FACTORS OF SURGERY FOR CERVICAL CORD TUMORS
Mahmoud Wahdan MD, Fathi El-Noss MD,Hossam MaatyMD ,Waleed Badawy
MD and Alaa Farag MD
Neurosurgery department - Faculty of medicine Banha University
ABSTRACT
Background: Spinal cord tumors represent 10% to 15% of central nervous system
(CNS) neoplasms. In adults, two thirds of these tumors are extramedullary and the
remaining third are intramedullary. Objective: We aimed to outline the prognostic factors
that affect the final outcome of cervical cord tumor surgeries. Patients and methods: Sixty
one patients with cervical spinal cord tumors underwent surgery between march 2009 and
march 2014. The neurological status before surgery, 1 month after the operation and at the
most recent examination were assessed based on the grading system of McCormick outcome.
The 61 patients, divided according to the histopathological diagnosis. Results: There were 22
ependymoma (36.1%), 13 Scwannoma (21.3%), 12 Meningioma (19.7%), 6 Neurofibroma
(9.8%), 3 Astrocytoma (4.9%) and 5 other pathologies collectively (8.2%). In this study
there was 75% of patients with total resection, 11.4% had subtotal and 13.1% had partial
resection or biopsy. Thirty seven patients was improved (60.7%), thirteen patients with no
change (21.3%), ten patients deteriorated (16.4%) and one died (1.6%). By statistical
analysis, there was significant correlation between postoperative outcome and the tumor
grade (P=0.015), the less the grade the better outcome .We found a significant correlation
between the pre-operative state and the final functional outcome, that, the better the
preoperative state the better outcome. There is statistically relevant correlation between the
recurrence and the degree of resection. Conclusion: The spinal cord tumors can be treated
safely and effectively by surgery. Total resection must be the essential aim before surgery.
Preoperative neurological state, pathological type, pathological grades, and degree of
resection are the most important factors that affect the final outcome .
Key words: cervical cord tumors, prognostic factors, outcome
Correspondence to Alaa A Farag. Department of Neurosurgery Banha University, Egypt.
email: Alaa1farag@yahoo.com
Tel. +2/01287518299
INTRODUCTION
Spinal cord tumors represent 10%
to 15% of central nervous system (CNS)
neoplasms. These tumors are generally
classified by their relationship to the dura
mater and spinal cord parenchyma: within
the spinal cord parenchyma (intramedullary), outside the spinal cord
parenchyma (extramedullary). In adults,
two thirds of these tumors are
extramedullary and the remaining third are
intramedullary. Tumors of the spinal cord
encompass a wide variety of histologic
types, and their optimal management
depends on accurate identification of the
pathologic process. Approximately 36% of
tumors were located in the cervical cord. 31
Glial tumors account for at least
80% of intramedullary tumors in most
series. These tumors are predominantly
astrocytomas and ependymomas; the latter
are more common. Hemangioblastomas are
the third most common type of
intramedullary tumors, and the remaining
include inclusion tumors and cysts,
vascular abnormalities, and metastases.25
Pain, weakness, and numbness are
the most frequent presenting symptoms.
Pain usually localizes to the level of the
tumor, and the distribution of the
numbness and weakness corresponds to the
location within the cord. Bowel and
bladder dysfunction may also occur, but
these tend to occur later.
Gadolinium-enhanced MRI is the
gold standard imaging modality for
preoperative evaluation of intramedullary
tumors. Such imaging studies can not only
help define the location of the tumor within
effective treatment for these benign, wellthe spinal cord and rule out the presence of
circumscribed tumors. 8
multiple lesions, but the tumor’s
The aim of this study is to outline
the prognostic factors that affect the final
appearance on the MR images can give
outcome of cervical cord tumor surgeries
diagnostic clues. The risk of recurrence
PATIENTS AND METHODS:
exists after the resection of any spinal cord
Sixty one patients with cervical
tumor, and serial imaging and follow-up
spinal cord tumors underwent surgery at
must be performed. The likelihood of
the Departments of Neurosurgery, Banha
tumor recurrence depends predominantly
University Hospitals, Nasser Institute
on the histology of the tumor and the
Hospital and EGE University Medical
completeness of the original resection. For
School–Izmir, Turkey between March
benign ependymomas, total resection is
8
2009 and March 2014. There were 38 men
often curative without adjuvant therapy.
and 23 women, age ranged from 2 to 76
Advances in imaging, surgical
years with a mean age of 41 years.
technique, and intraoperative sensory and
Clinical assessment of pre- and
motor electrophysiologic monitoring have
post-operative
neurologic function was
steadily improved the safety and efficacy
done
using
the
McCormick
scale proposed
of surgery. Most intramedullary tumors are
by McCormick et al in 1990 (table 1).21
low-grade neoplasms, and most authors
agree that surgery now represents the most
Table (1) : McCormick scale.21
Grade
1
1b
II
III
IV
Definition
Neurologically normal
Gait normal
Normal professional activity
Tired after walking several kilometers
Running is impossible, or moderate sensorimotor deficit does not
significantly affect the involved limb.
Moderate discomfort in professional activity
Presence of sensorimotor deficit affecting function of involved limb
Mild to moderate gait difficulty
Severe pain or dysesthetic syndrome impairs quality of life
Independent function and ambulation maintained
More severe neurological deficit
Requires cane and / or brace for ambulation
Bilateral upper-extremity impairment
May or may not function independently
Severe neurological deficit
Requires wheelchair or cane and/or brace with bilateral upper – extremity
impairment
Usually not independent.
The neurological status
before
surgery, 1 month after the operation and at
the last follow up was assessed based on
the grading system of McCormick. The
follow-up periods ranged from 6 months to
60 months with a mean of 17.1 months.
Magnetic resonance imaging (MRI) with
gadolinium contrast enhancement was
performed as standard radiological
investigation before and after surgical
treatment. For extramedullary lesion,
signal abnormalities, cerebrospinal fluid
capping, and spinal cord displacement
helped to identify most extramedullary
masses.
Gadolinium
enhancement
increased the sensitivity of magnetic
resonance imaging, particularly for small
tumors.
Surgical Technique
The primary goal of surgery was to
achieve complete tumor removal and to
avoid additional neurological damage.
Different surgical techniques were used
depending on the tumors’ localization and
extension.
Generally,
osteoplastic
laminotomy was the surgical approach of
choice, especially for long span lesions.
However, in earlier cases and in regions
considered
biomechanically
stable
(cervico-thoracic region) laminectomy was
performed. Duroplasty was done in some
cases if necessary.
A variety of strategies can be
employed for extra-medullary tumors
removal.
Dorsal
and
dorsolateral
meningiomas are delivered away from the
spinal cord by dissection through the
arachnoid plane. A circumscribing excision
of the dural origin completes the removal.
For lateral and ventral tumors, the
arachnoid over the exposed portion of the
tumor is incised and reflected so that the
dissection may proceed directly on the
tumor surface. The rostral and caudal
tumor poles were identified. The exposed
tumor surface is then cauterized to
diminish tumor vascularity and shrink the
tumor mass
In Intramedullary lesions, 250 mg
of methyl prednisilone was administered
intravenously just before the myelotomy,
to decrease spinal cord edema. The
myelotomy was advanced deeper until it
reached the surface of the tumour. Keeping
the plane along the lateral surface of the
tumour, the dissection was carried out in a
parallel direction. Internal decompression
of the tumour was performed. Feeding
vessels and arachnoid adhesion were
cauterized and divided close to the tumour.
In those lesions, which infiltrated normal
tissues, the Cavitron ultrasonic surgical
aspirator was used to achieve internal
decompression. When the waveform
worsened during the procedure (multiplephase waveform or loss of wave) the
manipulation of the spinal cord tumor was
suspended and resumed after recovery of
the waveform. After tumor resection,
intraoperative ultrasonography was used
(in some cases) to confirm whether any
residual tumor was present.
Cases that was operated in EGE
University, Izmir, Turkey, intra-operative
neurophysiologic monitoring was used.
The stimulations are repeatable at a rate of
0.5- 2 Hz. This provides practically realtime feedback. A decrease of more than
50% of the baseline amplitude was an
indication to stop.
The pathological classification of
WHO regarding pathological types and the
4 tiered classification suggested by
Kernohan and Fletcher as a basis to
classify the tumors according to their
degree of differentiation. This was adopted
by the pathologist in charge.26
Outcome:
We divided this topic into surgical
outcome and functional outcome. Surgical
outcome was in the form of degree of
resection and approach used. Functional
outcome was assessed by comparing the
pre-operative neurological status and the
most recent neurological status measured
by McCormick scale. This was classified
into ``improved'', ``unchanged'', ``deteriorated'' and ``death''.
The extent of tumor resection
was evaluated by categorizing into the
following 3 grades : total resection,
subtotal resection, partial resection or
biopsy. The standard definition of total
resection: "removal of 100% of the tumor
as evidenced by a microscopically
documented clean surgical field at the end
of the procedure" was used. When a small
tumor fragment was intentionally left in
place, the procedure was considered to be a
subtotal resection. Subtotal resection was
performed in this series when intraoperative evoked potential monitoring
changes heralded impending neurological
paralysis. In the same manner, 50–80%
resection was defined as partial resection
and < 50 % resection was defined as a
biopsy.
RESULTS:
The age range is from 2-75 years
with mean age is 40.9 years with a
standard deviation of 14.4 years . There
were 38 male and 23 female patients with a
percentage of 62.3 and 37.7 respectively.
The most common presenting symptoms
were sensory symptoms including pain
and parethesia (brachialgia and neck pain)
in 43 patient (70.5 %). The second most
common was motor symptoms in the form
of
monoparesis,
hemiparesis
or
quadriparesis in 41 patients (67.3%). The
third was sensory loss including lost deep
sensations and posterior column symptoms
as gait disturbance and instability in 19
patients (31%) (Table 2).
There were 28 total laminectomies,
17 laminotomy or hemilaminectomy, 8
laminoplasties and 8 patients operated by
other approaches than the posterior
approach in the form of anterior approach
and retro-pharyngeal approaches. The
latter were used for high cervical lesions
and lesions in the foramen magnum
compressing the high cervical cord
(Table 3).
The 61 patients, divided according
to the histopathological diagnosis into
ependymoma 22 (36.1%), (Fig. 1a, 1b),
Scwannoma 13 (21.3%), (Fig. 2a, 2b),
Meningioma 12 (19.7%), Neurofibroma 6
(9.8%), Astrocytoma 3 (4.9%) and other
pathologies
collectively
5
(8.2%)
(Heamangioblastoma, Metastatic Adenocarcinoma,
Subependymoma,
Heamagioma,
Nonspecific
Granuloma)
(Table 4).
In the 61 cases there were 11
(18%) complications. In 8 cases the tumor
recurred during the last follow up (13.1%).
The postoperative outcome was
divided into : improved, no change ,
deteriorated and dead. We had 37 patients
improved (60.7%),13 patients with no
change (21.3%), 10 patients deteriorated
(16.4%) and 1 died (1.6%). Any factor
suspected to affect outcome was studied
(Table 5).
Table (2): Preoperative Variables of the studied patients
Variables
Complaint
(N=61)
% (100%)
Monoparesis
14
23.0
Hemiparesis
14
23.0
Sensory dist.
19
31.1
Quadriparesis
13
21.3
Other complaints*(dysphagia)
1
1.6
Duration of complaint
(M)
Pain
Spasticity
Mc Cormic
Mean ± SD, median, range
19.5±27.5, 12, 1-120
No
37
60.7
yes
24
39.3
No
42
68.9
yes
19
31.1
Grade 1
23
37.7
Grade 2
27
44.3
Grade 3
8
13.1
Grade 4
3
4.9
Table (3): Intraoperative Variables
Variables
No
yes
Total laminectomy
Hemilaminectomy or
laminotomy
Laminoplasty
Other Approaches
No
yes
Total
Subtotal
Partial resection or biopsy
Intra-operative
monitor
Approach
Infiltration
Resection degree
No. (N=61)
12
49
28
% (100%)
19.7
80.3
45.9
17
27.9
8
8
44
17
46
7
8
13.1
13.1
72.1
27.9
75.4
11.4
13.1
Table (4) : The pathological type and grading of cases.
Variable
No.
% (100%)
(N=61)
Pathological
Astrocytoma
3
4.9
diagnosis
Ependymoma
22
36.1
Meningioma
12
19.7
Scwannoma
13
21.3
Neurofibroma
Other pathology†
6
5
9.8
8.2
Grade 1
31
50.8
Grade 2
27
44.3
Grade 3
2
3.3
Grade 4
1
1.6
Grade
Table (5) : Postoperative variables
Variables
Postoperative outcome
Post operative Mc Cormic
Complications
Recurrence
Need of radiotherapy
No change
Improved
Deteriorated
Died
Grade 1
Grade 2
Grade 3
Grade 4
No
yes
No
yes
No
yes
No. (N=61)
13
37
10
1
35
18
5
3
50
11
53
8
54
7
% (100%)
21.3
60.7
16.4
1.6
57.4
29.5
8.2
4.9
82.0
18.0
86.9
13.1
88.5
11.5
The correlation between the
outcome and many factors that may play a
role to affect it was studied. There was not
any significance or correlation between
age of presentation or the gender and final
outcome of the patients (p values were
0.85 and 0.61 for age and sex
respectively).
The pathological type of the tumor
was strongly correlated with significant
value to the outcome and good
postoperative state of the patient
(P=0.036). Best outcome was with
extramedullary tumours
specially
neurofibroma and meningioma (patients
improved 83% for both) followed by
schwannoma
with
69%
then
intramedullary tumors like ependymoma
36% and astrocytoma 33.4% (Table 6). By
statistical analysis significant correlation
between outcome and the tumor grade was
found (P=0.015), the less the grade the
better outcome.
Table (6): Relation between outcome and pathological diagnosis
Pathological diagnosis
Astrocytoma
Ependymoma
Meningioma
Scwannoma
Neurofibroma
Other pathology
Outcome
No change
/deteriorated/ died
2
66.7%
14
63.6%
2
16.7%
4
30.8%
1
16.7%
1
20.0%
We found a significant correlation
between the pre-operative state and the
final functional outcome. The better the
preoperative state the better outcome was.
Most of patients presented with Gr I and II
improved in the immediate post operative
time and on follow up (P = 0.012).
The next factor studied was the
usage of intraoperative monitoring. The
results were not significant because we
found that the percentage of improved
cases were nearly similar between the 2
Total
improved/
cured
1
33.3%
8
36.4%
10
83.3%
9
69.2%
5
83.3%
4
80.0%
3
100.0%
22
100.0%
12
100.0%
13
100.0%
6
100.0%
5
100.0%
groups. 7 of 12 cases (58.3%) in the non
monitored group and 30 of 49 cases
(61.2%) in the monitored group were
improved. The different approaches did not
alter the final outcome of the patients.
In this series, total resection of
tumor was achieved in 75% of cases.
11.4%, of patient had subtotal resection
and 13.1% of patient had partial resection
or biopsy. The final outcome was affected
by the degree of resection (P=0.027).
Fig. (1a): Preoperative MRI of a patient with Ependymoma
Fig. (1b):Postoperative MRI of a the same patient
Fig. (2a): Preoperative MRI of a patient with Schwannoma
Fig. (2b): Postoperative MRI of the same patient
In this study there were eleven
complications. The relation between
complications and other factors was
studied. There was no correlation with
preoperative state,
the usage of
intraoperative monitoring, the utilized
approach, pathological diagnosis or the
degree of resection and the development of
complications. The only significant
variable was the infiltration of the lesion to
the surrounding spinal cord tissue
(P = 0.007).
In eight cases the tumor recurred
during the last follow up (13.1%). There
was a statistically relevant correlation
between the recurrence and the degree of
resection (P= 0.008). In the 46 cases with
total resection, there was only 3
recurrences while in partial resection group
there was 4 of 8 cases showed recurrence
within the follow up period. There was no
significant correlation between type of
pathology and rate of recurrence
(P = 0.67).
DISCUSSION:
Kelkamp and samii reported in
their series that the majority of patients
presented a slowly progressive course
which started with pain or dysesthesias in
50% of patients. Twenty-two percent
noticed gait problems as the first symptom,
16% motor weakness, and 12% sphincter
disturbances or sensory deficits.17 Joaquim
et al. reported also that 8 out of his 12
patients 67% had painful dysthesia and the
second presenting symptom was long tract
symptoms as weakness and lost deep
sensory control 6 of 12 patients 50%.12
While Segal et al. mentioned in their series
that the most common presenting
symptoms were neurological disturbances
in 43.5%, back pain in 37.6% and a
combination of both in 18.8%35. In our
study, the most common presenting
symptoms were
sensory symptoms
including pain and parethesia (brachialgia
and neck pain) in 43 patient (70.5 %). The
second most common was motor
symptoms in the form of monoparesis,
hemiparesis or quadriparesis in 41 patients
(67.3%).
For many patients we tried to
minimize the amount of bone loss for the
issue of post operative instability and curve
problems in the cervical vertebrae. Choice
of approach based on location of the lesion
and the extent of the lesion. Joaquim et al.
in most of their patients used open-door
laminoplasty exposing one level above and
one below the lesion. inspite of that he had
2 patients developed post-operative
kyphosis, which required fusion12.
Nakamura et al. performed laminoplasty
for their all cervical patients (30 patients).
They felt that it will avoid post operative
kyphosis and they did not encounter any
post operative curve problems.23 Yeo et al.
concluded that unilateral hemilaminectomy
combined with microsurgical technique
provides sufficient room for the removal of
spinal cord tumors. They recommend
unilateral hemilaminectomy as a suitable
surgical option for the removal of tumors
in the spinal canal. 41
In 2006 and 2007, Sala et al. by
two consecutive works used SSEPs and
MEPs, setting the critical point of SSEPs
to a 50% reduction of the amplitude or
setting an alarm point of MEPs to loss of
the waveform; surgery was continued
when the D-wave did not decrease over
50% and abandoned when the D-wave
decreased by more than 50% with loss of
MEP.29,30 Also In 2007 Kothbauer and
colleagues14–16 also reported setting the
critical point to loss of MEP waveform and
a 50% reduction of the D-wave.15 Sutter et
al. concluded that the multimodal
intraoperative monitoring during surgery
of the spinal cord tumor proved to be a
valid and reliable method to contribute to
the improvement of the surgical results
allowing gross tumor resections.38
In the literature there were no much
studies that evaluate all the intradural
pathologies compared to studies that deal
with only specific type of tumour. Nambiar
et al. reported that 51% of nerve sheath
tumor improved (this study was 73%)
while 29.4% of their ependymomas
improved or cured (this study was 36%)
and 57.7% of meningiomas improved (this
study was 83%).24 Sandalicioglu et al.
reported that, in 16 of 30 patients with
ependymomas,
the
postoperative
functional state was unchanged compared
to the preoperative condition, and in 11
patients the functional grade deteriorated
by one grade. While in their patients with
astrocytomas in eight of 12 patients (67%)
the post- operative state was unchanged
compared to the preoperative state,
whereas in four patients, the functional
state deteriorated by one grade. These
results are comparable to the results in this
study regarding both tumor types.34
In all of their 20 patients with
Anaplastic ependymomas Liu et al.
reported that immediately after surgery, 12
patients (60%) had unchanged neurological
function; the condition of 8 patients
deteriorated, but 3 of these 8 patients
(15%)
experienced
only
transient
deterioration and later recovered to the
preoperative status in follow-up.19
Raco et al mentioned that, the
prognosis for high-grade astrocytomas, like
their intracranial counterparts, is extremely
poor, and virtually all patients die as a
consequence of progressive disease.28
Ohata et al. presented a study with 18
cases, the final outcome was improved in 1
case, unchanged in 15 cases and
deteriorated in 2 cases 26. Others have
better
results like Nakamura and
colleagues as they reported that, functional
improvement was obtained in 16 of 33
ependymoma cases (48.5 %) with total
tumor resection and the functional
outcomes were poorer in the astrocytoma
cases than in the ependymoma cases, and
improvement of paralysis was found only
in three of the 23 astrocytoma cases 23 In
extramedullary tumors the situation is
different with all authors the results were
marvelous.
This study demonstrated that those
patient with grade III and IV tumors have a
poorer prognosis, this was not statistically
significant, because of the small number of
patients. Sun et al. found that the
histological grade was significant in the
prognosis of patients with multi-segment
malignant astrocytoma (p = 0.01)37. Babu
et al. reported that, the incidence of new
deficits was seen to vary by tumor grade,
with those having high-grade astrocytoma
experiencing a significantly higher
complication rate
(P = 0.047). 2
Nambiar et al concluded that
outcomes are influenced by pre-morbid,
pre-operative and post-operative clinical
grades, extent of resection, tumour grade
and location with respect to the spinal
parenchyma. Other significant predictors
of good neurological outcome included
low tumour grade (p = 0.004) and
extramedullary tumour location (p=
0.003).24
Sandalicioglu
wrote
that
surprisingly, patients with low-grade
neuroepithelial
tumors
and
tumor
extension of more than three spinal
segments showed a good functional
outcome only in 52%.34. This observation
can be explained by the fact that tumors
extending by more than three segments
were mostly ependymomas, and as
mentioned above, characterized by a
clearer-defined plane of dissection
compared to astrocytomas.
In this study, results denote that the
better the preoperative state the better
outcome. Most of patients presented by
Gr1 and Gr. II showed improvement in the
immediate post operative time and on
follow up and the statistical values was of
significance (P = 0.012). In this topic there
is a universal agreement in the literature
about the importance of the pre operative
state as a major prognostic factor that
determines the outcome.
Joaquim et al. presented their work
with 12 patients with ependymoma, 8 of
them were grade 2 (67%). 50% of their
patients improved on the follow up
period12. In our series, 37% of patient with
ependymoma had improved on the follow
up period. Ohata et al. also used
McCormick scale as a measuring tool to
assess the pre and post operative state for
the purpose of evaluation and outcome
assessment in their 18 patients , and by
means of this assessment found results
showed that the most important factor
determining the long-term functional
prognosis is the pre-operative functional
status, indicating that surgery must be
carried out at an early stage of the disease
or at the time of diagnosis. 26
Balooshi and colleagues from
kingdom of Saudi Arabia used McCormick
scale for 17 patients and concluded that
post operative outcome
is strongly
correlated with preoperative state with
significant value8. In 1999 Kane et al.
reported that the gait status was aggravated
and unchanged in 6 (12%) and 45 (82%) of
54 patients with intramedullary tumors
respectively.3
Quigley presented patients with a
good pre-operative Frankel grade tended to
maintain functional status post-operatively
though this did not reach statistical
significance (P= 0.090).27 But their results
were comparable to ours, 88% were
ambulant pre-operatively and12% were
non-ambulant. Following treatment, 78%
of their patients who were ambulant preoperatively, maintained or improved their
functional status. These results are near to
ours as we had 50 patients ambulated
before surgery (81.9%) and after surgery
all preserved ambulation except 2 of them.
There was 5 patients non ambulated
preoperatively became ambulated after
surgery. So the net result was 53
ambulation after surgery (86.8%).
Sandalcioglu et al. reported that the
outcome was aggravated in 27 (34.6%) and
unchanged in 51 (65%) of 78 cases of
intramedullary tumor.34 McCormick et al.
reported that long follow-up evaluation
revealed an improvement in clinical grade
in 8 patients, no significant change in 12
patients, and deterioration in 3 patients.21
Epstein et al. reported that during the long
follow-up periods, clinical deterioration
was observed in 1 of 18 functional grade 1
patients, 4 of 11 grade 2 patients, 4 of 8
grade 3 patients. He concluded that the
morbidity of surgery was directly related to
the pre-operative neurological condition.5
Xu et al. mentioned that,
neurologic improvement after surgery is
more likely in patients undergoing total
resection than partial resection 39 Jallo et
al. reported, in their series, the extent of
resection gross total (>95%) or subtotal
resection (80-95%) did not significantly
affect the long-term
outcome. Only
patients who underwent a partial resection
(<80%) fared significantly worse than
those with radically removed tumors.10
McCormick et al. reported that
complete removal was achieved in all of 23
patients with ependymoma and no
recurrence was observed during the mean
follow-up periods of 62 months. Long
follow-up
evaluation
revealed
an
improvement in clinical grade in 8 patients,
no significant change in 12 patients, and
deterioration in 3 patients.21
In the series of Epstein et al. total
removal was achieved in 37 of 38
intramedullary spinal cord ependymomas.
During the long follow-up periods, clinical
deterioration was observed in 1 of 18
functional grade 1 patients, 4 of 11 grade 2
patients, 4 of 8 grade 3 patients.5
We compared the percentage of
total resection of ependymoma in some
series. Total resection rates vary from 58 to
100% of the cases. in different series.
21,42,1,5,9,12
(Table 7)
Table (7): The degree of resection in cases of ependymoma
Authors
McCormick et al., 1990
N
23
Total resection
22 (96%)
Partial resection
1 (4%)
Yoshii et al., 1999
8
6 (75%)
2 (25%)
Asazuma et al., 1999
26
15 (58%)
11 (42%)
Epstein et al., 1993
38
37 (97%)
1 (3%)
Hanbali et al., 2002
26
23 (88%)
3 (12%)
Joaquim et al., 2008
12
12 (100%)
0
Electophysiological
monitoring
(EPM) used in 49 cases and not used in 12
cases, in the monitored cases 30 cases
improved in postoperative neurological
state (61.2%) and the other 19 cases were
either deteriorated or not changed. In the
non monitored cases, 7 of 12 improved
(58.3%) and five deteriorated or not
changed from the preoperative state. There
was no statistically significant correlation
between usage of monitoring and final
outcome of the patient. At the same time
we cannot deny that presence of EPM gave
a sense of safety during the operations
ensuring that no waves were lost during
any of our surgeries but it couldn’t reach
the statistically significant levels.
Kothbauer et al. reported that
monitoring is a predictive of functional
motor outcome for intrinsic spinal cord
tumor surgery15. Jallo et al. reported that
the
intraoperative
monitoring
has
significantly improved the safety of
complete resection of intramedullary
neoplasms. In particular, the electrophysiological monitoring of motor
pathways is extremely helpful to achieve a
radical resection for these intramedullary
tumors.10 Kelleher et al. recommended
intraoperative monitoring in all operations
with neurological risk despite the low
incidence of neurological complications.
He also mentioned that, a limitation of
neurophysiological
monitoring is the
inherent inability to accurately record data
from the spinal cord with severe
preoperative dysfunction seen in patients
with
myelopathy,
trauma,
or
intramedullary tumors.16 This limitation in
our opinion is the factor that may prevent
the use of Neurophysiological monitoring
to reach the threshold to be statistically
evident. Another factor is lack of
prospective comparative studies that may
analyze usage versus non usage of
monitoring due to legal regulations.
Nagasawa et al. agreed with this
study in that, the presence of neurological
deficits and deterioration is not uncommon
complications associated with spinal cord
surgery. Such complications may be
particularly incapacitating and slow the
patient’s progress toward rehabilitation.
They added that such complications are
believed to result from a disruption of
adjacent microvasculature and edema
caused by surgical manipulation of
surrounding tissue. 22
Conti et al. advocated that
postoperative morbidity can be affected by
spinal location of nerve-sheath tumors,
with cervical and thoracic lesions
predicting worse neurological outcome
than more caudal sites.4 Kane et al reported
that, because of the infiltrative nature of
even low-grade fibrillary astrocytomas,
gross total resection of these tumors is
difficult without risking perioperative and
postoperative morbidity and mortality.13
Yanni et al. reported that, occasionally,
resection may become complicated by cord
edema, arachnoid fibrosis, or capillary
neovascularization, resulting in cord
rotation, asymmetrical enlargement.40
Lu et al. mentioned that
postoperative kyphosis is of particular
concern for tumors of the cervical and
lumbar spine, as these regions lack a rib
cage that can function as an internal brace
providing biomechanical support for the
thoracic levels 20. Joaquim et al. reported
that Cervical kyphosis was observed in two
cases (both on cervico-thoracic junction
with more than 3 level laminoplasty), that
required posterior instrumentation and fusion, but with no additional neurological
deterioration. 12
In the series of Karikari et al. the
patients with ependymomas, the more
common and less aggressive tumor, had a
tumor recurrence rate of 7%. Patients with
astrocytoma, the more aggressive and less
common tumor type, had a recurrence rate
of 48%.14 McCormick et al. reported that
complete removal was achieved in all of 23
patients with intradural spinal cord tumors
and no recurrence was observed during the
mean follow-up periods of 62 months.21
Kucia et al. reported three recurrences
(4.5%) followed definitive treatment
(average time 3.9 years; range, 2.2 to 5.6
years). 2 of these patients underwent gross
total resection (GTR) at presentation. 1
patient had a recurrence at the original site;
the other had a recurrence above the
original site. Both underwent GTR at the
time of recurrence.18 Subačiūtė in his
work about meningiomas, there were 6
recurrences 6% after the first operation
and subtotal tumour excision. Good results
at the last follow-up was found in 50% of
cases. These results are comparable to this
study 8.3%36 Nambiar et al. and Jenkinson
et al. have nearly the same overall
recurrence rate
11.0% and 10.4%
respectively in patients with intradural
spinal cord tumors which is near to
ours.24,11
There was a statistically relevant
correlation between the recurrence and the
degree of resection (P= 0.008), in all
cases with total resection 46 cases we had
only 3 recurrences while in partial
resection group we had 4 of 8 cases
recurred within the follow up period. This
is coincidental with most of the results in
the literature, Karikari et al. summarized
28 adult patients diagnosed with
astrocytomas and found that complete
tumor removal for low-grade astrocytomas
was achieved in 38.9% of patients (7/18)
and for high-grade astrocytomas in 20%
(2/10). They concluded that the extent of
surgery was closely associated with
recurrence and poor prognosis. 14 Gezen et
al. reported that , in case of menigiomas.
The tumor recurrence rate with total or
subtotal resection is between 3% and 7%.6
Conti et al. reported that in case of
nerve sheath tumors tumor recurrence is
less than 5% and might have a high
association with subtotal tumor removal4.
There was not any correlation
between recurrence and intraoperative
monitoring (IOM) or the approach used.
When reviewing the literature we did not
find specific works that could find a direct
relation
between
recurrence
and
intraoperative monitoring.
CONCLUSIONS:
The spinal cord tumors can be
treated safely and effectively by surgery as
a main method with or without any
adjuvant method in the form of
radiotherapy or chemotherapy. Total
resection must be the essential aim before
surgery and must be tried whenever
possible.
Preoperative neurological state,
pathological type, pathological grades, and
degree of resection are the most important
factors that affected the final outcome of
our patients
The most important predicting
factor for postoperative outcome is the
preoperative neurological condition. This
observation suggests that operative
treatment should be performed in an early
stage of the disease.
Age, sex, primary complaint,
approach used and neuromonitoring did
not appear significantly affect the final
outcome of patients. Intraoperative
neurophysiology of the spinal cord has
become a critical part of neurosurgery and
orthopedics surgery, as well as a part of
clinical neurophysiology.
Complications are encountered
mainly with high grade and infiltrative
masses that
were hard to be removed
without any post operative neurological
deficit. Recurrence is an important issue
and is directly correlated with the degree of
tumor resection and pathological grade and
infiltrative nature of the tumor. Once the
tumor is removed completely, close
clinical and radiological examination is
necessary to detect tumor re-growth at an
early stage.
REFERENCES:
1. Asazuma T, Toyama Y, Suzuki N,
Fujimura
Y,
Hirabayshi
K.
Ependymomas of the spinal cord and
cauda equine : an analysis of 26 cases
and a review of the literature. Spinal
Cord; 37:753-759, 1999
2. Babu R, Isaac O. Karikari, Owens R,
Carlos A Bagley. Spinal Cord
Astrocytomas A Modern 20-Year
Experience at a Single Institution,
Spine; 39(7):533-540, 2014
3. Balooshi M, M Hassounah, A Alkhani.
Prognostic factors in surgery for
intramedullary spinal ependymoma pan
Arab Journal of neurosurgery
volume 13, No. 2, 2009.
4. Conti P, Pansini G, Mouchaty H, et al.
Spinal
neurinomas:
retrospective
analysis and long-term outcome of 179
consecutively operated cases and review
of the literature. Surg Neurol; 61: 34–
43, 2004.
5. Epstein FJ, Farmer JP, Freed D. Adult
intramedullary
spinal
cord
ependymomas: the result of surgery in
38 patients. J Neurosurg 79: 204- 209,
1993.
6. Gezen F, Kahraman S, Canakci Z,
Beduk A. Review of 36 cases of spinal
cord meningioma. Spine; 25: 727–
31,2000.
7. Gomez DR, Missett BT, Wara WM,
Lamborn KR, Prados , Chang S, et al.
High
failure
rate
in
spinal
ependymomas with long-term followup. Neuro Oncol 7:254–259, 2005.
8. Groves D Morris. Tumors of the
intramedullary and intra dural space In"
Tumors of the brain and spine " 1st ed.
Forwarded by R. Sawaya New York,
Springer Science,pp302-310, 2007.
9. Hanbali F, Fourney DR, Marmor E, et
al. Spinal cord ependymoma: radical
surgical and outcome. Neurosurgery;
51:1162-1172, 2002.
10. Jallo GI, Bong-Soo Kim and Fred
Epstein: The Current Management of
In tramedullary Neoplasms in
Children and Young Adults Annals of
Neurosurgery, 1(1), 1-13, 2001.
11. Jenkinson MD, Simpson C, Nicholas
RS, Miles J, Findlay GF and Pigott
TJ:
Outcome
predictors
and
complications in the management of
Intradural spinal tumours. Eur Spine
J 15: 203–210, 2006.
12. Joaquim A F, marcos juliano dos
santos, hélder tedeschi: surgical
management of intramedullary spinal
ependymomas arq neuropsiquiatr;
67(2-a) : 284 – 289, 284, 2009.
13. Kane PJ, El-Mahdy W, Singh A,
Powell MP, Crockard HA. Spinal
intradural
tumours:
Part
II–
Intramedullary. Br J Neurosurg
13:558–563, 1999.
14. Karikari IO, Nimjee SM, Hodges TR,
Cutrell E, Hughes BD, Powers CJ, et
al. Impact of tumor histology on
resectability and neurological outcome
in primary intramedullary spinal cord
tumors: a single-center experience
with
102
patients.
Neurosurgery.;68(1):188-97, 2011.
15. Kaothbauer KF. Intraoperative neurophysiological
monitoring
for
intramedullary spinal cord tumor
16.
17.
18.
19.
20.
21.
22.
23.
24.
surgery. Neurophysiol Clin 37:407–
414, 2007.
Kelleher MO, Tan G, Sarjeant R,
Fehlings MG: Predictive value of
intraoperative
neurophysiological
monitoring during
cervical spine
surgery: a prospective analysis of 1055
consecutive patients. J Neurosurg
Spine 8:215–221, 2008.
Klekamp J, Samii M. Surgical results
for spinal meningiomas. Surg Neurol;
52:552– 62, 1999.
Kucia E, Nicholas C Bambakidis,
Steve W Chang, Robert F. Spetzler:
Surgical Technique and Outcomes in
the Treatment of Spinal Cord
Ependymomas, Part 1: Intramedullary
Ependymomas, vol. 68 operative
neurosurgery, 2011 .
Liu X D , Bing Sun , QiWu Xu ,
XiaoMing Che, Jie Hu, ShiXin Gu,
and JiaJun Shou, MD. Outcomes in
treatment for primary spinal anaplastic
ependymomas: a retrospective series
of 20 patients. J Neurosurg Spine
19:3–11, 2013
Lu DC, Lawton MT. Clinical
presentation and surgical management
of
intramedullary
spinal
cord
cavernous malformations. Neurosurg
Focus 29(3):E12, 2010.
McCormick PC, Torres R, Post KD,
Stein
BM.
Intramedullary
ependymoma of the spinal cord. J
Neurosurg; 72: 523 - 32, 1990.
Nagasawa D, B A, Zachary A Smith,
Nicole Cremer, Christina Fong, Daniel
C. Lu, and Isaac Yang: Complications
associated with the treatment for
spinal Ependymomas Neurosurg
Focus 31 (4):E13, 2011.
Nakamura M, K Ishii, K Watanabe, T
Tsuji, H Takaishi, M Matsumoto and
K Chiba : Surgical treatment of
intramedullary spinal cord tumors:
prognosis and complications, Spinal
Cord 46, 282–286, 2008.
Nambiar M, Kavar B: Clinical
presentation and outcome of patients
with intradural spinal cord tumours
Journal of Clinical Neuroscience 19
: 262–266, 2012.
25.
26.
27.
28.
29.
30.
31.
32.
33.
Neumann S and C Woolf :
Regeneration of Dorsal Column Fibers
into and beyond the Lesion Site
following Adult Spinal Cord Injury.
Neuron 23: 83-91, 1999.
Ohata K. , Takami T., Gotou1.T., ElBahy K., and Hakuba A: Surgical
Outcome of Intramedullary Spinal
Cord Ependymoma Acta Neurochir
(Wien) 141: 341- 347, 1999.
Quigley DG, Farooqi N, Pillay R,
Pigott TJ, Findlay GF, Buxton N and
Jenkinson MD:Outcome predictors in
the management of spinal cord
Ependymoma. Eur Spine J 16:399–
404, 2007.
Raco A, Manolo Piccirilli,
Alessandr O Landi, et al. High-grade
intramedullary astrocytomas: 30 years’
experience at the Neurosurgery
Department of the University of Rome
“Sapienza” J Neurosurg Spine
12:144–153, 2010.
Sala F, Albino B, Franco F, Paola
L, Massimo G: Surgery for
intramedullary spinal cord tumors : the
role
of
intraoperative
(neurophysiological) monitoring. Eur Spine
J 16:S130–S139, 2007.
Sala F, Palandri G, Basso E,
Lanteri P, Deletis V, Faccioli F, et al.:
Motor evoked potential monitoring
improves outcome after surgery for
intramedullary spinal cord tumors: a
historical
control
study.
Neurosurgery 58:1129–1143, 2006.
Samii M and KleKamp J:
Extramedullary Tumors. In Sami M
and KleKamp J (eds): Surgery of
Spinal Tumors, first edition, New
York, Springer Berlin Heidelberg, 4,
144-312, 2006.
Samii M and KleKamp J :
Extramedullary Tumors. In Sami M
and KleKamp J (eds): Surgery of
Spinal Tumors, first edition, New
York, Springer Berlin Heidelberg, 4,
144-312, 2006.
Samii
M
and
KleKamp
J:
Intratramedullary Tumors. In Sami M
and KleKamp J (eds): Surgery of
Spinal Tumors, first edition, New
34.
35.
36.
37.
38.
39.
40.
41.
42.
York, Springer Berlin Heidelberg, 3,
20-131, 2006.
Sandalcioglu, T Gasser, S Asgari,
A Lazorisak, T Engelhorn, T Egelhof,
D Stolke1 and H Wiedemayer:
Functional outcome after surgical
treatment of intramedullary spinal
cord tumors: experience with 78
patients IE Spinal Cord 43, 34–41,
2005.
Segal D, Lidar Z, Corn A,
Constantini S. Delay in diagnosis of
primary intradural spinal cord tumors.
Surg Neurol Int;3:52, 2012.
Subačiūtė
Jadvyga:Spinal
meningioma
surgery:
predictive
factors of outcome ACTA MEDICA
LITUANICA.. Vol. 17. No. 3–4. P.
133 – 136, 2010.
Sun J, Wang Z, Li Z, Liu B:
Microsurgical treatment and functional
outcomes
of
multi-segment
intramedullary spinal cord tumors
Journal of Clinical Neuroscience 16 :
666–671, 2009.
Sutter M, Eggspuehler A, Grob D
and
Dvorak J: The validity of
multimodal intraoperative monitoring
(MIOM) in surgery of 109 spine and
spinal cord tumors. Eur Spine J 16
(Suppl 2):S197–S208, 2007.
Xu QW, Bao WM, Mao RL, Yang
GY:
Aggressive
surgery
for
intramedullary tumor of cervical
spinal cord. Surg Neurol 46:322-328,
1996
Yanni DS, Ulkatan S, Deletis V,
Barrenechea IJ, Sen C, Perin NI :
Utility
of
neurophysiological
monitoring using dorsal column
mapping in intramedullary spinal cord
surgery. J Neurosurg Spine 12:623–
628, 2010.
Yeo D K, Soo Bin Im, Kwan
Woong Park, Dong et al.: Profiles of
Spinal Cord Tumors Removed through
a Unilateral Hemilaminectomy J
Korean Neurosurg Soc 50 : 195-200,
2011.
Yoshii S, Shimizu K, Ido K,
Nakamura T: Ependymoma of the
spinal cord and the cauda equina
region. J Spinal Disord;12:157-161,
1999.