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Radical excision of intramedullary spinal cord tumors: surgical morbidity and long-term follow-up evaluation in 164 children and young adults

Shlomi Constantini, Douglas C. Miller, Jeffrey C. Allen, Lucy B. Rorke, Diana Freed, and Fred J. Epstein

Object. The majority of intramedullary spinal cord tumors (IMSCT) in children and young adults are low-grade gliomas. Radical resection of similar tumors in the cerebral hemisphere or cerebellum is usually curative; however, the conventional management for IMSCTs remains partial resection followed by radiotherapy because of the concern for surgical morbidity. Nevertheless, radical resection of IMSCTs without routine adjuvant treatment has been the rule at our institution since 1980. In an attempt to resolve this controversy, the long-term morbidity and survival in a large series of children have been retrospectively reviewed.

Methods. The database records and current status of 164 patients 21 years of age and younger in whom an IMSCT was resected were reviewed. A gross-total resection (> 95%) was achieved in 76.8% of the surgical procedures. Subtotal resections (80–95%) were performed in 20.1%. The majority of patients (79.3%) had histologically low-grade lesions.

There were no deaths due to surgery. When comparing the preoperative and 3-month postoperative functional grades, 60.4% stayed the same, 15.8% improved, and 23.8% deteriorated. Only 13 patients deteriorated by more than one functional grade. Patients with either no deficits or only mild deficits before surgery were rarely injured by the procedure, reinforcing the importance of early diagnosis and treatment.

The major determinant of long-term patient survival was histological composition of the tumor. The 5-year progression-free survival rate was 78% for patients with low-grade gliomas and 30% for those with high-grade gliomas. Patients in whom an IMSCT was only partially resected (< 80%) fared significantly worse.

Conclusions. The long-term survival and quality of life for patients with low-grade gliomas treated by radical resection alone is comparable or superior to minimal resection and radiotherapy. The optimum therapy for patients with high-grade gliomas is yet to be determined.

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Intramedullary spinal cord tumors in patients older than 50 years of age: management and outcome analysis

Raj K. Shrivastava, Fred J. Epstein, Noel I. Perin, Kalmon D. Post, and George I. Jallo

Object. Intramedullary spinal cord tumors (IMSCTs) in the older-age adult population pose complex management issues regarding the extent of resection and functional outcome, especially in terms of quality of life. Historically, IMSCTs in the older adult population were treated with irradiation alone because it was assumed that functional recovery would be poor. The authors examined their IMSCT database and report the first large series of IMSCTs in patients older than 50 years of age.

Methods. In this retrospective clinical and chart review there were 30 cases meeting inclusion criteria drawn from databases at three different institutions. A modified McCormick Scale was used to assess functional levels in all 30 patients pre- and postoperatively. The mean age of patients in this cohort was 59.8 years (range 50–78 years), and the mean follow- up period was 10.6 years (range 2–16 years).

Ependymoma was the most common tumor (83%), and 55% were located in the thoracic spine. The most common presenting symptom was sensory dysesthesia, with rare motor loss. The prodromal period to treatment was 19.4 months. Based on the McCormick Scale score at last follow-up examination 67% of patients were clinically functionally the same, 9% were worse, and 24% were improved after surgery. There were two deaths due tumor progression (both malignant tumors) and one recurrence (anaplastic astrocytoma). All three patients in whom malignant astrocytomas were diagnosed underwent postoperative radiation therapy.

Conclusions. In the population of patients older than age 50 years, thoracic ependymomas are the most common IMSCTs that present characteristically with sensory symptoms. The longer prodromal period in the older adult population may reflect the fact that their diagnosis and workup is inadequate. There was no significant increase in the length of stay in the neurosurgical ward. The authors recommend motor evoked potential-guided aggressive microsurgical resection, because the long-term outcome of benign lesions is excellent (good functional recovery and no tumor recurrence).