Surgical approaches and long-term outcomes of intramedullary spinal cord cavernous malformations: a single-center consecutive series of 219 patients

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OBJECTIVE

Optimal surgical strategies for intramedullary spinal cord cavernous malformations (ISCCMs) are not optimized and remain problematic. In this study the authors identify rational surgical strategies for ISCCMs and predictors of outcomes after resection.

METHODS

A single-center study was performed with 219 consecutive surgically treated patients who presented from 2002 to 2017 and were analyzed retrospectively. The American Spinal Injury Association (ASIA) Impairment Scale was used to evaluate neurological functions. Patient characteristics, surgical approaches, and immediate and long-term postoperative outcomes were identified.

RESULTS

The average ISCCM size was 10.5 mm. The spinal level affected was cervical in 24.8% of patients, thoracic in 73.4%, and lumbar in 1.8%. The locations of the lesions in the horizontal plane were 30.4% ventral, 41.6% dorsal, and 28.0% central. Of the 214 patients included in the cohort for operative evaluation, 62.6% had superficially located lesions, while 37.4% were embedded. Gross-total resection was achieved in 98.1% of patients. The immediate postoperative neurological condition worsened in 10.3% of the patients. Multivariate logistic regression identified mild preoperative function (p = 0.014, odds ratio [OR] 4.5, 95% confidence interval [CI] 1.4–14.8) and thoracolumbar-level lesions (p = 0.01, OR 15.7, 95% CI 1.9–130.2) as independent predictors of worsening. The mean follow-up duration in 187 patients was 45.9 months. Of these patients, 63.1% were stable, 33.2% improved, and 3.7% worsened. Favorable outcomes were observed in 86.1% of patients during long-term follow-up and were significantly associated with preoperative mild neurological and disability status (p = 0.000) and cervically located lesions (p = 0.009). The depths of the lesions were associated with worse long-term outcomes (p = 0.001), and performing myelotomy directly through a yellowish abnormal surface in moderate-depth lesions was an independent predictor of worsening (p = 0.023, OR 35.3, 95% CI 1.6–756.3).

CONCLUSIONS

Resection performed with an individualized surgical approach remains the primary therapeutic option in ISCCMs. Performing surgery in patients with mild symptoms at the thoracolumbar level and embedded located lesions requires more discretion.

ABBREVIATIONS ADREZotomy = anterior to dorsal root entry zone myelotomy; ASIA = American Spinal Injury Association; CI = confidence interval; CM = cavernous malformation; DREZotomy = dorsal root entry zone myelotomy; ISCCM = intramedullary spinal cord CM; OR = odds ratio.

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Article Information

Correspondence Hongqi Zhang: Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China. xwzhanghq@163.com.

INCLUDE WHEN CITING Published online April 5, 2019; DOI: 10.3171/2018.12.SPINE181263.

J.R. and T.H. contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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    Surgical approaches used in ISCCMs through safe entry zones. A: Surgical approach for dorsally located ISCCMs. Preoperative MRI indicated dorsally located ISCCMs. Intraoperative photographs show the myelotomy performed through the posterior midline. Illustration showing posterior midline myelotomy for dorsal/central lesions, with an arrow indicating the approach to posterior lesions through the dorsal median sulcus. B: Surgical approach for posterolateral ISCCMs. Preoperative MRI indicated posterolateral ISCCMs. Intraoperative photographs show the DREZotomy. Illustration show the approach used in posterolateral lesions through the substantia gelatinosa and the posterolateral tract of Lissauer (arrow). C: Lateral approach for lateral ISCCMs. Preoperative MRI indicated lateral ISCCMs. Intraoperative photographs and illustration show the lateral myelotomy performed between the ventral and dorsal nerve roots on the ventral side of the dentate ligament (arrow). D: ADREZotomy for ventrolateral ISCCMs. Preoperative MRI indicated ventrolateral ISCCMs. The spinal cord was entered between the dorsolateral tract and the dorsal spinocerebellar tracts, anterior to the lateral fasciculus proprius of the spinal cord and posterior to the lateral corticospinal tract. Artwork is published with the permission of the artist, Jian Ren. Figure is available in color online only.

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    ASIA scale grades (A–E) at admission, immediately postoperative, and at the final follow-up clinical evaluation in 187 patients. Figure is available in color online only.

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    Images obtained in a 38-year-old woman who presented with transient pain in the back. Preoperative MRI (A and B) indicated thoracic ISCCMs dorsally located at the T7 vertebral level. The ASIA scale grade was E (normal). Intraoperative photographs (C and D) show the surgical procedures. A slightly yellowish abnormal surface was noticed at the left dorsal column (arrow). A myelotomy was performed through the abnormal surface. Gross-total resection was achieved. Immediately after surgery, the patient complained of a new symptom of numbness of the left lower extremity. The ASIA scale grade was D. During the follow-up of 12 years, the patient’s neurological function remained unchanged with numbness of the left lower extremity. This case highlights that myelotomy directly through the yellowish abnormal surface of the moderate-depth lesions may cause irreversible worsening after surgery and a myelotomy trans safe entry zone is still the first choice. Figure is available in color online only.

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