Treatment of intramedullary tumors: analysis of surgical morbidity and long-term results

Clinical article

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Object

Surgery of intramedullary tumors is established as the treatment of choice for these challenging lesions. This study presents a detailed analysis of risk factors for surgical morbidity and data on long-term results for intramedullary tumors.

Methods

Among 1317 patients with tumors of the spinal canal treated between 1980 and 2012, 278 patients with intramedullary tumors are presented. A total of 225 of these patients underwent 246 operations for treatment of 250 tumors. The mean patient age was 41 ± 17 years (range 3 weeks to 83 years). Patients underwent follow-up through outpatient visits and questionnaires with a mean follow-up of 41 ± 53 months. Tumors were subdivided into 3 groups: displacing tumors (Type A, n = 162), infiltrating tumors (Type B, n = 80), and nonproliferating tumors (Type C, n = 8). A gross-total resection (GTR) was attempted for every tumor except for Type C lipomas. Participating surgeons were divided into 3 groups according to the number of operations they performed. Short-term results were determined for individual symptoms and the modified McCormick Scale, whereas tumor recurrence rates were calculated with Kaplan-Meier statistics.

Results

Overall, 83.3% of Type A tumors underwent GTR compared with 22.5% of Type B and none in Type C. Gross-total resection rates increased throughout the study period and correlated significantly with surgical experience. A worsened neurological state after surgery was seen in 61% of patients. This deterioration was transient in 41.5% and was a common observation after GTR. Permanent morbidity (19.5%) was lowest after GTR and correlated significantly with surgical experience and the preoperative neurological state. Further analysis showed that patients with tumors of thoracic levels, tumor hemorrhages, and malignant and recurrent tumors were at a higher risk for permanent morbidity. In the long term, tumor recurrence rates for ependymomas and benign astrocytomas correlated significantly with the amount of resection. Long-term morbidity affected 3.7% with a postoperative myelopathy related to cord tethering at the level of surgery and 21.9% in form of neuropathic pain syndromes. The rate of postsurgical cord tethering could be lowered significantly by using pia sutures after tumor resection. Neuropathic pain syndromes were more common after surgery for tumors with associated syringomyelia or those located in the cervical cord.

Conclusions

Intramedullary tumors should be surgically treated as soon as neurological symptoms appear. Gross-total resection is possible for the majority of benign pathologies. Cervical tumors are associated with higher GTR and lower permanent morbidity rates compared with thoracic tumors. Surgery on intramedullary tumors should be performed by neurosurgeons who deal with these lesions on a regular basis as considerable experience is required to achieve high GTR rates and to limit rates of permanent morbidity.

Abbreviations used in this paper:GTR = gross-total resection; PR = partial resection; STR = subtotal resection; VHL = von Hippel-Lindau.

Article Information

Address correspondence to: Jörg Klekamp, M.D., Department of Neurosurgery, Christliches Krankenhaus, Danziger Strasse 2, Quakenbrück 49610, Germany. email: j.klekamp@ckq-gmbh.de.

Please include this information when citing this paper: published online May 17, 2013; DOI: 10.3171/2013.3.SPINE121063.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A: Preoperative T2-weighted MR image of a C7–T2 subependymoma in a 36-year-old woman without a syrinx. The tumor appeared isodense on T1-weighted imaging without contrast enhancement. B: Postoperative image obtained 1 week later demonstrating GTR. C: Image obtained 3 months later confirming the complete resection without any adhesion of the spinal cord to the dura. No myelopathy or neuropathic pain syndrome developed. The patient retained her preoperative McCormick Grade I.

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    A: Preoperative T2-weighted MR image of a C6–T1 fibrillary astrocytoma in a 38-year-old man. The tumor was not accompanied by a syrinx, displayed no contrast enhancement, and appeared isodense to cord tissue on T1-weighted imaging. At another institution, the patient underwent a biopsy, which was nondiagnostic, with a C-6 and C-7 laminectomy and duraplasty for decompression. B: Due to the laminectomy a slight C7–T1 kyphosis developed. Due to neurological progression a second attempt for tumor removal was recommended. C: Postoperative MR image demonstrating GTR. D: The MR image obtained 1 year later discloses adhesions of the cord to the dura at the upper and lower poles of the duraplasty with adjacent hypodense signal changes in the posterior part of the cord. No myelopathy or neuropathic pain syndrome developed. The patient retained his preoperative McCormick Grade II.

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    A: Preoperative T2-weighted MR image of a T3–5 ependymoma with accompanying syrinx in a 70-year-old woman who was walking with assistance at presentation. Hemosiderin caps indicate minor tumor hemorrhages. B: The partly cystic tumor enhanced with contrast on T1-weighted imaging. C: The immediate postoperative T2-weighted image demonstrating GTR, preservation of the hemosiderin-containing gliosis, and decrease of the syrinx. D and E: Two years later, the sagittal (D) and axial (E) contrast-enhanced T1-weighted images with contrast show no tumor recurrence or remnant, a further decrease of the syrinx, and tethering of the cord to the dura posteriorly. The patient's postoperative neurological course was characterized by a significant worsening of motor functions and gait followed by an incomplete recovery, leaving the patient wheelchair dependent. Three months after surgery, her neuropathic pain syndrome started to become considerably aggravated.

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