Intradural Extramedullary Research Articles

Surgical Outcome of Tumors of Spinal cord, Nerve roots, Meninges, and Vertebral column – Our Experience in Tertiary level Hospital

Background: Spinal cord tumors can result in dramatic neurological and functional disabilities in the patients. We aimed to know the different types of spinal tumors and the correlation between clinical presentation and pathological findings and compare the outcomes of these tumors postoperatively. Methods: A total of 410 patients were included in the retrospective study group. The duration of the study was January 2016 to October 2022 (82 months). After a thorough clinical evaluation, patients were subjected to magnetic resonance imaging (MRI) and then surgery. They were described based on age, sex, location of the tumor, type of the tumor, symptoms, histopathological type, surgical resection, and complications. Results: The study included 229 (56%) males and 181 (44%) females and their ages ranged from 6 years to 74 years. Out of the 410 patients, 203(49.51%) had intradural extramedullary, 121(29.51%) had extradural and 86(20.98%) had intradural intramedullary spinal tumors. A predilection towards the thoracic region (39.50%) and cervical region (28.40%). Lumbar region (20.10%) and Sacral region (4.10%), Cervicodorsal region (1.40%), Dorsolumbar region (3.00%), and Craniovertebral junction (3.50%) were seen. The tumors were excised completely in 72.68% of the patients while neartotal resection was done in 17.82%, subtotal resection in 7.32%, and only biopsy in 2.2% of patients. Histopathologically most of the tumors were Schwannoma (38.78%), then Meningioma (11.71%), Ependymoma (11.70%), Astrocytoma (10.98%), and others were found. There was significant improvement (33.66%) in the modified McCormicks score at discharge follow-up. Conclusions: Intradural extramedullary is the most common spinal cord tumor. The majority of the cases presented with sensorimotor symptoms and pain is the predominant clinical complaint. Spinal cord tumors are most commonly observed in the 2nd to 4th decade of life with a gradual decline in the incidence towards the extremes of age group. Surgery is the definitive treatment and the aim of the surgery is gross total resection Bang. J Neurosurgery 2024; 13(2): 112-120

Does the presence or absence of preoperative lower extremity neurologic symptoms influence postoperative clinical outcome in patients with cervical intradural extramedullary tumors?: a single-center retrospective comparative study.

Retrospective comparative study OBJECTIVES: To investigate whether the presence or absence of preoperative lower extremities neurological symptoms (LENS) influences clinical outcomes following tumor resection in patients with cervical intradural extramedullary (IDEM) tumors. The single institution in Japan. Ninety-two patients with cervical IDEM tumors requiring surgical resection were included. Based on the degree of preoperative LENS assessed using the modified McCormick scale (MMCS), patients were categorized into LENS (-) and (+) groups. Demographic and surgical characteristics were compared between both groups. There were no significant differences observed in sex, tumor location, tumor size, surgical time, estimated blood loss, approach for tumorectomy, or tumor histopathology between the two groups. Additionally, the overall surgical outcomes were favorable for both groups. At the final follow-up, 91.1% of the patients in the LENS (+) group were able to walk without support. Improvement in LENS was observed after surgery in most patients with preoperative MMCS II-IV, but it persisted in approximately 40% of patients with preoperative MMCS V. In the LENS (+) group, there were no significant differences in demographic or surgical data between the patients with MMCS I and II-III at the final follow-up. Regardless of the presence or absence of preoperative LENS, clinical improvement was observed after tumor resection in most patients with cervical IDEM tumors. These findings suggest that neurological status is likely to improve sufficiently if tumor resection is performed before preoperative LENS deteriorates to an extremely severe stage as MMCS V.

Management of intradural extramedullary and intramedullary spinal tumors

Intradural spine tumors are relatively uncommon and include tumors outside (extramedullary) or within the spinal cord (intramedullary). The proximity of these tumors to important neural structures can cause significant neurologic morbidity and prompt management is critical for maintaining function. Surgical intervention is generally the primary treatment depending on presenting symptoms, radiologic features, and the likelihood of a clear surgical planes vis-à-vis the spinal cord. Adjuvant radiation, chemotherapy, or other novel therapeutic strategies may play a role in postoperative management. Here we review management strategies for common intradural extramedullary (meningiomas, schwannomas, and neurofibromas) and intradural intramedullary tumors (astrocytomas, ependymomas, and hemangioblastomas).

Transcranial Corticospinal Motor-Evoked Potentials in Cases of Ventral and Ventrolateral Intradural Extramedullary Cervical Spinal Cord Tumors.

Background and Objectives: We studied the clinical significance of an amplitude decrement and disappearance alarm criteria in transcranial motor-evoked potential (MEP) monitoring during surgeries on extramedullary tumors at the cervical spine with reference to postoperative morbidity. Material and Methods: We diagnosed and surgically treated fourteen patients with intradural extramedullary ventral or ventrolateral lesions to the cervical spinal cord in the Clinic of Neurosurgery at the University Hospital St Ivan Rilski from January 2018 to July 2022. Eight cases were diagnosed with schwannoma, and the remaining six had meningiomas. The follow-up period for neurological assessment was six months. Results: A decrease in the intraoperative transcranial MEPs of 50% or more compared to baseline in two cases (14.3%) resulted in an immediate postoperative motor deficit. One patient demonstrated full neurological recovery within six months, while the other exhibited only partial improvement. In six cases (42.9%) with preoperative motor deficits, tumor resection and decompression of the cervical spinal cord led directly to an increment of the transcranial MEPs by more than 20%. Postoperatively and at the 6-month follow-up, these patients showed recovery from the preoperative deficits. In the remaining cases, MEPs were stable during surgery with no clinical deterioration of the motor function. Conclusions: The decremented MEP criteria corresponded to postoperative motor deficit, whereas the improvement of the same parameters after decompression implied future recovery of preoperative motor deficits. The combination of different MEP criteria is likely to be helpful when tailored to a specific case of ventral or ventrolateral extramedullary lesions in the cervical spine.

Identifying functional cortical plasticity after spinal tumour resection using navigated transcranial magnetic stimulation.

Our aim was to investigate the effectiveness of navigated transcranial magnetic stimulation (nTMS) brain mapping to characterise preoperative motor impairment caused by an intradural extramedullary (IDEM) tumour and postoperative cortical functional reorganisation. Preoperative and 1-year follow-up clinical, radiological and nTMS data from a case of thoracic spinal meningioma that underwent surgical resection of the lesion were collected and compared. A 67-year-old patient presented with severe progressive thoracic myelopathy (hypertonic paraparesis, clonus, insensate urinary retention) secondary to an IDEM tumour. Initial nTMS assessment showed bilateral upper limb representation with no positive responses for both lower limbs. He underwent successful surgical resection for his IDEM (meningioma WHO grade 1). At 1-year follow-up, the patient's gait was improved and his bladder function normalised. nTMS documented positive responses for both upper and lower limbs and a decrease in the area (right side: 1.01 vs 0.39cm2; left side: 1.92 vs 0.81cm2) and volume (right side: 344.2 vs 42.4uVcm2; left side: 467.1 vs 119uVcm2) of cortical activation for both upper limbs, suggesting a functional reorganisation of the motor areas after tumour resection. nTMS motor mapping and derived metrics can characterise preoperative motor deficit and cortical plasticity during follow-up after IDEM resection.

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

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

Epidemiology study on the prognostic factors of intradural extramedullary spinal tumors.

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. 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. 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). 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.

SPINAL INTRADURAL EXTRAMEDULLARY TUMORS AND SIMILAR PATHOLOGIES: A SINGLE CENTER STUDY

Background: We wanted to analyze the neurological symptoms and prognosis of five spinal IDEM (intradural extramedullary) tumors cases diagnosed, and to emphasize that a spinal cord tumor can be found incidentally in evoluation of the proximal regions of the vertebral column in patients who were mistakenly operated for lumbar disc herniation on lumbar MRI, but whosesymptoms did not resolve. Objective: To emphasize the need for examinations such as MRI along the vertebral columna in patients with different spinal pathologies and whose symptoms and clinical signs do not improve. Methods: Patients with spinal IDEM tumors treated with surgical excision and followed for more than 2 years were retrospectively analyzed. Issessed pain with the visual analo scale (VAS), and neurological function with the Nurrick grade.Preoperative complaint time,location of tumor in sagital and axial sections in MRI and pathological diagnosis were investigated. Results: The pathological diagnosis in our study was meningioma in two cases,dural arteriovenous fistula in one case,teratoma in one case ,and myxopapilary epandimoma in one case.İn one case,disc herniation surgery was performed in another hospital due to misdiagnosis, but because the patient’s complaints were resistant. In examination, an IDEM tumor at T11 level was detected, and he was operated. In all cases the VAS score (mean) was reduced from 7.8 to 0.4 as well as the Nurrick grade (mean) was from 2.0 to 0.6. In the dAVF case, spasticity in the lower extremities, bladder and bowel disfunction continued. Conclusion: In cases with severe neurological deficits, MRI scanning of the proximal parts of the vertebral column will help in the differential diagnosis of the lesion occupying the intraspinal space.

Delayed Presentation of Intradural Extramedullary Tuberculoma of Spine in an Immunocompetent MDR-TB Patient

Abstract Intradural spinal tuberculoma is a rare entity, constituting <5% of CNS tuberculoma, whereas intradural extramedullary tuberculoma of spinal cord (IETSC) is even less frequently encountered. Here, we report a case of IETSC at two noncontiguous levels in spinal cord presenting with compressive myelopathy in a patient on multidrug-resistant tuberculosis (MDR-TB) treatment. Surgical decompression and appropriate ATT regimen resulted in gradual return to near-normal neurological function with no functional disability. To our knowledge, this is the first case report of IETSC developing in an immunocompetent patient on MDR regimen for drug resistant sputum-positive pulmonary tuberculosis.

Diagnostic Accuracy of Somatosensory Evoked Potential and Transcranial Motor Evoked Potential in Detection of Neurological Injury in Intradural Extramedullary Spinal Cord Tumor Surgeries: A Short-Term Follow-Up Prospective Interventional Study Experience from Tertiary Care Center of India.

Objective Intraoperative neuromonitoring (IONM) is an acknowledged tool for real-time neuraxis assessment during surgery. Somatosensory evoked potential (SSEP) and transcranial motor evoked potential (MEP) are commonest deployed modalities of IONM. Role of SSEP and MEP in intradural extramedullary spinal cord tumor (IDEMSCT) surgery is not well established. The aim of this study was to evaluate sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of SSEP and transcranial MEP, in detection of intraoperative neurological injury in IDEMSCT patients as well as their postoperative limb-specific neurological improvement assessment at fixed intervals till 30 days. Materials and Methods Symptomatic patients with IDEMSCTs were selected according to the inclusion criteria of study protocol. On modified McCormick (mMC) scale, their sensory-motor deficit was assessed both preoperatively and postoperatively. Surgery was done under SSEP and MEP (transcranial) monitoring using appropriate anesthetic agents. Gross total/subtotal resection of tumor was achieved as per IONM warning alarms. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of SSEP and MEP were calculated considering postoperative neurological changes as "reference standard." Patients were followed up at postoperative day (POD) 0, 1, 7, and 30 for convalescence. Statistical Analysis With appropriate tests of significance, statistical analysis was carried out. Receiver-operating characteristic curve was used to find cutoff point of mMC for SSEP being recordable in patients with higher neurological deficit along with calculation of sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of SSEP and MEP for prediction of intraoperative neurological injury. Results Study included 32 patients. Baseline mean mMC value was 2.59. Under neuromonitoring, gross total resection of IDEMSCT was achieved in 87.5% patients. SSEP was recordable in subset of patients with mMC value less than or equal to 2 with diagnostic accuracy of 100%. MEP was recordable in all patients and it had 96.88% diagnostic accuracy. Statistically significant neurological improvement was noted at POD-7 and POD-30 follow-up. Conclusion SSEP and MEP individually carry high diagnostic accuracy in detection of intraoperative neurological injuries in patients undergoing IDEMSCT surgery. MEP continues to monitor the neuraxis, even in those subsets of patients where SSEP fails to record.

Differentiation of the Intradural Extramedullary Spinal Tumors, Schwannomas, and Meningiomas Utilizing the Contrast Ratio as a Quantitative Magnetic Resonance Imaging Method

Schwannomas and meningiomas are the most common intradural extramedullary spinal tumors; however, differentiating between them using magnetic resonance imaging (MRI) is a frequent challenge. In this study, we aimed to investigate the use of the contrast ratio (CR) as a quantitative MRI method in the differentiation of schwannomas and meningiomas. We analyzed the data of patients with intradural extramedullary spinal tumors who underwent surgery and were diagnosed with either schwannomas or meningiomas by histopathological analysis. Regions of interest were set for the entire spinal tumor on T2-weighted sagittal MRI. To obtain the CR values of spinal tumors (CRtumor), we used the signal intensity (SI) values of the tumor (SItumor) and spinal cord (SIcord) according to the following formula: [CRtumor= (SItumor-SIcord)/(SItumor+SIcord)]. The study included 50 patients (23 males and 27 females) with a mean age of 61.5 years old (11-85 years old). Histopathological analysis revealed that 33 and 17 patients were diagnosed with schwannomas and meningiomas, respectively. The mean CR values of the schwannomas and meningiomas were 0.3040±0.1386 and 0.0173±0.1929, respectively. The CR value of the schwannomas was statistically significantly higher than that of meningiomas (P<0.01). The cutoff CR value obtained from the receiver operating characteristic curve was 0.143, with a specificity and sensitivity of 90.9% and 88.2%, respectively. Furthermore, the value for the area under the receiver operating characteristic curve was 0.925 (95% confidence interval: 0.852-0.998). The evaluation of CRs by using MRI to distinguish between schwannomas and meningiomas is a beneficial quantitative tool.

Functional outcomes in intradural extramedullary spinal tumors.

Intradural extramedullary (IDEM) spinal cord tumors account for approximately two-thirds of benign intraspinal neoplasms. These are amenable to gross total excision but can have variable functional outcomes, which plays a key role in assessing their impact on a patient's quality of life. Understanding the functional outcomes associated with these tumors is crucial for healthcare professionals to devise appropriate treatment plans and provide comprehensive care. In this study, we retrospectively reviewed the outcomes of 130 patients with IDEM tumors who underwent surgery in the past six years between January 2017 and December 2022 at a single institution. Patient demographics, symptoms, and tumor characteristics (anatomical and pathological) in all operated spinal IDEM tumors were analyzed. The neurological findings obtained during the preoperative stage and the postoperative follow-up were evaluated according to the Frankel grading. The back pain was assessed using the Denis pain scale (DPS). The age range, gender distribution, presentation, histopathology, and tumor characteristics were analyzed. The histopathological outcomes of the study were as follows: 56 cases of schwannoma, 37 cases of meningiomas, 16 patients of neurofibroma, six cases of epidermoid cyst, five cases each of ependymoma and dermoid cyst, three cases of arachnoid cyst, two cases of metastasis, and one case of paraganglioma. Pain was the most common symptom (38.5%), followed by weakness in limbs (31.5%), paresthesia/numbness (22.3%), and sphincter disturbance (7.7%). Complete total resection was seen in 93% of cases, with 7% undergoing subtotal excision. The complications encountered were - four cases of surgical site infection and one case each of cerebrospinal fluid leak, pseudomeningocele, and epidural hematoma. In our series, 49.3% of patients had significantly good improvement in functional outcomes as per improvement in Frankel score, and 43% of patients had good functional improvement. Significant functional improvement was noted at immediate postoperative follow-up, 2-week follow-up, and six-month follow-up periods. Reoccurrence was seen in 7 cases (5.4%). The DPS score mean values showed a significant decrease over the follow-up duration as compared to preoperative mean values. Significantly poor outcome was seen in IDEM tumours present anteriorly. The IDEM tumors are usually benign and are readily detected by contrast-enhanced magnetic resonance imaging scans. These have variable functional outcomes in different centers. Assessing this functional outcome is an essential aspect of managing IDEM spinal tumors. It was observed through our study that the ventral location of the tumor, thoracic tumors, and poor preoperative neurological status of the patient correspond with poorer postoperative functional outcomes. Furthermore, a significant decrease in the pain symptoms with improvement of Frankel score was seen postoperatively, thus this being suggestive of a significant improvement of functional outcome after surgery. This study helps to conclude that the morbidity associated with the resection of IDEM tumors is not as significant as originally thought to be.

Evaluation of surgically treated primary spinal cord tumors in a single Indian institution: A case series study of 178 patients.

Primary spinal cord tumors are rare tumors that are usually heterogeneous having variable histopathological subtypes. Rapidly, growing space-occupying lesions in the spinal canal cause severe loss of function. This study aimed to analyze all adult patients diagnosed with primary spinal cord tumors and to describe their location, symptoms, histopathological types, surgical outcome, complications, recurrence in a single institution, and prognostic factors. The study was a retrospective study of 178 patients with spinal tumor who underwent surgical intervention at the department of neurosurgery at a tertiary care institute from 2014 to 2021. Patient demographic characteristics, symptoms, radiological features, spinal level of tumor, spinal compartment, preoperative and postoperative McCormick grade, and complications were recorded, and a comparison of outcomes after surgical intervention was done. In our study, 97 patients were males and the rest of the 81 patients were females. The mean age at the time of surgery was 43.5 years. The thoracic region of the spinal canal was the most involved with 67 (37.64%) cases, whereas intradural extramedullary was the most common (65.73%). Schwannoma was the most common histopathological subtype (46.06%). Total excision was achieved in 154 cases. A total of 37 patients were in Grades 4 and 5 of modified McCormick's grade preoperatively. However, postoperatively, there were only 17 patients in this group. Two patients with cervical intramedullary tumor expired in the postoperative period. Early surgical intervention with sound microneurosurgical skills gives good outcomes independent of the type and location of tumor. Better outcomes are seen in extradural tumors, early surgical intervention, tumors better amenable to total resection, and in patients with better preoperative neurological status.

Digital 3D Exoscope is Safe and Effective in Surgery for Intradural Extramedullary Tumors: A Comparative Series

Digital 3D exoscopes have been shown to be comparably safe and effective as surgical microscopes in complex microneurosurgical procedures. However, the results of exoscopic spinal tumor surgeries are scarce. The purpose of this study is to compare results of a transition from microscope to exoscope in surgeries for spinal intradural extramedullary tumors. We included all consecutive patients with intradural extramedullary spinal tumors operated on by the senior author during January 2016 to October 2023. The 3D exoscope was used in the latter half of the series from November 2020. We evaluated pre- and postoperative clinical findings, imaging studies, intra- and postoperative events, and analyzed surgical videos from the operations retrospectively. We operated 35 patients (exoscope n= 19, microscope n= 16) for intradural extramedullary tumors (meningioma n= 18, schwannoma n= 12, other n= 5). Tumors in the cervical and thoracic spine were more common than in the lumbar region. The duration of surgery was slightly longer (median 220 vs. 185 minutes) in the exoscope group. However, the rate of gross total resection of the tumor was higher (81% vs. 67%) and the tumors more often located anteriorly to the spinal cord (42% vs. 13%) in the exoscope group. No major complications (i.e., permanent motor deficit or postoperative hematoma) occurred in either group. We saw postoperative gait improvement in 81% and 85% of the patients with preoperative deterioration of gait after exoscopic and microscopic surgeries, respectively. This study demonstrates that exoscope-assisted surgery for spinal intradural extramedullary tumors is comparable in safety and effectiveness to traditional microscopic surgery.

Upstream Effects: Intraoperative Migration of Intradural Extramedullary Tumor After Non–Adjacent Level Stenosis Decompression

A 74 year-old man with back pain, foot numbness, and hip/thigh radiculopathy was found to have an L1-2 intradural extramedullary (IDEM) neoplasm and severe L4-5 stenosis. He was taken to surgery for L4-5 minimally-invasive (MIS) laminectomy for decompression and concomitant L1-2 MIS laminectomy for tumor resection. The L4-5 laminectomy was completed first followed by the separate L1-2 laminectomy. Upon extensive intradural exploration at L1-2, no neoplasm was found. Immediate postoperative imaging showed that the IDEM tumor had migrated caudally by nearly a complete spinal level, presumably as a result of changes in cerebrospinal fluid pressure and resultant shift in intradural contents after the L4-5 laminectomy. The patient was taken back to surgery for successful resection of the IDEM, with improvement in his symptoms.

Intradural Extramedullary Spinal Tumors: A Clinical Study and Management without the Aid of Nerve Monitoring

Abstract Background: The incidence of primary spinal cord tumors is less and the true incidence is still not known and various studies are still being done. These tumors are benign and slow growing, and they generally present with pain – either radiculopathy or axial back pain or focal neurological deficits due to the loss of roots, myelopathy from spinal cord compression, or cauda equina symptoms due to chronic compression. Early diagnosis and operation are gratifying as the lesions are mostly benign and can be completely resected as well as preservation of functionality if operated as early as possible. Although rare, an inadvertent neurological injury during surgery is a concerning complication that can potentially be prevented with the assistance of intraoperative nerve monitoring (IONM). This technology enables real-time assessment of spinal cord function by providing feedback from sensory tracts, motor tracts, and individual nerve roots. However, the definitive requirement for IONM in the treatment of a highly curable condition is still under consideration. Objective: our study aims at studying the clinical features of intradural extramedullary tumors and their operative management without nerve monitoring. Material and Methods: Patients with intradural extramedullary (IDEM) spinal cord tumors who fit the inclusion criteria and who were willing to investigations, surgical procedures, and follow up were enrolled in the study, and consent was obtained. Patient assessment was done clinically by McCormick’s Scale and radiologically by magnetic resonance imaging. Patients who underwent operation were followed up. The data was collected and analysed using SPSS software. Results: Nineteen patients were enrolled in the study. The age group ranged from 6 years to 79 years. There were 13 females and 6 males in the study group. The common presenting complaints were backache and upper and lower limb pain. Nine out of the 19 patients underwent operative procedures after thorough radiological and clinical evaluation. Histopathology showed five cases of schwannoma and four cases of meningioma. The mean McCormick’s Scale preoperatively was 4.11, whereas postoperatively, it was 3.10. The operative procedures were performed without the aid of IONM, yet there were no inadvertent intraoperative injuries and postoperative outcomes were good. Our study data were comparable with other studies. Conclusion: IDEM tumors, though technically challenging to operate, have excellent results in terms of outcomes due to their benign characteristics as well as complete resectability. Therefore, it is essential to conduct a comprehensive examination and imaging for patients experiencing backaches and weakness. Following a careful evaluation, early surgical intervention should be considered, as the timeliness of the surgery contributes to enhanced outcomes. The unavailability of nerve monitoring did not portend any added risk of surgery if done meticulously though its aid would make the operative procedure safer and gross resection better.

Isolated lumbar myxopapillary ependymoma Case-report

INTRODUCTION Spinal ependymoma is described typically as an intramedullary tumor arising from ependymal cells lining the ventricles and the central spinal canal. Intradural extramedullary (IDEM) ependymomas subtype are extremely rare. (1) Case-report: It’s about a 32-year-old patient with no past medical history who was admitted to our neurosurgical department for non-systematized bilateral lumbocrural pain set on upon an intense sport activity limiting his ability of walking with a perimeter reduced to 50 meters deteriorating progressively over 6 months.

SURG-27. 17-YEAR EXPERIENCE OF SURGICAL MANAGEMENT OF INTRADURAL EXTRAMEDULLARY (IDEM) TUMORS: CLINICAL OUTCOMES FROM A LOW- AND MIDDLE-INCOME COUNTRY

Abstract INTRODUCTION Surgical outcomes of intradural extramedullary (IDEM) tumors have been well-reported in the literature from high-income countries. However, limited contemporaneous data from low- and middle-income countries (LMICs) exists. This study sought to analyze the clinical outcomes of all IDEM tumor cases operated during a 17-year period at a resource-limited setting in an LMIC. METHODS The present work was conducted and reported in accordance with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. A retrospective cohort study was carried out to analyze all IDEM tumor cases, operated upon by a consultant neurosurgeon, during 2004-2021, at a resource-limited setting in Southern India. All patients underwent routine biochemical and radiological investigations, including contrast-enhanced MRI. Laminectomy and tumor resection under the microscope were done without using intraoperative neuro-monitoring. Nerve fibers running through the tumor were sacrificed. Bilateral facet joints were preserved to ensure integrity without spinal fusion. All cases received a dural closure with 5-0 Prolene, with postoperative MRI confirming complete resection. Patients received telephonic and/or in-person follow-up visits. RESULTS 50 patients with a mean age of 46.3 years (range 13-80) were included, with 31 males and 19 females. Their clinical presentation included radiculopathy (78%), radiculomyelopathy (12%), and radiculomyelopathy with bowel and bladder symptoms (10%). Histologically, schwannomas were the most common (52%), followed by neurofibromas (34%), meningiomas (12%), and ependymomas (2%). Two individuals were diagnosed with Neurofibromatosis Type 1. All meningiomas occurred in the thoracic region, with 83.3% of cases being in females. All patients had symptomatic relief postoperatively. No major adverse events occurred, including CSF leaks, permanent neurological deficits, or spinal instability. Recurrence occurred in two 'dumbbell' tumors (4%) at 5 and 7 years after primary excision during follow-up, managed with successful re-resection. CONCLUSION Microsurgical excision of IDEM tumors carries high safety and efficacy, including in resource-limited settings like LMICs.

Spinal intradural extramedullary tumors: microscopic keyhole resection with the focus on intraoperative neurophysiological monitoring and long-term outcome

ObjectiveSpinal schwannomas (SS) and spinal meningiomas (SM) account for most intradural extramedullary (IDEM) tumors. These tumors are usually benign lesions, which generally respond favorably to surgical excision. Few studies up to now tried to determine the long-term outcome after minimally invasive surgery (MIS) with multimodal intraoperative neurophysiological monitoring (IONM) for IDEM tumors. The aim of this study was to present one of the largest case series with special regard to IONM findings and long-term outcome after MIS-keyhole surgery with a tubular retractor system.MethodsBetween January 2013 and August 2018, 87 patients with IDEM tumors who underwent tumor removal surgery via MIS-keyhole approach under multimodal IONM were retrospectively reviewed. The neurological status was assessed using a modified McCormick grading scale pre- and postoperatively. Multimodal IONM consisted of motor evoked potentials (MEP), somatosensory evoked potentials (SEP), and electromyography (EMG). Both short-term and long-term clinical evaluations as well as patients’ medical files were retrospectively analyzed.ResultsSurgeries were performed for resection of SS in 49 patients and SM in 38 patients. Tumor locations were cervical in 16.1%, thoracic in 48.3%, thoracolumbar in 4.6%, lumbar 31%. Critical IONM changes were detected in 9 operations (10.3%) in which there were 2 SEPs, 5 MEPs, and 2 EMG events. Three IONM changes (2 MEPs, 1 EMG) were turned out to be transient change in nature since they were resolved in a short time when immediate corrective actions were initiated. Six patients with permanent IONM changes (2SEPs, 3MEPs, 1EMG event), all deficits had resolved during hospitalization or on short -term follow-up evaluation. Sensitivity, specificity, and positive and negative predicted values of IONM were 100, 96, 67, and 100%, respectively. Gross total resection rate was 100%, and a stable or improved McCormick grade exhibited in all patients. No tumor recurrence and no spinal instability were found in the long-term follow-up evaluation (mean 5.2 ± 2.9 years postoperatively). Overall, 94% of patients were either satisfied or very satisfied with their operation, and 93% patients reported excellent or good general clinical outcome according to Odom’s criteria.ConclusionMIS-keyhole surgery with multimodal IONM for IDEM tumors enables a high level of satisfaction and a satisfying long-term clinical and surgical outcome.

Intradural Extramedullary Tumors and Associated Syndromes.

Most intradural tumors are located within the intradural extramedullary compartment, and the most common tumors are schwannomas and meningiomas. Other less common neoplasms include neurofibroma, solitary fibrous tumor, myxopapillary ependymoma, lymphoma, metastatic leptomeningeal disease, malignant peripheral nerve sheath tumor, and paraganglioma. Patients usually present with gait ataxia, radicular pain, and motor and sensory deficits due to chronic compressive myelopathy or radiculopathy. MRI is the modality of choice for detecting and evaluating intradural extramedullary spinal tumors. This imaging technique helps narrow the differential diagnosis and therefore decide treatment.