Intramedullary Spinal Tumors Research Articles

Contemporary management of adult intramedullary spinal tumors—pathology and neurological outcomes related to surgical resection

Retrospective chart review and review of the recent literature. To present our experience, over an 8-year period, with aggressive microsurgical resection of intramedullary spinal tumors in adults focusing on histology, microsurgical techniques, short-term neurological outcomes, complication avoidance and dorsal column dysfunction (DCD). University of Miami/Jackson Memorial Medical Center Miami, FL, USA. We conducted a retrospective review of a series of adult patients with intramedullary spinal tumors treated with microsurgical excision at the University of Miami/Jackson Memorial Medical Center between January 1997 and September 2005. Histologic analysis revealed a predominance of ependymomas (50%) with astrocytomas only comprising 12.5% of the tumors. We found no significant difference in pre- and postoperative McCormick grades. Although patients did not manifest significant motor weakness postoperatively as a result of surgery, 43.6% of patients exhibited the signs and symptoms of DCD, resulting in significant postoperative morbidity. We present a contemporary adult series of intramedullary spinal tumors. The most significant postoperative morbidity experienced by patients was DCD. The neurosurgeon should recognize the impact of these symptoms, prepare the patient and his/her family for the possibility of DCD, and minimize dorsal column manipulation in an attempt to decrease its prevalence.

Spinal deformity and pediatric intramedullary spinal cord tumors

Spinal deformity and pediatric intramedullary spinal cord tumors

Current opinions and recommendations on multimodal intraoperative monitoring during spine surgeries

With the rapid development of imaging techniques and better understanding of structural and functional pathology of the spine and spinal cord there has been a worldwide increase in the number of spine surgeries performed, particularly in specialized interdisciplinary spine centers. In addition to the congenital and acquired deformities of the spine and relatively rare spinal cord tumors, common degenerative spine disease within the aging general population contributes to a growing number of pathologies with myelopathies. This is important because antecedent myelopathy increases spinal cord risk during surgical treatment. The possibility of having functional neurophysiological assessment during spine and spinal cord surgery was introduced in 1970s by applying somatosensory evoked potentials (SEPs) as well as spinal evoked potentials [15, 21, 32, 33]. Meanwhile these modalities and continuous EMG recording have been enhanced by the addition of corticospinal motor pathway monitoring through the use of motor evoked potentials (MEPs) elicited by transcranial electrical stimulation [3]. The application of multimodal intraoperative monitoring (MIOM) became routine in several spine centers, being documented by publications about the specificity and sensitivity as well as clinical experience and outcome measurements during different spinal surgical procedures [6, 9, 13, 14, 17, 22, 24, 26, 27]. In this supplement on intraoperative monitoring the Spine Center of the Schulthess Clinic presents their experience with the application of MIOM during spine surgery analyzing 1,017 operations in the years 2000–2005. The patients for monitoring were selected out of 11,356 who received spine surgery at the institution during the study period. The indication for each monitoring procedure was discussed and established within the monitoring and surgical team. The detailed analysis of this large patient population resulted in a sensitivity of 89% and specificity of 99%. Sutter et al. [31] conclude that MIOM is an effective method of monitoring the spinal cord functional integrity during spine surgery and therefore can lead to reduction of neurological deficits and consequently improve postoperative results. An independent series of 206 thoracolumbar surgeries also presented in this supplement supports this conclusion [19]. Sala et al. [27] discussed in their recent publication of a historical control study the ethical limitation for performing prospective randomized studies to assess the efficacy of MIOM while clearly documenting that monitoring improves outcome after surgery for intramedullary spinal tumors. The Spine Society of Europe (SSE) supported the development of MIOM by presentations of the results at its annual meetings and organized workshops to stimulate discussion and communication between the spine surgeons and clinical neuroscientists. The SSE has also introduced quality control management in spine surgeries by establishing Spine Tango, a web-based international registry that includes MIOM documentation (http://www.eurospine.org). Other international spine societies such as Scoliosis Research Society presented several original papers on MIOM at the 41st annual meeting in 2006 [2, 5, 23] illustrating its advantages for surgery of adolescent idiopathic and infantile scoliosis. Recently, the International Society of Intraoperative Neurophysiology (ISIN) was founded to stimulate interdisciplinary communication and collaboration between surgeons, neurologists, neurophysiologists and anesthetists (http://www.ptsroma.it/isin). The aim of a first consensus meeting on intraoperative monitoring during spine surgeries in Verona (28 September 2006) was to provide recommendations for the improvement and appropriate application of monitoring techniques during spine surgeries. Experts in the field were invited for a meeting with the support of the European Spine Journal (Max Aebi, MD, Editor-in-chief, Marek Szpalski, MD, Supplement Editor) to summarize the current state-of-the-art and prepare current opinions and recommendations. This consensus statement represents a work in progress and as with all other recommendations or proposals, it must be updated as new information is gained.

Intramedullary spinal tumor causing “belly dancer syndrome”

This article includes Supplementary Video, available online at http://www.interscience.wiley.com/jpages/0885-3185/suppmat Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Photodynamic diagnosis in surgery for spinal ependymoma

Protoporphyrin IX (PPIX), a metabolic product of 5-aminolevulinic acid (5-ALA) accumulating specifically in tumor tissue, shows fluorescence on exposure to excitation light having a peak wavelength of 405 6 1 nm (laser spectrum overlaps that of ultraviolet light), and thus it allows detection of small amounts of tumor. 1‐3 We applied this fluorescence chemonavigation technique, which has been used in cerebral glioma surgery, 2,3 to a case of spinal ependymoma. This 19-year-old man presented with nuchal pain. Magnetic resonance imaging revealed a homogeneously enhancing intramedullary C4‐5 spinal tumor (not shown); the tumor was then removed. One gram of 5-ALA was administered orally 2 hours before the induction of anesthesia. The tumor was exposed through the posterior median sulcus (Fig. 1A). After darkening the microscope light, the excitation light—provided by a semiconductor laser device (VLD-V1 version 2; M & M Co., Ltd., Tokyo, Japan)4,5—was directed at the tumor through a fiberoptic cable. A vivid reddish fluorescence of the tumor was observed through a low-cut filter (cut , 420 nm, M & M Co., Ltd.) (Fig. 1B). The laser spectrum was analyzed using a spectrometer (BWTEK, Inc., Newark, DE), and was revealed to have two emission peaks at 635 and 704 nm, compatible with those of PPIX. En bloc removal of the tumor attached to the anterior raphe was performed. On routine inspection of the resection bed, no residual tumor was visible (Fig. 1C), and no fluorescence was noted in this area after exposure to the excitation light. However, analysis of the fluorescent spectrum revealed the existence of a tiny fluorescent area embedded in the anterior raphe. The laser spectrum of this area showed the same emission peaks as during the first examination, albeit at a lower fluorescence intensity (Fig. 1D). Thus the area was considered to be a residual fragment of the tumor, and using simultaneous motor evoked potential monitoring, was removed with great care not to damage the central vessels. A final laser examination of the tumor bed showed no emission peaks and thus complete removal was accomplished. The pathological diagnosis of removed tissue was ependymoma. The patient was discharged from the hospital, and he experienced improvement in his preoperative symptoms. The role of fluorescence spectrum analysis is significant in detecting the weak fluorescence of tiny amounts of residual tumor tissue, 4 and thus may be used in other cases of primary intramedullary spinal tumors to reduce the number of residual tumors and improve completeness of surgical removal.

Imaging for Spine Tumors and New Applications

Discuss intramedullary, intradural/extramedullary, and extradural spinal tumors including imaging characteristics with emphasis on MR and advances in treatment. Literature and institutional review. Spinal tumors: intramedullary, intradural/extramedullary, and extradural, comprise a wide range of histological tumors with an even wider range of clinical symptoms and prognostic features. They are relatively rare and if left untreated, can cause serious neurological deficits and disability. An accurate diagnosis is therefore crucial in determining prognosis and directing therapy. Magnetic resonance imaging (MRI) has revolutionized the diagnosis of intraspinal tumors, allowing for early detection and improved anatomical localization. Magnetic resonance has also become an integral part in staging of both primary and metastatic neoplasms of the spine for guiding therapy and is an excellent modality for follow-up. Advances in MRI (perfusion and molecular imaging) may help refine and describe these neoplasms for accurate treatment and prognosis in the future. Surveillance protocols and role of magnetic resonance are not well established. Magnetic resonance plays an integral role in evaluation of spinal tumors with increasing role in staging and treatment.

Enlargement of the spinal cord: Inflammation or neoplasm?

Intramedullary spinal tumours are uncommon lesions that can cause significant difficulties in the differential diagnosis between inflammatory diseases such as multiple sclerosis and acute disseminated encephalomyelitis, and vascular malformations or neoplasms. We report five cases in which the history and the clinical symptoms suggested an inflammatory process of the spinal cord but the MRI characteristics were those of neoplastic lesions. Both non-neoplastic and neoplastic intramedullary lesion may have very similar symptoms, and even CSF abnormalities, but in every one of our cases, a more detailed history and longer observation of the clinical course would have led to the correct diagnosis; in such problem cases, empirical treatment and a follow-up MRI after a month's observation would be a more prudent approach providing that the patient is not rapidly deteriorating.

Spinal intramedullary tumors. When is surgical treatment indicated?

Timing of surgery in patients with intramedullary tumors is the subject of controversy. The aim of this retrospective study is to evaluate whether patients with intramedullary ependymomas and astrocytomas have a better postoperative prognosis without or with slight preoperative deficits than those with severe preoperative neurological disturbances. During a period of 8.5 years (January 1992-August 2000), 34 patients with intramedullary tumors underwent surgery in our Neurosurgical Department. Among them there were five astrocytomas WHO grade II and ten ependymomas WHO grade II. Recurrences were observed in two patients with astrocytomas and one patient with ependymoma. Pre- and postoperative functional performance was classified according to the McCormick scale in grade I-IV (grade I: neurologically normal or mild focal deficit and grade IV: severe neurological deficits and without functional independence). The follow-up period varied from 4 to 76 months (mean: 27.9 months). All seven grade I patients remained unchanged after surgery. Two of four grade II patients improved to grade I; two deteriorated to grade III. Two of three grade III and IV patients remained unchanged and another one deteriorated from grade III to IV. At the best, intramedullary astrocytomas and ependymomas should be operated when symptoms are mild. Early surgery can achieve good functional outcome.

2.脊髄髄内腫瘍の診断と治療方針

2.脊髄髄内腫瘍の診断と治療方針

Neoplasms of the spinal cord and filum terminale: radiologic-pathologic correlation.

Intramedullary spinal cord neoplasms are rare, accounting for about 4%10% of all central nervous system tumors. Despite their rarity, these lesions are important to the radiologist because magnetic resonance (MR) imaging is the preoperative study of choice to narrow the differential diagnosis and guide surgical resection. On contrast materialenhanced MR images, intramedullary spinal tumors almost always manifest as expansion of the spinal cord and show enhancement. Syringohydromyelia and cystic lesions are frequently associated with intramedullary tumors. Nontumoral cysts tend to be located at the poles of the tumors and do not enhance on contrast-enhanced MR images, whereas cysts within the substance of the tumor are considered tumoral cysts and typically demonstrate peripheral enhancement. Spinal cord ependymomas are the most common type in adults, and cord astrocytomas are most common in children. Both entities constitute up to 70% of all intramedullary neoplasms. A central location within the spinal cord, presence of a cleavage plane, and intense homogeneous enhancement are imaging features that favor an ependymoma. Intramedullary astrocytomas are usually eccentrically located within the cord, are ill defined, and have patchy enhancement after intravenous contrast material administration. Even with these characteristics, it may not be possible to differentiate these two entities on the basis of imaging features alone. Cord hemangioblastomas are the third most common type of intramedullary spinal tumor. Gangliogliomas commonly extend over more than eight vertebral segments. Paragangliomas and primitive neuroectodermal tumors have an affinity for the filum terminale and cauda equina. Other spinal cord tumors include metastatic disease, which is characterized by prominent cord edema for the size of the enhancing portion, and primary lymphoma.

頭蓋内, 脊髄に多発性腫瘍を合併したneurofibromatosis type 2の1例 : 脊髄髄内腫瘍の治療について

Neurofibromatosis type 2(NF2)の髄内, 髄外の症候性脊髄腫瘍例に対し, 2回の手術を行い良好な結果を得た.NF2は両側聴神経鞘腫を合併することで有名であるが, 近年脊髄腫瘍についても報告が増えてきている.過去の報告例と自験例を検討した結果, NF2に合併する髄内腫瘍は境界明瞭である場合, 上衣腫や神経鞘腫の可能性が高く, 多くは良好な結果が期待できるため積極的な手術適応がある.

Postmyelographic computerized tomographic scan in the differential diagnosis of radiculomeningeal arteriovenous malformation: Technical note

The differential diagnosis of radiculomeningeal arteriovenous malformation (AVM) includes spinal intramedullary tumor and spinal cord myelitis. In making the diagnosis of radiculomeningeal AVM, clinical features of the history and magnetic resonance (MR) imaging findings are important initially, followed by selective spinal arteriography with or without myelography to confirm the diagnosis. The differential diagnosis, however, is not always easy. We encountered five radiculomeningeal AVM and 14 intramedullary thoracolumbar tumors that were accurately diagnosed preoperatively. We performed postmyelographic computerized tomography (CT) in all five patients with radiculomeningeal AVM and five patients with intramedullary thoracolumbar tumors that were not able to exclude radiculomeningeal AVM with only MR imaging. In all our patients with radiculomeningeal AVM, postmyelographic CT demonstrated the dilated coronal venous plexus on the dorsal aspect of the spinal cord in contrast with a single swelling of the spinal cord in the patients with intramedullary tumor. We believe that this finding is useful when the serpentine dilated coronal venous plexus is not clearly identified on myelogram and selective spinal arteriography is not apparently indicated.

Intramedullary spinal cord tumors in neurofibromatosis.

Neurofibromatosis (NF) describes the most commonly inherited disorders affecting the nervous system. These autosomal dominant, neurocutaneous syndromes are associated with multiple tumors of the nervous system, including neurofibromas, schwannomas, meningiomas, and intracranial gliomas. Spinal cord involvement in NF is typically from extramedullary growth of spinal nerve root tumors. Intramedullary spinal cord tumors in NF have been reported as scattered, single cases in literature. However, this association has not been clearly defined as have other nervous system neoplasms that are typically linked with NF. We present a series of nine patients with NF with intramedullary spinal cord tumors who were managed at our institution from 1984 to 1994. The patients' ages ranged from 4 to 31 years. There were seven male patients and two female patients. Three patients had NF-1 (von Recklinghausen's), five patients had NF-2, and one patient had NF, type uncertain. There were three cervicomedullary tumors, two cervical tumors, three cervicothoracic tumors, and one thoracic tumor. A histological examination revealed five ependymomas, three astrocytomas, and one intramedullary schwannoma. Two patients with malignant intramedullary spinal ocrd tumors have died with progressive disease. One other patient has required a subsequent operation for recurrent tumor. The other six patients are doing well, and their prognosis is expected to be related to their systemic disease. We conclude that there is a clinical entity of intramedullary spinal cord tumors associated with NF.

MR Findings of Intramedullary Spinal Tumor

MR Findings of Intramedullary Spinal Tumor

Dorsal root reflexes: Do they play a role in chronic “Neuropathic” pain patients?

A t a break during the meeting on Abnormal Somatosensory Mechanisms organized by Lillian Pubols and Barry Sessle and held at Timberline Lodge, Oregon, in 1986, Wilfrid Janig and one of us wondered whether dorsal root reflexes might involve primary C-nociceptor afferents.The question was prompted by the amazing case of Mr. B, a patient who had suffered from persistent burning pain in the right upper extremity for 17 years. Together with spontaneous pain and mechanical hyperalgesia, Mr. B expressed substantial hyperthermia of the symptomatic part. There were some trophic changes.The patient had been investigated and treated unsuccessfully through the sympathetic dystrophy paradigm. We suspected Mr. B. had sensitized primary nociceptors but could not raise definitive proof. Eventually, we diagnosed a benign intramedullary spinal tumor in the cervical cord. Skilled neurosurgical approach ablated much of the tumor with minimal cord complications. The hyperalgesia was replaced by hypoesthesia, which the patient preferred. The spontaneous pain and the hyperthermia were relieved.The clinical picture was rationalized as the consequence of irritation of the central branches of primary nociceptor afferents within the spinal cord, with resultant pain and antidromically determined neurogenic inflammation and hyperalgesia. If we had known that Manfred Zimmermann had published a very pertinent basic paper on C-fiber stimulation and dorsal root potentials [reference 94 in Focus article; Zimmermann M: Dorsal root potentials after C-fiber stimulation. Science 160:896-898, 1968], we might have written the case of Mr. B. at that time. In a related context, a few years later we argued that human radiculopathy may

Tumores intramedulares. Estudo anatomo clínico.

The authors review 36 cases of intramedullary spinal tumours, 17 ependymomas, 12 astrocytomas, 6 hemangioblastomas and 1 metastasis of leiomyosarcoma. The tumours were localized in the cervical region in 19 patients, in the thoracic region in 10 in the lumbar region in 4, and in the conus medullaris in 3. All patients presented a clinical picture of myelopathy. No differences were observed between the different hystological types. In 5 patients the tumour was associated with syringomyelia and one of these patients also presented a type I Chiari malformation. All patients were submitted to surgery (using microsurgical techniques in the last seven years). Radiation therapy was also given in 16 cases. Our results demonstrate that microsurgical resection is the only treatment that significantly improves the prognosis of these patients, from both the standpoint of the functional status and survival.

Intramedullary spinal cord tumors: significance of associated hemorrhage at MR imaging.

Magnetic resonance (MR) images obtained in 35 patients with intramedullary spinal tumors were reviewed. Hypointense areas on both T1- and T2-weighted images were seen within or around eight tumors, all of which were in the cervical cord. Hypointensity at the tumor margin was seen in seven cases. Hypointensity within the tumor was seen in two cases. (One case had both types of hypointensity). In seven surgically confirmed cases, hypointensity at the tumor margin was found to be a relatively firm pseudocapsule, and hypointensity within the tumor corresponded to intratumoral hematoma. All of the tumors with hypointensity were ependymomas at histologic examination. When MR imaging shows an intramedullary tumor with hypointensity at the tumor margin, it is suggestive, but not pathognomonic, of an ependymoma.

MR Imaging of Spinal Intramedullary Tumors

MR Imaging of Spinal Intramedullary Tumors

MR Imaging of Spinal Intramedullary Tumors

The MR examinations in 25 patients with intramedullary tumors were analyzed. Seven patients were diagnosed with astrocytoma, 6 ependymoma, 2 unspecified glioma, 3 medulloblastoma, 2 metastasis, one neurinoma, and one teratoma. In 3 patients the diagnosis was uncertain. The tumors frequently involved a large portion of the cord and were often accompanied by intratumor necrosis, cystic degeneration, and edema, which was well demonstrated on MR. Gd-DTPA was used in 6 patients and was helpful in separating solid tumor components from cysts and edema. It was difficult to separate different kind of tumors based on morphologic and signal characteristics on MR. Some prominent features could, however, be distinguished. Complete cystic degeneration was more common in astrocytomas than in other tumors, and ependymomas frequently had a heterogeneous signal pattern on both T1- and T2-weighted sequences. The single teratoma had a characteristic content of fat and calcification, and the melanoma had a signal pattern consistent with blood. CSF pathway spread in cases of medulloblastoma was demonstrated by ill-defined contour of the cord and CSF or tumor nodules on the surface of cord and nerve roots.

Magnetic resonance imaging in neurological disorders.

To investigate the role of magnetic resonance imaging (MRI) in neurological disorders, 115 children were studied in two groups. Group A (78 patients) was studied by paired computed tomography and MRI cranial scans. Group B (37 patients) was studied by paired computed tomography assisted myelography (CTM) and MRI spinal scans. In group A, the scans were generally equivalent for supratentorial tumours and for investigating fits, hydrocephalus, benign intracranial hypertension, and cerebral atrophies, but MRI scanning was superior for posterior fossa tumours and cysts. In group B, MRI scans were superior for intramedullary spinal tumours, spinal dysraphic problems with tethering or syrinx, and were complementary to CTM in diastematomyelia.