McCormick Score Research Articles

Intraoperative changes in electrophysiological monitoring can be used to predict clinical outcomes in patients with spinal cavernous malformation.

The study aimed to evaluate the sensitivity and specificity of these monitoring parameters in predicting postoperative neurological dysfunction. In this study, a total of 85 patients with spinal cavernous malformations (SCMs) treated at Xuanwu Hospital, Capital Medical University, from November 2012 to August 2017 were included. During the surgical procedures, all patients underwent monitoring of motor evoked potentials (MEP) and somatosensory evoked potentials (SEP). The criteria for warning included a reduction of ≥80% in MEP amplitude and ≥50% in SEP amplitude. Among 85 patients, 40 (47.1%) had SCMs located in the thoracic segment, 35 (41.2%) in the cervical segment, 6 (7.1%) in the cervical thoracic segment, and 4 (4.7%) in the lumbar segment. MEP recordings were obtained from 81 patients, and the preoperative McCormick score was 1.53 ± 0.69. The sensitivity of multimodal monitoring combined with the criteria of 80% reduction in MEP amplitude and SEP was 83.9%, with a specificity of 69%, a positive predictive value of 69%, and a negative predictive value of 90.4%. This study emphasizes the crucial role of electrophysiological monitoring, particularly MEP and SEP, during the surgical resection of SCMs. The findings demonstrate that this approach is effective in predicting and preventing postoperative neurological dysfunction, thereby improving patient outcomes.

Factors influencing outcome in patients with intramedullary spinal cord tumors undergoing resective surgery.

We evaluated whether preoperative functional status influenced surgical outcomes for patients with intramedullary spinal cord tumors (IMSCT). We analyzed whether lower preoperative McCormick scores impacted primary outcomes for 78 consecutive patients with IMSCT of World Health Organization (WHO) grades I and II undergoing tumor resection between 2010 and 2018. Patients averaged 33.6 years of age, 57.5% were male, and lesions predominantly involved the cervical 23 (29.5%) followed by the thoracic spine 19 (24.3%). Over the average follow-up interval of 69.83 months, IMSCTs recurred in 11.5% of patients, with 6.4% showing functional deterioration. At follow-up, 73.5% of patients with a preoperative modified McCormick score of two or one showed better functional improvement. The WHO pathological grades I and II did not significantly influence outcomes for patients with intramedullary spinal cord lesions. However, patients with low preoperative McCormick scores (two or one) demonstrated better functional outcomes.

1077 Operative Management and Outcomes in Spinal Hemangioblastoma: A Multi-institutional Case Series of 59 Patients

INTRODUCTION: Hemangioblastoma is a rare benign neoplasm that accounts for 2-5% of all spinal cord tumors and is associated with von-Hippel Landau (VHL) disease in about 25-30% of patients. Symptomatic spinal hemangioblastomas are typically managed with en bloc microsurgical resection, but the infrequent nature of these lesions has limited the detailed characterization of reported management and surgical outcomes in the literature. METHODS: We retrospectively reviewed all patients with pathology-proven spinal hemangioblastoma. We collected information about demographics, preoperative symptoms and imaging, intraoperative characteristics, and postoperative course. We analyzed what variables influence postoperative changes in motor scores and McCormick scores. RESULTS: We included 59 patients (35 sporadic, 24 VHL). The average age of diagnosis was 48.7 (± 16.1) for sporadic tumors and 35.1 (± 12.6) for those associated with VHL (p = 0.001). Most tumors were cervical (46.6%) or thoracic (34.5%) and both intradural (93.2%) and intramedullary (71.2%). Most patients (69.5%) had multiple spinal tumors. The average lesion volume was 0.98 (± 1.1) cm3. The average symptom duration before surgery was 24.7 (± 73.2) months. Adjuvant therapies included radiation (6.8%) and chemotherapy (1.7%). At 1 month postoperatively, 4.4% had motor loss in any muscle group and 31.1% had motor gain, while 18.6% had a decreased McCormick score and 28.8% had an improved score at 1 month. While 72.9% of patients had numbness/paresthesia preoperatively, only 59.3% did at 1 month. Duration of pre-operative symptoms and time from diagnosis to surgery were not found to influence outcomes. CONCLUSIONS: Overall, surgical planning should be guided by symptom management. In this population, duration of preoperative symptoms and timing of surgery did not influence post-operative functional outcomes.

P11.22.B ANALYSIS OF FACTORS RELATED TO POSTOPERATIVE RECURRENCE AND PROGNOSIS ABOUT HIGH GRADE SPINAL CORD GLIOMAS

Abstract BACKGROUND High grade spinal glioma (HGSG), an extremely rare tumor, accounts for about 7-30% of spinal glioma. Its incidence is only 0.22/100000. The tumor has a rapid clinical progression and a poor prognosis, with a median survival time of 12-24 months. In previous studies on the prognosis of HGSG, the factors related to the prognosis are quite different due to inconsistent tumor classification and diagnosis criteria. It is rarer in the study of postoperative recurrence. Therefore, various factors limit the clinician’s judgment on the factors related to the recurrence and prognosis of HGSG after surgery. MATERIAL AND METHODS In this study, the clinical data of 44 patients who were pathologically diagnosed with HGSG and admitted to the Department of Neurosurgery of Beijing Tsinghua Changgung Memorial Hospital from January 1, 2015 to January 1, 2020 were retrospectively analyzed. The postoperative recurrence and death were considered as the research end time, the individual characteristics, imaging characteristics, pathological characteristics, age in treatment, gender, McCormick score, tumor location, WHO grade, tumor volume, degree of resection, radiotherapy, chemotherapy, and H3K27M expression, Ki-67 index, and P53 expression were included in the COX regression model for the univariate and multivariate analysis. The factors related to the recurrence and prognosis of HGSG after surgery were further explored. RESULTS The median recurrence-free duration of 44 patients with HGSG was 13.0 months, and the recurrence-free rates of 6 months and 1 year after surgery were 75.0% and 51.9%; the median survival time of the enrolled patients was 21.0 months. The multivariate COX regression analysis on the recurrence of HGSG after surgery showed that the risk of the recurrence was higher in the III-IV group than that the I-II group for the McCormick score ( p=0.001). For WHO grade, the risk of the recurrence was higher in the IV group than that in the III group (p=0.029). The multivariate COX regression analysis on that survival after HGSG surgery showed that the risk of the death was higher in the III-IV group than that in the I-II group for the McCormick score (p=0.006), and the risk of the death was higher for the tumor in the cervical segment than that in the cervical thoracic segment ( p=0.005), thoracic segment ( p=0.003), thoracolumbar segment ( p=0.011). The risk of the death was higher in the H3K27M positive group ( p=0.014) than that in the H3K27M negative group. 0.049). CONCLUSION HGSG, as a highly malignant tumour, exhibits rapid progression even after surgical treatment. For future post-operative recurrence and prognosis determination of HGSG, there is a need to focus on assessing the preoperative spinal cord functional status, tumour location, WHO classification and H3K27M mutation status to assist clinicians in giving the best treatment plan.

Operační léčba tuberkulózní spondylodiscitidy

PURPOSE OF THE STUDY The paper presents a monocentric retrospective study of patients treated surgically for spinal tuberculosis. Clinical and radiological results are analysed, early and late complications are recorded. The study aims to answer the following questions. 1. Can we use instrumentation to restore the stability and alignment in the infected spinal focus? 2. Should we always perform radical anterior resection of TBC lesions? 3. What is the prognosis of surgical treatment of TBC patients with neurological deficit manifestation? MATERIAL AND METHODS Between 2010 and 2020, a total of 12 patients were treated for spinal tuberculosis at our department, of whom 9 patients (5 men, 4 women) with the mean age of 47.3 years (range 29 to 83 years) underwent a surgery. A total of three patients were operated on before the final confirmation of the TBC and treatment with antituberculosis medication, four patients in the initial therapy phase and two patients in the continuous phase. Two patients only underwent a non-instrumented decompression surgery followed by external support fixation. In the other seven patients, always with spinal deformity, instrumentation was used (3 cases of isolated posterior decompression, transpedicular fixation, posterior fusion, 4 cases of anteroposterior instrumented reconstruction). In 2 cases a structural bone graft and in 2 cases an expandable titanium cage were used for anterior column reconstruction. RESULTS Of the total number of patients, altogether eight patients were assessed at 1 year after surgery (one 83-year-old patient died from heart failure 4 months after surgery). Of the remaining eight patients, three patients exhibited a neurological deficit and postoperative regression of the finding. The McCormick score improved from the preoperative mean score of 3.25 to 1.62 at 1 year after surgery (p < 0.001). The clinical VAS score regressed from 5.75 to 1.63 at 1 year after surgery (p < 0.001). Radiographic healing of the anterior fusion was achieved in all patients, both after decompression and instrumented surgery. The initial mean kyphosis of 20.36 degrees of the operated segment measured by the mCobb angle was corrected to 14.6 degrees postoperatively, with a subsequent slight deterioration to 14.86 degrees (p < 0.05). The greatest correction was achieved in patients who had undergone a two-stage surgery with anterior resection and AP reconstruction. DISCUSSION In our cohort, titanium instrumentation was used in seven of nine patients. One patient only manifested persistent tuberculosis with nonspecific bacterial flora superinfection. Revision surgery with anterior radical debridement and subsequent treatment with antituberculotic drugs healed the patient. There were four patients with major preoperative neurological deficit persisting more than 2 weeks before the final treatment with subsequent improvement in all cases. These patients were treated with anteroposterior reconstruction and anterior radical debridement. CONCLUSIONS No increased risk of recurrent infection associated with the use of spinal instrumentation was found in the study. Anterior radical debridement is performed in patients with manifested kyphotic deformity and spinal canal compression, followed by reconstruction with a structural bone graft or a titanium cage. The other patients are treated based on the principle of "optimal" debridement with or without the use of transpedicular instrumentation. If adequate spinal canal decompression and stability are achieved, neurological improvement can be anticipated even in case of a major neurological deficit. Key words: spine tuberculosis, tuberculous spondylitis, Pott's disease, anterior debridement, spine instrumentation.

Role of Posterior Longitudinal Ligament Complex in Spinal Deformity Secondary to Surgical Resection of the Intradural Tumor.

In most cases, complete resection of the intradural tumor is accompanied by long-term neurological complications. Postoperative spinal deformity is the most common complication after surgical resection of intradural tumors, and posterior longitudinal ligament complex (PLC) plays an important role in postoperative spinal deformity. In this study, we investigated the role of PLC in spinal deformity after the surgical treatment of intradural tumors. We analyzed the data of 218 consecutive patients who underwent intradural tumor resection from 2000 to 2018 in this retrospective study. Before 2010, patients underwent laminoplasty without maintaining the integrity of PLC (laminoplasty group, n=155). After 2010, patients performed single-port laminoplasty to maintain the integrity of PLC (laminoplasty retain posterior ligament complex group, n=63). The score of quality of life, painful cortex, spinal cord movement, progressive kyphosis or scoliosis, perioperative morbidity, and neurological results were analyzed in the laminoplasty group and laminoplasty retain posterior ligament complex group. The distributed variable was shown as mean ± standard deviation and an independent t-test or one-way analysis of variance was calculated. There are 155 patients (71.1%) included in the laminoplasty group, and 63 patients (28.9%) in the laminoplasty retain posterior ligament complex group. The average age of patients was 42 ± 2.3 years, and the average modified McCormick score was 2. There were 158 (72.4%) patients with intramedullary tumors and 115 (52.7%) patients with extramedullary tumors. The length of hospital stays (8 days vs. 6 days; p=0.023) and discharge to inpatient rehabilitation (48.4% vs. 26.9%; p=0.012) were significantly lower in the laminoplasty retain posterior ligament complex group than the laminoplasty group. There was no significant difference in the risk of progressive deformity between the two groups at 18months after surgery (relative risk 0.12; 95% confidence interval [CI] 0.43-1.25; p=0.258) and at 20months after surgery (relative risk 0.24; 95% CI 0.21-2.1). Laminoplasty retains posterior ligament complex showed no impact on the spinal deformities compared with laminoplasty, but significantly improved the postoperative spinal activity, alleviated pain symptoms, and reduced hospital recovery time.

Spinal oncologic paraparesis: Analysis of neurological and surgical outcomes in patients with intramedullary, extramedullary, and extradural tumors.

Paraparesis due to oncologic lesions of the spine warrants swift neurosurgical intervention to prevent permanent disability and hence maintain independence of affected patients. Clinical parameters that predict a favorable outcome after surgical intervention could aid decision-making in emergency situations. Patients who underwent surgical intervention for paraparesis (grade of muscle strength <5 according to the British Medical Research Council grading system) secondary to spinal neoplasms between 2006 and 2020 were included in a single-center retrospective analysis. Pre- and postoperative clinical data were collected. The neurological status was assessed using the modified McCormick Disability Scale (mMcC) Score. In a univariate analysis, patients with favorable (discharge mMcC improved or stable at <3) and non-favorable outcome (discharge mMcC deteriorated or stable at >2) and different tumor anatomical compartments were statistically compared. 117 patients with oncologic paraparesis pertaining to intramedullary lesions (n=17, 15%), intradural extramedullary (n=24, 21%) and extradural lesions (n=76, 65%) with a mean age of 65.3 ± 14.6 years were included in the analysis. Thoracic tumors were the most common (77%), followed by lumbar and cervical tumors (13% and 12%, respectively). Surgery was performed within a mean of 36±60 hours of admission across all tumors and included decompression over a median of 2 segments (IQR:1-3) and mostly subtotal tumor resection (n=83, 71%). Surgical and medical complications were documented in 9% (n=11) and 7% (n=8) of cases, respectively. The median hospital length-of-stay was 9 (7-13) days. Upon discharge, the median mMcC score had improved from 3 to 2 (p<0.0001). At last follow-up (median 180; IQR 51-1080 days), patients showed an improvement in their mean Karnofsky Performance Score (KPS) from 51.7±18.8% to 65.3±20.4% (p<0.001). Localization in the intramedullary compartment, a high preoperative mMcC score, in addition to bladder and bowel dysfunction were associated with a non-favorable outcome (p<0.001). The data presented on patients with spinal oncologic paraparesis provide a risk-benefit narrative that favors surgical intervention across all etiologies. At the same time, they outline clinical factors that confer a less-favorable outcome like intramedullary tumor localization, a high McCormick score and/or bladder and bowel abnormalities at admission.

Current Knowledge on Spinal Meningiomas-Surgical Treatment, Complications, and Outcomes: A Systematic Review and Meta-Analysis (Part 2).

Most of the knowledge on spinal meningiomas is extrapolated from their intracranial counterparts, even though they are considered separate entities. This review aimed to systematically summarize studies covering different aspects of spinal meningiomas and their management. Databases were searched for all studies concerning spinal meningiomas dating from 2000 and onwards. When possible, a meta-analysis was performed. Neurological outcomes of surgery were consistently favorable across studies, with a complication rate of 7.9% and 78.9% of the patients demonstrating good postoperative neurological function (McCormick score 1-2). The most relevant predictors of unfavorable outcomes were poor preoperative status, longer time from diagnosis to surgery, and surgery of recurrent tumors. The recurrence rate after surgery was estimated at 6%. Meta-analysis and/or survival analysis revealed that higher WHO grade (p &lt; 0.001), higher Simpson grade (p &lt; 0.001), ventral tumor location (p = 0.02), and male sex (p = 0.014) were all associated with higher odds of recurrence. However, the meta-analysis did not show any difference between Simpson grade 1 and grade 2 with respect to the odds of recurrence (p = 0.94). Surgery provided immediate and durable health-related quality-of-life improvement, as well as a high frequency of return to work. Spinal meningioma surgery is a relatively safe procedure with a low risk of tumor recurrence and high likelihood of favorable postoperative outcomes.

Unsuccessful external validation of the MAC-score for predicting increased MIB-1 index in patients with spinal meningiomas.

Recently, the MAC-spinal meningioma score (MAC-score) was proposed to preoperatively identify spinal meningioma patients with high MIB-1 indices. Risk factors were age ≥ 65 years, a modified McCormick score (mMCs) ≥ 2, and absence of tumor calcification. The aim of this study was to externally validate the MAC-score in an independent cohort. Using the same inclusion and exclusion criteria as in the original study, we performed a retrospective, single-center, population-based, cohort study that included patients who had undergone surgical treatment for spinal meningiomas between 2005 - 2017. Data was collected from patient charts and radiographic images. Validation was performed by applying the MAC-score to our cohort and evaluating the area under the receiver operating characteristic curve (AUC). In total, 108 patients were included. Baseline and outcome data were comparable to the original development study. An increased MIB-1 index (≥5%) was observed in 56 (52%) patients. AUC of the MAC-score in our validation cohort was 0.61 (95% CI: 0.51 - 0.71), which corresponds to a poor discriminative ability. The MAC-score showed poor discriminative ability for MIB-1 index prediction in patients with spinal meningiomas. Moreover, the MAC-score rests on a weak theoretical and statistical foundation. Consequently, we argue against its clinical implementation.

The effect of intraoperative neurophysiological monitoring on neurological outcomes after spinal tumors operations: A single institution experience

We aim to report our study about using multimodality intraoperative neurophysiological monitoring (IONM) in intradural spinal tumor surgery. This cohort present a retrospective review of the patient who underwent intraspinal tumors surgery at Vajira Center of Excellence in Neurosurgery; between 2005 and 2020. Transcranial motor evoked potentials, somatosensory evoked potentials, and free run electromyography were used for IONM with alarm criteria. Patient record were reviews with preoperative and postoperative neurological outcome measurements; Frankel Grading, McCormick Score, American Spinal Injury Association (ASIA) Grading, Karnofsky Performance Status (KPS) Scale and The Japanese Orthopedic Association (JOA) Score at 1, 6, 12, 24 months after operation. Overall, 104 patients were operated. 77.4 % operations were used IONM. 70.2 % of tumor located at intradural extramedullary (IDEM) space and 16.7 % located at intramedullary space. There were demonstrating statistically significant (p-value < 0.050) improvement between preoperative and postoperative neurological outcome in all follow up time in IONM group. The sensitivity and specificity of alarm IONM to predict early worsening postoperative neurological outcome were 66.7 % and 88.7 %, respectively. IDEM spinal cord tumor surgery are associated with good neurological outcome (OR 0.187 [95 % CI 0.05–0.71]; p-value 0.014). Used of IONM in intradural spinal tumor surgery statistically significant improved postoperative neurological outcome and decrease postoperative neurological deficit. IONM has ability to detect postoperative neurological deficit and poor outcome with fair sensitivity and high specificity. Especially, using of IONM in IDEM have preferable postoperative neurological outcomes.

Intramedullary spinal cord cavernous malformations—association between intraoperative neurophysiological monitoring changes and neurological outcome

BackgroundMicrosurgical resection of spinal cord cavernous malformations can be assisted by intraoperative neurophysiological monitoring (IONM). While the clinical outcome after surgical resection has been discussed in several case series, the association of intraoperative IONM changes and detailed neurological outcome, however, has not been analyzed so far.MethodsSeventeen patients with spinal cavernomas underwent surgery between 02/2004 and 06/2020. Detailed neurological and clinical outcome as well as IONM data including motor-evoked potential (MEP) and somatosensory-evoked potential (SSEP) monitoring were retrospectively analyzed. Intraoperative IONM changes were compared to outcome at 3-month and 1-year follow-up in order to identify surrogate parameters for an impending neurological deficit.ResultsCompared to the preoperative state, McCormick score at 1-year follow-up remained unchanged in 12 and improved in five patients, none worsened, while detailed neurological examination revealed a new or worsened sensorimotor deficit in 4 patients. The permanent 80% amplitude reduction of MEP and 50% amplitude reduction of SSEP showed the best diagnostic accuracy with a sensitivity of 100% and 67% respectively and a specificity of 73% and 93% respectively. The relative risk for a new neurological deficit at 1-year follow-up, when reversible IONM-deterioration was registered compared to irreversible IONM deterioration, was 0.56 (0.23–1.37) for MEP deterioration and 0.4 (0.18–0.89) for SSEP deterioration.ConclusionsReversible IONM changes were associated with a better neurological outcome at follow-up compared to irreversible IONM deterioration during SCCM surgery. Our study favors the permanent 80% amplitude reduction criterion for MEP and 50% amplitude reduction criterion for SSEP for further prospective evaluation of IONM significance and the effectiveness of corrective maneuvers during SCCM surgeries.

Prognostic factors for surgically managed intramedullary spinal cord tumours: a single-centre case series.

Intramedullary spinal cord tumours (IMSCTs) are comparatively rare neoplasms. We present a single-centre clinical case series of adult patients with surgically managed IMSCTs. We performed a retrospective analysis of electronic patient records in the time period spanning July 2010 to July 2021. All adult patients that had undergone surgical management for IMSCTs were eligible for inclusion. Baseline and post-operative clinical and radiological characteristics, along with follow-up data, were assessed. We also performed a literature review with a focus on surgical outcomes for IMSCTs. Sixty-six patients matched our selection criteria, with a median age of 42years (range 23-85). Thirty-four ependymomas, 17 haemangioblastomas, 12 astrocytomas, 2 lymphomas and 1 teratoma were included. Statistical analysis yielded several significant findings: IMSCTs spanning a greater number of vertebral levels are significantly associated with poor McCormick outcomes (p = 0.03), presence of gait disturbance before surgery is significantly associated with poor outcome for both post-operative McCormick and Nurick scores (p = 0.007), and radicular pain present pre-operatively issignificantly associated with a good post-operative McCormick score (p = 0.045). Haemangioblastomas are significantly more likely to have a clear intra-operative dissection plane compared to ependymomas and astrocytomas (p = 0.009). However, astrocytomas have a significantly higher prevalence of good McCormick outcomes compared to ependymomas and haemangioblastomas (p = 0.03). Histological diagnosis, cranio-caudal extent of the tumour and the presence or absence of baseline deficits-such as gait impairment and radicular pain-are significant in determining neurological outcomes after surgery for IMSCTs.

Magnetic resonance imaging indicators for neurological outcome after surgery in patients with intramedullary spinal ependymomas.

This is a retrospective study. The aim of this study was to determine the indicators of neurological outcome after surgery in patients with intramedullary spinal ependymomas by using magnetic resonance imaging (MRI).A total of 106 consecutive patients (mean age: 42.4 ± 1.3 years; 52.8% male) diagnosed with intramedullary spinal ependymomas were retrospectively recruited. All patients underwent spine MRI and subsequent surgical resection for the spinal tumors. Data regarding clinical symptoms and pathological grades of tumors were collected from clinical records. The McCormick score was used for grading patients’ neurological status before and after surgery at 12 months. Good outcome was defined as stable McCormick score (McC) score (no change of McC score between preoperation and post-operation at 12 months) or improvement in McC score (post-operative McC score at 12 months < preoperative McC score). Poor outcome was determined when there was an increase in McC score at 12 months after surgery. The MRI characteristics of spinal ependymomas between patients with good and poor neurological outcomes were compared. Logistic regression was performed to assess the association between MRI characteristics of tumors and post-operative neurological outcomes.Patients with poor neurological outcomes had larger longitudinal length (4.7 ± 0.5 vs 3.3 ± 0.2, P = .004) and higher enhancement signal-to-noise-ratio (SNR) (102.4 ± 12.3 vs 72.8 ± 4.6, P = .022) than those with good neurological outcomes. After adjusting for confounding factors, longitudinal length (OR, 0.768; 95% CI, 0.604–0.976; P = .031) and enhancement SNR (OR, 0.988; 95% CI, 0.978–0.999; P = .026) of spinal ependymomas were significantly associated with poor neurological prognosis.The longitudinal length of tumor and enhancement SNR on T1-weighted images are independently associated with neurological outcome after surgery.

Spinal cord compression in relation to clinical symptoms in patients with spinal meningiomas

ObjectiveSpinal meningiomas are common primary tumors of the spinal canal and the resulting spinal cord compression (SCC) is intrinsically related to symptoms and outcome, but literature concerning this association is limited. We aimed to present data on both degree of SCC and tumor occupancy percentage in relation to neurological symptoms and outcome. MethodsPatients ≥ 18 years with a histological diagnosis of spinal canal meningioma treated between 2000 and 2017 were retrospectively evaluated for symptoms and neurological outcome in relation to SCC (i.e. compression of spinal cord at maximal tumor compression compared to maximum area above/below compression) and tumor occupancy percentage (percentage of dural sac area occupied by tumor at maximal tumor compression). Area segmentation of spinal cord, tumor and dural sac (as marker of spinal canal) was performed manually on magnetic resonance imaging (MRI) scans. The neurological deficit was assessed pre- and postoperatively according to the McCormick score. A logistic regression was made with a training set to identify the cut-off level for motor deficit. ResultsThe cohort included 111 patients with a mean age of 62.5 years and 77.5% were female. The dominating symptoms preoperatively were sensory disturbance (91.0%), motor deficit (80.2%) and gait disturbance (67.6%). Postoperatively 53.2% of patients, also in some of those with severe deficit and high tumor occupancy, improved their neurological deficit and 43.2% were unchanged. Patients with intradural meningioma and assessable MRI scans were included to evaluate SCC (n = 83). The mean extent of SCC was 50.6%. Exploration of tumor occupancy percentage identified a cut-off at 65% tumor occupancy to best discriminate between patients with or without motor deficit. ConclusionPatients with an intradural tumor occupancy percentage of > 65% are more likely to have a preoperative symptom and deficit, validating previous findings. Therefore, we suggest that even in asymptomatic, otherwise fit, patients with tumor occupancy approaching 65% should be considered for surgery since there is a high risk of developing deficit with even minimal growth. Concerning recovery, patients with tumor both high tumor occupancy and significantly impaired function tended to improve their functional level postoperatively.

Surgical management of spinal “Subpial” lipomas

BackgroundThis study reports five cases of subpial lipomas via a new grouping method with respect to the cases’ distinctive magnetic resonance imaging characteristics to provide insight into the management of this entity. MethodFrom January 2013 to December 2014, five cases of pathologically diagnosed subpial lipomas that received surgical treatment in our department were included. The clinical histories and medical records were carefully reviewed, and the radiological characteristics were periodically inspected after surgery. The preoperative radiology and symptoms were reviewed with regard to outcome. ResultsAll five patients were confirmed as having lipomas based on their histological results. Total removal was achieved in one patient only, with partial removal in the other four patients. Neurological deterioration was observed in all patients immediately after surgery, with a typically lower McCormick score. Two of the patients returned to preoperative level one year later. Based on radiological traits, the lipomas could be divided into “simple” and “invasive.” The syrinx formation and neurological recovery were different between these two kinds of lipoma. ConclusionSurgery for subpial lipomas without dysraphisms is frequently accompanied by neurological deterioration, temporally or permanently. Thus, this new classification of subpial lipomas into “simple” and “invasive” based on radiological traits may be valuable for making better surgical decisions.

Reintervention rate of arachnolysis versus shunting for nonforaminal syringomyelia.

Surgical treatment for nonforaminal syringomyelia related to spinal arachnoiditis is still controversial. The authors sought to assess respective outcomes and rates of reintervention for shunting and spinal cord untethering (arachnolysis) in spinal arachnoiditis with syringomyelia. This retrospective cohort study was conducted at a single reference center for syringomyelia. Patients undergoing arachnolysis and/or shunting interventions for nonforaminal syringomyelia were screened. The study included 75 patients undergoing 130 interventions. Arachnolysis without shunting was performed in 48 patients, while 27 patients underwent shunting. The mean follow-up between the first surgery and the last outpatient visit was 65.0 months (range 12-379 months, median 53 months). At the last follow-up, the modified McCormick score was improved or stabilized in 83.4% of patients after arachnolysis versus 66.7% after shunting. Thirty-one (41.3%) patients underwent reintervention during follow-up, with a mean delay of 33.2 months. The rate of reintervention was 29.2% in the arachnolysis group versus 63.0% in the shunting group (chi-square = 8.1, p = 0.007). However, this difference was largely driven by the extension of the arachnoiditis: in patients with focal arachnoiditis (≤ 2 spinal segments), the reintervention rate was 21.6% for arachnolysis versus 57.1% for shunting; in patients with extensive arachnoiditis, it was 54.5% versus 65.0%, respectively. Survival analysis assessing the time to the first reintervention demonstrated a better outcome in both the arachnolysis (p = 0.03) and the focal arachnoiditis (p = 0.04) groups. Arachnolysis led to fewer reinterventions than shunting in patients with nonforaminal syringomyelia. There was a high risk of reintervention for patients with extensive arachnopathies, irrespective of the surgical technique.

A comprehensive model including preoperative peripheral blood inflammatory markers for prediction of the prognosis of diffuse spinal cord astrocytoma following surgery

PurposeDue to the rarity of diffuse spinal cord astrocytoma, an effective model is still lacking to stratify their prognosis. Here, we aimed to establish a prognostic model through comprehensively evaluating clinicopathological features and preoperative peripheral blood inflammatory markers in 89 cases.MethodsWe performed univariate and multivariate Cox regression to identify prognosis factors. The Kaplan–Meier curves and ROC curves were employed to compare the prognostic value of selected factors.ResultsIn addition to clinicopathological factors, we revealed the preoperative peripheral blood leukocyte count, neutrophils-to-lymphocytes ratio (NLR), and platelet-to-lymphocyte ratio (PLR) were also significantly correlated with overall survival of spinal cord astrocytoma in univariate Cox regression, and NLR was still significant in multivariate Cox analysis. Further, we demonstrated that NLR ≤ 3.65 and preoperative McCormick score (MMS) ≤ 3 were independently correlated with better survival of WHO grade IV tumors. Meanwhile, Ki-67 < 10% and resection extent ≥ 90% were independent prognostic factors in WHO grade II/III tumors. Finally, we developed a prognostic model that had better predictive efficiencies than WHO grade and histological grade for 1-year (AUC = 76.6), 2- year (AUC = 80.9), and 3-year (AUC = 80.3) survival. This model could classify tumors into 4 classifications with increasingly poor prognosis: 1, WHO grade II/III, with Ki-67 < 10% and resection extent ≥ 90%; 2, WHO grade II/III, Ki-67 ≥ 10% or resection < 90%; 3, WHO grade IV, NLR ≤ 3.65 and MMS ≤ 3; 4, WHO grade IV, with NRL > 3.65 or MMS = 4.ConclusionWe successfully constructed a comprehensive prognostic model including preoperative peripheral blood inflammatory markers, which can stratify diffuse spinal cord astrocytoma into 4 subgroups.

Surgical outcome and prognostic factors in spinal cord ependymoma: a single-center, long-term follow-up study.

Objective:Spinal cord ependymomas account for 3–6% of all central nervous system tumors and around 60% of all intramedullary tumors. The aim of this study was to analyze the neurological outcome after surgery and to determine prognostic factors for functional outcome.Patients and Methods:Patients treated surgically due to a spinal cord ependymoma between 1990 and 2018 were retrospectively included. Demographics, neurological symptoms, radiological parameters, histopathology, and neurological outcome (using McCormick Score [MCS]) were analyzed. Possible prognostic factors for neurological outcome were evaluated.Results:In total, 148 patients were included (76 males, 51.4%). The mean age was 46.7 ± 15.3 years. The median follow-up period was 6.8 ± 5.4 years. The prevalence was mostly in the lumbar spine (45.9%), followed by the thoracic spine (28.4%) and cervical spine (25.7%). Gross-total resection was achieved in 129 patients (87.2%). The recurrence rate was 8.1% and depended on the extent of tumor resection (p = 0.001). Postoperative temporary neurological deterioration was observed in 63.2% of patients with ependymomas of the cervical spine, 50.0% of patients with ependymomas of the thoracic spine, and 7.4% of patients with ependymomas of the lumbosacral region. MCS 1–2 was detected in nearly two-thirds of patients with cervical and thoracic spinal cord ependymoma 36 months after surgery. Neurological recovery was superior in thoracic spine ependymomas compared with cervical spine ependymomas. Poor preoperative functional condition (MCS >2), cervical and thoracic spine location, and tumor extension >2 vertebrae were independent predictors of poor neurological outcome.Conclusion:Neurological deterioration was seen in the majority of cervical and thoracic spine ependymomas. Postoperative improvement was less in thoracic cervical spine ependymomas compared with thoracic spine ependymomas. Poor preoperative status and especially tumor extension >2 vertebrae are predictors of poor neurological outcome (MCS >2).

Hemorrhage in long segment cervical schwannoma; case report and literature review.

Background: Although hemorrhages associated with cervical and thoracic intraspinal schwannomas are typically localized to the subarachnoid hemorrhages (SAH) or subdural hemorrhages (SDH) compartments, rare intratumoral bleeds may also occur.Methods: In the literature, we found and analyzed multiple factors for 13 cases (e.g., epidemiological, clinical, and pathological) of cervical schwannomas with intratumoral hemorrhages (ITH). We added the 14th case of a 35-year-old female with along segment cervical schwannoma with ITH who presented with acute quadriplegia and respiratory decompensation.Results: These 14 patients averaged 51.77 years of age, 60% were male, and the tumor involved 2.83 segments. The incidence of SAH and ITH was noted in five cases each, while SDH’s were very rare. The pathological characteristics were consistent with the diagnosis of cellular schwannomas with S-100 positivity. The clinical outcomes were good (100%) in all the cases, including the one presented (modified McCormick score III).Conclusion: Cervical schwannomas with ITH are rare, and the surgical outcomes in such patients are good-excellent (>90%). The histopathology is always of prime importance and decisive in establishing and confirming the etiology of such ITH.

Sacral and thoracic chordoma with pulmonary metastases: A case report and review of the literature.

Chordoma is a sporadic type of cancer that affects the spine and is particularly challenging to treat due to the paucity of reported cases and scientific literature. In particular, primary chordomas affecting both the sacral and thoracic vertebrae are extremely rare. We herein report a rare case of chordoma in the sacral and thoracic vertebrae with pulmonary metastasis, along with a literature review. The objective of the present study was to explore treatment options and long-term outcomes in patients with metastatic chordoma. Posterior decompression was performed for the thoracic tumor, followed by extended resection of the sacral tumor. The symptoms of the patient were relieved after surgery, and the postoperative Nurick score decreased from grade 3 to grade 2, while the postoperative McCormick score was I. Therefore, complete chordoma excision and internal spinal fixation may effectively reduce tumor recurrence and metastasis.