Resection Of Intradural Extramedullary Tumors Research Articles

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.

Dural reconstruction following resection of ventral and lateral spinal cord meningiomas: Fenestrated Durotomy with Oversized Graft technique

BackgroundMeningiomas, although benign, often require complete resection due to their tendency for recurrence. However, dural reconstruction poses significant challenges, especially in the case of ventral meningiomas. While some reports have highlighted the usefulness of dural reconstruction using an artificial dura mater, no studies have yet confirmed dural canal enlargement through MRI post-surgically. This study aimed to assess the effectiveness of the Fenestrated Durotomy with Oversized Graft (FDOG) technique in cases of meningiomas and other intradural extramedullary tumors and evaluated dural canal dilation through MRI after using an artificial dura mater. MethodsThis retrospective case series included 8 patients who underwent combined resection of intradural extramedullary tumors and dural repair using the FDOG technique. An artificial dura mater larger than that resected was inserted into the dural defect resulting from complete tumor resection on the ventral or lateral side of the spinal cord. The new dura mater was secured with a single dorsal suture. The dural incision was closed using watertight sutures following standard procedure. Measurement of the extent of dural canal enlargement was achieved via pre- and postoperative MRI scans. ResultsNone of the patients required additional treatments or lumbar drainage. All achieved independent ambulation without complications, and imaging tests indicated satisfactory dural expansion without signs of cerebrospinal fluid leakage. ConclusionsThe proposed method for dural repair in cases involving large dural defects on the ventral or lateral side of the spinal cord was shown to be a straightforward and effective approach with minimal postoperative complications.

Minimally Invasive Resection of Intradural Extramedullary Tumors Using Tubular Retractors.

Minimally Invasive Resection of Intradural Extramedullary Tumors Using Tubular Retractors.

Minimally Invasive Resection of Intradural Extramedullary Tumors Using Tubular Retractors.

Minimally Invasive Resection of Intradural Extramedullary Tumors Using Tubular Retractors.

Microsurgical Tubular Resection of Intradural Extramedullary Spinal Tumors With 3-Dimensional-Navigated Localization.

The safety and efficacy of minimally invasive spine surgical (MISS) approaches have stimulated interest in adapting MISS principles for more complex pathology including intradural extramedullary (IDEM) tumors. No study has characterized a repeatable approach integrating the MISS surgical technique and 3-dimensional intraoperative navigated localization for the treatment of IDEM tumors. To describe a safe and reproducible technical guide for the navigated MISS technique for the treatment of benign intradural and extradural spinal tumors. Retrospective review of prospectively collected data on 20 patients who underwent navigated microsurgical tubular resection of intradural extramedullary tumors over a 5-year period. We review our approach to patient selection and report demographic and outcomes data for the cohort. Our experience demonstrates technical feasibility and safety with a 100% rate of gross total resection with no patients demonstrating recurrence during an average follow-up of 20.2 months and no instances of perioperative complications. We demonstrate favorable outcomes regarding blood loss, operative duration, and hospital length of stay. Navigated localization and microsurgical tubular resection of IDEM tumors is safe and effective. Adherence to MISS principles and thoughtful patient selection facilitate successful management of these patients.

30-day postoperative sepsis risk factors following laminectomy for intradural extramedullary tumors.

Posterior laminectomy (LA) for resection of intradural extramedullary tumors (IDEMTs) is associated with postoperative complications, including sepsis. Sepsis is an uncommon but serious complication that can lead to increased morbidity and mortality, prolonged hospital stays, and greater costs. Given the susceptibility of a solid tumor patients to sepsis-related complications, it is important to recognize IDEMT patients as a unique population when assessing the risk factors for sepsis after laminectomy. The study design was a retrospective cohort study. Adult patients undergoing LA for IDEMTs from 2012 to 2018 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Baseline patient characteristics/comorbidities, operative and hospital variables, and 30-day postoperative complications were collected. Of 2,027 total patients undergoing LA for IDEMTs, 38 (2%) had postoperative sepsis. On bivariate analysis sepsis was associated with superficial surgical site infection [odds ratio (OR) 11.62, P<0.001], deep surgical site infection (OR 10.67, P<0.001), deep vein thrombosis (OR 10.75, P<0.001), pulmonary embolism (OR 15.27, P<0.001), transfusion (OR 6.18, P<0.001), length of stay greater than five days (OR 5.41, P<0.001), and return to the operating room within thirty days (OR 8.72, P<0.001). Subsequent multivariate analysis identified the following independent risk factors for sepsis and septic shock: operative time ≥50th percentile (OR 2.11, P=0.032), higher anesthesia class (OR 1.76, P=0.046), dependent functional status (OR 2.23, P=0.001), diabetes (OR 2.31, P=0.037), and chronic obstructive pulmonary disease (OR 3.56, P=0.037). These findings can help spine surgeons identify high-risk patients and proactively deploy measures to avoid this potentially devastating complication in individuals who may be more vulnerable than the general elective spine population.

Outcomes of the surgical resection of intradural extramedullary tumors

Aim To evaluate the postoperative status after the tumor resection and compare it with the preoperative status. Background The intradural extramedullary tumors remain curable diseases and carry a favorable outcome. Early diagnosis is crucial to improve the outcome. Resection of the intradural extramedullary tumors improves the pain and the functional outcome of the patients. Patients and methods A retrospective study was done in the Neurosurgery Department, Sohag Faculty of Medicine, to patients diagnosed with intradural extramedullary tumors confirmed by MRI spine between April 2014 and April 2018. Forty-two cases were presented with female predominance, with mean age 46.6 ± 17 years with different presentations. They were operated and follow-up was done for 1 year postoperatively. They were evaluated preoperatively regarding pain, motor, and sphincteric function. Results The most frequent symptom was back and leg pain (88.1%), followed by paraparesis (23.8%), sensory disturbances in seven (16.7%) patients, and urinary incontinence in seven (16.7%) patients. The most common pathology was schwannoma (61.9%). Surgical resection improves the outcome in 35 (83.3%) patients. The dorsal spine was mostly affected in 30 patients followed by the lumbar spine in nine patients. The most effective prognostic factor was the early surgical intervention. Complications were reported in 19 patients, including cerebrospinal fluid leak, urinary incontinence, and wound infection. Conclusion These types of tumors have excellent results after excision. We recommend early intervention, irrespective of the tumor location or the pathology. After total excision, marked improvement regarding pain and neurological function was reported, while the recurrence rate was less than 2.5%. Prognostic factors include tumor extension, time of intervention, and Simpson grade of excision.

Intraoperative neurophysiological monitoring for intradural extramedullary spinal tumors: predictive value and relevance of D-wave amplitude on surgical outcome during a 10-year experience.

OBJECTIVEThe purpose of this study was to evaluate the technical feasibility, accuracy, and relevance on surgical outcome of D-wave monitoring combined with somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) during resection of intradural extramedullary (IDEM) spinal tumors.METHODSClinical and intraoperative neurophysiological monitoring (IONM) data obtained in 108 consecutive patients who underwent surgery for IDEM tumors at the Institute for Scientific and Care Research "ASMN" of Reggio Emilia, Italy, were prospectively entered into a database and retrospectively analyzed. The IONM included SSEPs, MEPs, and-whenever possible-D-waves. All patients were evaluated using the modified McCormick Scale at admission and at 3, 6, and 12 months of follow-up .RESULTSA total of 108 patients were included in this study. A monitorable D-wave was achieved in 71 of the 77 patients harboring cervical and thoracic IDEM tumors (92.2%). Recording of D-waves in IDEM tumors was significantly associated only with a preoperative deeply compromised neurological status evaluated using the modified McCormick Scale (p = 0.04). Overall, significant IONM changes were registered in 14 (12.96%) of 108 patients and 9 of these patients (8.33%) had permanent loss of at least one of the 3 evoked potentials. In 7 patients (6.48%), the presence of an s18278 caudal D-wave was predictive of a favorable long-term motor outcome even when the MEPs and/or SSEPs were lost during IDEM tumor resection. However, in 2 cases (1.85%) the D-wave permanently decreased by approximately 50%, and surgery was definitively abandoned to prevent permanent paraplegia. Cumulatively, SSEP, MEP, and D-wave monitoring significantly predicted postoperative deficits (p = 0.0001; AUC = 0.905), with a sensitivity of 85.7% and a specificity of 97%. Comparing the area under the receiver operating characteristic curves of these tests, D-waves appeared to have a significantly greater predictive value than MEPs and especially SSEPs alone (0.992 vs 0.798 vs 0.653; p = 0.023 and p < 0.001, respectively). On multiple logistic regression, the independent risk factors associated with significant IONM changes in the entire population were age older than 65 years and an anterolateral location of the tumor (p < 0.0001).CONCLUSIONSD-wave monitoring was feasible in all patients without severe preoperative motor deficits. D-waves demonstrated a statistically significant higher ability to predict postoperative deficits compared with SSEPs and MEPs alone and allowed us to proceed with IDEM tumor resection, even in cases of SSEP and/or MEP loss. Patients older than 65 years and with anterolateral IDEM tumors can benefit most from the use of IONM.

Spinal intradural extramedullary tumors: the value of intraoperative neurophysiologic monitoring on surgical outcome

Nerve sheath tumors and meningiomas account for most intradural extramedullary (IDEM) tumors. These tumors are benign and amenable to complete surgical resection. In recent years, these surgeries are performed with intraoperative neurophysiologic monitoring (IONM) in order to minimize neurological injury, but the evidence for the statistical efficacy of this utility is lacking. This paper evaluates IONM benefits in IDEM tumor resection. Data of patients treated surgically for spinal intradural tumors from 1998 to 2003 was previously collected and analyzed. We retrospectively evaluated patients' charts operated in the years 2011 to 2013. Patients' medical files were reviewed including radiological examinations and electrophysiological reports. The data was collected and evaluated. Forty-one cases of meningioma or nerve sheath tumor resection surgery were performed in the study period. The surgical results were compared to 70 cases of historical controls. Demographic data was similar in these two groups. Sensitivity, specificity, and positive and negative predicted values of IONM were 75, 100, 100, and 97%, respectively. New neurological deficit rate was evident in 10 and 14% for the study and control groups, respectively (not significant). While IONM predicts neurological deficits with high accuracy level, this study does not suggest that there is a significant global benefit of IONM in these cases. As reported by others, in this series, the rate of new neurological deficits in non-monitored cases is similar to the monitored cases series; hence, IONM role in preventing new neurological deficits has yet to be proven.

Image Merge Assisted Minimally Invasive Resection of Intradural Extramedullary Tumors: A Retrospective Series of Eight Cases

Introduction Intradural extramedullary spinal tumors are rare lesions, with a prevalence of 3 to 10 per 100,000 in general population. Open bilateral laminectomy with partial or total facet removal is the standard surgical access for gross total resection (GTR) of such tumors. Studies in patients operated with laminectomy, the risk of developing postoperative deformity, particularly in the cervical spine, is still significant, accounting of 20 to 60% of patients treated with laminectomy. In addition, ventrolateral or ventrally placed tumors are often not easily accessible through a standard translaminar approach. In the present series, preoperative MRI data and intraoperative three-dimensional (3D) fluoroscopic images are manually merged in the operating room. Minimally invasive surgical techniques through a tubular retractor system are then used to resect the tumor. The merged images are used to plan the ideal trajectory to the lesion, thus, facilitating tumor access while minimizing bone and soft tissue resection in these patients. Methods A retrospective chart review of 45 consecutive surgical cases of intradural tumors over a 7-year period was performed. Eight patients operated for intradural extramedullary tumors using the image merge technique. Preoperative MRI and intraoperative 3D fluoroscopic data were manually merged using Synergy Cranial 2.2 software and Stealth Merge 1.2. Accuracy of manual image merging was verified with anatomic landmarks as references. Using these merged images, a trajectory from skin to tumor is planned to facilitate microsurgical tumor resection. The trajectory chosen defines the skin incision, and the type and extent of bone resection. Following 3 to 4 cm skin incision, a transmuscular expandable retractor is “docked” onto the spine. Bone drilling is tailored to the tumor margins using the merged images. From this point on, standard microsurgical resection is performed, followed by dural closure. Results From December 2012 to September 2014, five male and three female patients underwent tubular resection of intradural extramedullary spine tumors with the image merge assistance. Preoperative Nurick score was 3 in three patients, 1 in two patients, and 0 in remaining three patients. Follow-up neurological Nurick scores recording reveal a favorable neurological outcome with a score of 0 in seven patients. Follow-up ranges from 2 to 14 months (average, 5.8 months). No patient showed postoperative neurological deterioration. Only one patient with a resected L1 Schwannoma complains of postoperative radicular pain, which is responsive to medical treatment. MRI confirmed GTR in all cases. Conclusion In this small series, image merge assisted minimally invasive resection of intradural extramedullary lesions achieves maximum tumor resection while minimizing spinal cord manipulation and tailoring bone resection to reduce the risk of postoperative instability. This appears to be a safe and feasible procedure for such lesions.

Evaluation of hemilaminectomy use in microsurgical resection of intradural extramedullary tumors.

The aim of this study was to investigate the microsurgical techniques of hemilaminectomy, used in the excision of intradural extramedullary (IDEM) tumors, and to illustrate its clinical effects. Clinical data obtained from 16 patients (seven males, nine females) with IDEM tumors, which were treated at the China-Japan Union Hospital between January 2009 and December 2011, were retrospectively analyzed. The mean age of patients was 49 years, ranging from 34–72 years. The IDEM tumors were located cervically in three patients, thoracically in four patients and at the thoracico-lumbar level in nine patients. Fourteen patients underwent hemilaminectomy, while two patients were treated with laminectomy during surgery. The clinical effect of hemilaminectomy was evaluated based on Frankel grade. The mean bleeding volume was 300 ml (range, 150–500 ml) and the mean duration of surgery was 140 min (range, 90–200 min). The maximum and minimum tumor volumes were 4×1.5×1.5 cm and 1.5×1.0×1.0 cm, respectively. Neurinoma was evident in 11 patients, meningioma in four cases and neurofibroma in one case. Three cases improved from Frankel grade B to C, five cases improved from grade C to D and seven cases improved from grade D to grade E. All patients were followed up for a period of 6–40 months, with a mean follow-up time of 23.7 months. None of the patients exhibited tumor recurrence or spinal instability. The mean bleeding volume of patients that underwent hemilaminectomy and laminectomy was 275 and 475 ml, respectively. The advantages of hemilaminectomy are minor invasion, less bleeding and retention of spinal stability. In general, hemilaminectomy for the excision of IDEM tumors has a satisfactory outcome.