|
|
ORIGINAL ARTICLE |
|
Year : 2021 | Volume
: 34
| Issue : 3 | Page : 1184-1188 |
|
Outcomes of the surgical resection of intradural extramedullary tumors
Ahmed Saro, Ahmed K Abdelhameid
Department of Neurosurgery, Sohag Faculty of Medicine, Sohag, Egypt
Date of Submission | 02-Jun-2021 |
Date of Decision | 21-Jun-2021 |
Date of Acceptance | 28-Jun-2021 |
Date of Web Publication | 18-Oct-2021 |
Correspondence Address: Ahmed Saro Department of Neurosurgery, Sohag Faculty of Medicine, Sohag Egypt
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/mmj.mmj_109_21
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.
Keywords: excision, intradural, meningioma, schwannoma, spinal cord
How to cite this article: Saro A, Abdelhameid AK. Outcomes of the surgical resection of intradural extramedullary tumors. Menoufia Med J 2021;34:1184-8 |
Introduction | | |
Intradural extramedullary spinal tumors are rare neoplasms that can cause significant pain, gait disturbances, sensory changes, and decreased longevity. Intradural extramedullary tumors account for two-thirds of primary spinal tumors [1]. Most intradural extramedullary tumors are benign, and they exhibit no specific symptoms, the majority of spinal tumor pathologies in the intradural extramedullary compartments of the spine are schwannomas, meningiomas, and neurofibromas [2]. However, these histologically benign tumors can cause profound impairment on the quality of life through pain and myeloradicular symptoms caused by direct compressive effects [3].
Therefore, the primary goal of the therapy for spinal intradural tumors is to decompress the spinal cord and remove it thoroughly without recurrence. The used approach is according to the tumor location, posterior, posterolateral, or anterolateral. The most used one is posterior midline [3].
The effectiveness of tumor resection for the treatment of the clinical symptoms of intradural extramedullary tumors has been well documented. Studies have also shown improved functional outcomes following tumor resection. However, there is minimal evidence demonstrating improvement of patient quality of life compared with preoperative values [4].
Schwannoma is a firm globoid tumor that arises from Schwann cells in the nerve roots. Most schwannomas arise from one nerve root and rarely arise from multiple ones [5]. Usually, schwannomas are slowly growing and may remain silent for years before the first presentation due to the small size. Meningiomas arise from arachnoid cap cells [6]. The first successful spinal meningioma excision was performed in 1887 by Sir Victor Horsley and Sir William Gowers [7].
Spinal meningiomas were identified as one of the most favorable prognoses if compared with other spinal tumors (Cushing and Eisenhardt) [8]. In our study, the schwannomas account for 61% that is higher than similar studies that vary between 25 and 33% [9],[10]. The maximum incidence of those tumors is in the fifth and sixth decade, which is similar to our study; the mean age was 46.6 years with slight female predominance (57%), which may be attributed to hormonal effect that was proved by the presence of estrogen and progesterone receptors on histological examination [11].
Our aim in this study was to evaluate the postoperative status after the tumor resection and compare it with the preoperative status.
Patients and methods | | |
A retrospective study was done in the Neurosurgery Department, Sohag Faculty of Medicine, between April 2014 and April 2018.
After written informed consent, 42 cases diagnosed with intradural extramedullary tumors confirmed by MRI spine were subjected to total tumors' excision. All cases were operated and the mean follow-up period was 13.3 months. All patients' data were recorded regarding their age, sex, and mean duration of symptoms. They were evaluated preoperatively regarding pain, motor, and sphincteric function. Pain evaluation was made using a graphic rating scale. All patients were subjected to MRI spine with gadolinium contrast. All patients received intravenous dexamethasone 1 week before the procedure.
Under general anesthesia, patients with prone position, the procedure was through midline incision extending two levels above and two levels below the detected tumor to allow dural traction, muscular dissection, and laminectomy with partial facetectomy on the tumor side, midline dural incision with the traction of its edges using vicryl 4/0 sutures. Hemostasis was done using small cotton pads and bipolar coagulation with a microscopic opening of the arachnoid layer and cutting the dentate ligament. Blunt dissection of the tumor edges using microdissectors was performed. Microscopic closure of the dural opening with primary sutures was carried out using the same suture. All specimens were sent for pathological examination.
Statistical analysis
- Data were analyzed using a Statistical Package for Social Sciences (IBM-SPSS), Statistical Package for the Social Sciences, version 25 (August 2017; IBM Corporation, Chicago, Illinois, USA) was used for statistical data analysis.
- Data were expressed as mean, SD, number, and percentage. Mean and SD were used as a descriptive value for quantitative data.
- Student t test was used to compare the means between two groups, and Pearson χ2 test was used to compare percentages of qualitative variables.
- For all these tests, the level of significance (P value) was explained as
- No significance P value more than 0.05.
- Significance P value less than 0.05.
- High significance P value less than 0.001.
- The study protocol was approved by the Local Ethical Committee of Sohag Faculty of Medicine, under the number 3474/2014.
Results | | |
The mean duration of symptoms was 27.2 months. There was slight female predominance (57%) and the mean age was 46 years. The most frequent symptom was back and radicular 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 meningiomas (60.9%) [Table 1].
Surgical resection improves the outcome in 35 (83.3%) patients. The most effective prognostic factor was the early surgical intervention. Complications were reported in seven patients, including cerebrospinal fluid leak, urinary incontinence, and wound infection. Five patients with cerebrospinal fluid leak were improved after administration of carbonic anhydrase inhibitor (acetazolamide), while the remaining two improved after lumbar drainage. None of our patients received preoperative or postoperative radiotherapy [Table 2] and [Table 3]. | Table 3: Comparison between improved cases and those who did not improve
Click here to view |
The evaluation was made using Frankel grading and McCormick scale [5],[6]. Twenty-five (59.5%) patients were Frankel grades A, B, and C in comparison with 28.6% postoperatively. Regarding the McCormick scale, 80.1% of our patients were grades III, IV, and V preoperatively compared with 23.8% postoperatively.
Frankel grading is a grading scale to detect the motor and sensory affection, as A is complete motor and sensory affection, B is complete motor loss with incomplete sensory loss, and C is incomplete motor loss with preserved sensation, while E is normal sensory and motor function [Figure 1], [Figure 2], [Figure 3], [Figure 4]. | Figure 2: Postoperative MRI, sagittal cuts showing complete tumor excision in the same patient.
Click here to view |
Discussion | | |
The most common site was the dorsal spine (71.4%) followed by the lumbar spine (21.4%), which coincides with other studies [12],[13]. The clinical presentations usually have a gradual onset with a progressive course and the clinical pattern varies among patients according to the tumor site, size, and rate of growth. The mean time of symptom duration was 27.2 months, which is longer compared with other studies (12–24 months). The most common histological types were the psammomatous and meningotheliomatous types that are in line with other studies [13],[14].
The most clinical presentations were local pain, radicular pain, motor deficit, paresthesia, and urinary incontinence, which are consistent with other studies [13],[15],[16]. There were no recurrent cases in our study during the follow-up period; however, the recurrence rate in other studies ranges between 1.4 and 15% and this might be related to incomplete resection, Simpson grade, WHO grade, and anterior location. A long preoperative presentation with incomplete resection and severe neurological deficit (either sensory or motor) is alike other studies [16],[17],[18].
Conclusion | | |
These types of tumors have excellent results after excision. After total excision, marked improvement regarding pain and neurological function was reported, while the recurrence rate was less than 2.5%. Prognostic factors include the severity and the duration of the preoperative presentation, WHO grade, time of intervention, and Simpson grade of excision. We recommend early intervention, irrespective of the tumor location or the pathology.
Acknowledgements
Authors' contributions: both authors gave the idea and collected the patients' data and postoperative follow-up of the study. Both of them put the study design and analyzed the data. They wrote with meticulous revision of the paper and approved its final version.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References | | |
1. | Hsu S, Quattrone M, Ostrom Q, Ryken TC, Sloan AE, Barnholtz-Sloan JS. Incidence patterns for primary malignant spinal cord gliomas: a surveillance, epidemiology, and end results study. J Neurosurg Spine 2011; 14:742–747. |
2. | Dorsi MJ, Belzberg AJ. Paraspinal nerve sheath tumors. Neurosurg Clin N Am 2004; 15:217–222. |
3. | Bret P, Lecuire J, Lapras C, Deruty R, Dechaume JP, Assaad A. Intraspinal meningiomas. A series of 60 cases. Neurochirurgie 1976; 22:5–22. |
4. | Westwick HJ, Yuh SJ, Shamji MF. Complication avoidance in the resection of spinal meningiomas. World Neurosurg 2015; 83:627–634. |
5. | Frankel HL, Hancock DO, Hyslop G, Melzak J, Michaelis LS, Ungar GH, et al. The value of the postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia 1969; 7:179–192. |
6. | McCormick PC, Stein BM. Intramedullary tumors in adults. Neurosurg Clin N Am 1990; 1:609–630. |
7. | Mulholland RC. Sir William Gowers 1845-1915. Spine 1996; 21:1106–1110. |
8. | Pendleton C, Olivi A, Brem H, Quiñones-Hinojosa A. Harvey Cushing's early treatment of meningiomas: the untold story. World Neurosurg 2013; 80:217–221. |
9. | Ahn DK, Park HS, Choi DJ, Kim KS, Kim TW, Park SY. The surgical treatment for spinal intradural extramedullary tumors. Clin Orthop Surg 2009; 1:165–172. |
10. | Emel E, Abdallah A, Sofuoglu OE, Ofluoglu AE, Gunes M, Guler B, et al. Long-term surgical outcomes of spinal schwannomas: retrospective analysis of 49 consecutive cases. Turk Neurosurg 2017; 27:217–225. |
11. | Klekamp J, Samii M. Surgical results for spinal meningiomas. Surg Neurol 1999; 52:552–562. |
12. | Roux FX, Nataf F, Pinaudeau M, Borne G, Devaux B, Meder JF. Intraspinal meningiomas: a review of 54 cases with discussion of poor prognosis factors and modern therapeutic management. Surg Neurol 1996; 46:458–463. discussion 63-64. |
13. | Nambiar M, Kavar B. Clinical presentation and outcome of patients with intradural spinal cord tumors. J Clin Neurosci 2012; 19:262–266. |
14. | Kim CH, Chung CK. Surgical outcome of a posterior approach for large ventral intradural extramedullary spinal cord tumors. Spine 2011; 36:E531–E537. |
15. | Tumialán LM, Theodore N, Narayanan M, Marciano FF, Nakaji P. Anatomic basis for minimally invasive resection of intradural extramedullary lesions in thoracic spine. World Neurosurg 2018; 109:e770–e777. |
16. | Raco A, Pesce A, Toccaceli G, Domenicucci M, Miscusi M, Delfini R. Factors leading to a poor functional outcome in spinal meningioma surgery: remarks on 173 cases. Neurosurgery 2017; 80:602–609. |
17. | Setzer M, Vatter H, Marquardt G, Seifert V, Vrionis FD. Management of spinal meningiomas: surgical results and a review of the literature. Neurosurg Focus 2007; 23:E14. |
18. | Tarantino R, Donnarumma P, Nigro L, Rullo M, Santoro A, Delfini R. Surgery of intradural extramedullary tumors: retrospective analysis of 107 cases. Neurosurgery 2014; 75:509–514. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]
|