Clinical presentation and surgical management of intramedullary spinal cord cavernous malformations

Lu, Daniel C.; Lawton, Michael T.

doi:10.3171/2010.6.focus10139

Cited by 49 publications

(39 citation statements)

References 11 publications

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“…Eligibility criteria were met by 39 articles, totaling 608 patients 1,5,6,8,9,11,12,14,15,17,[20][21][22][23]27,28,30,[34][35][36][37][38][39][40][41][42]45,46,49,50,53,54,58,59,[62][63][64]67,73 (Fig. 1), in addition to our institutional series of 24 patients with ISCCMs (total of 40 series and 632 patients).…”

Section: Resultsmentioning

confidence: 99%

“…1,5,12,30,34,37,50,53,73 According to our meta-analysis, the calculated pooled estimate of the annual hemorrhage rate was 2.1% (95% CI 1.3%-3.3%) (Fig. 2).…”

Section: Clinical Outcomesmentioning

confidence: 99%

“…Included articles described use of various methods to report outcomes, most commonly a simple scale of better, same, or worse. Several articles reported use of a standardized scoring tool for assessing neurological function, including the McCormick, 1,12,15,17,20,30,35,37,39,40 Frankel, 5,6,8,42,53,59,73 American Spinal Injury Association impairment, 50 and Aminoff-Logue disability 36 scales. For each included study, we defined improved, unchanged, or worsened neurological function the same as that reported by the authors of eligible articles.…”

Section: Definition Of Variablesmentioning

confidence: 99%

“…7,24,73 Since then, several additional large series have been published. 1,2,6,12,17,20,27,32,34,36,37,39,42,59,62,67 Because of the relative rarity of these lesions, information pertaining to clinical outcomes for patients harboring ISCCMs is scarce.…”

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confidence: 99%

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Surgical outcomes and natural history of intramedullary spinal cord cavernous malformations: a single-center series and meta-analysis of individual patient data

Badhiwala¹,

Farrokhyar

Alhazzani

et al. 2014

SPI

118

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Object Information pertaining to the natural history of intramedullary spinal cord cavernous malformations (ISCCMs) and patient outcomes after surgery is scarce. To evaluate factors associated with favorable outcomes for patients with surgically and conservatively managed ISCCMs, the authors performed a systematic review and metaanalysis of the literature. In addition, they included their single-center series of ISCCMs. Methods The authors searched MEDLINE, EMBASE, CINAHL, Google Scholar, and The Cochrane Library for studies published through June 2013 that reported cases of ISCCMs. Data from all eligible studies were used to examine the epidemiology, clinical features, and neurological outcomes of patients with surgically managed and conservatively treated ISCCMs. To evaluate several variables as predictors of favorable neurological outcomes, the authors conducted a meta-analysis of individual patient data and performed univariate and multivariate logistic regression analyses. Variables included patient age, patient sex, lesion spinal level, lesion size, cerebral cavernomas, family history of cavernous malformations, clinical course, presenting symptoms, treatment strategy (operative or conservative), symptom duration, surgical approach, spinal location, and extent of resection. In addition, they performed a meta-analysis to determine a pooled estimate of the annual hemorrhage rate of ISCCMs. Results Eligibility criteria were met by 40 studies, totaling 632 patients, including the authors' institutional series of 24 patients. Mean patient age was 39.1 years (range 2–80 years), and the male-to-female ratio was 1.1:1. Spinal levels of cavernomas were cervical (38%), cervicothoracic (2.4%), thoracic (55.2%), thoracolumbar (0.6%), lumbar (2.1%), and conus medullaris (1.7%). Average cavernoma size was 9.2 mm. Associated cerebral cavernomas occurred in 16.5% of patients, and a family history of cavernous malformation was found for 11.9% of evaluated patients. Clinical course was acute with stepwise progression for 45.4% of patients and slowly progressive for 54.6%. Symptoms were motor (60.5%), sensory (57.8%), pain (33.8%), bladder and/or bowel (23.6%), respiratory distress (0.5%), or absent (asymptomatic; 0.9%). The calculated pooled annual rate of hemorrhage was 2.1% (95% CI 1.3%–3.3%). Most (89.9%) patients underwent resection, and 10.1% underwent conservative management (observation). Outcomes were better for those who underwent resection than for those who underwent conservative management (OR 2.79, 95% CI 1.46–5.33, p = 0.002). A positive correlation with improved neurological outcomes was found for resection within 3 months of symptom onset (OR 2.11, 95% CI 1.31–3.41, p = 0.002), hemilaminectomy approach (OR 3.20, 95% CI 1.16–8.86, p = 0.03), and gross-total resection (OR 3.61, 95% CI 1.24–10.52, p = 0.02). Better outcomes were predicted by an acute clinical course (OR 1.72, 95% CI 1.10–2.68, p = 0.02) and motor symptoms (OR 1.76, 95% CI 1.08–2.86, p = 0.02); poor neurological recovery was predicted by sensory symptoms (OR 0.58, 95% CI 0.35–0.98, p = 0.04). Rates of neurological improvement after resection were no higher for patients with superficial ISCCMs than for those with deep-seated ISCCMs (OR 1.36, 95% CI 0.71–2.60, p = 0.36). Conclusions Intramedullary spinal cord cavernous malformations tend to be clinically progressive. The authors' findings support an operative management plan for patients with a symptomatic ISCCM. Surgical goals include gross-total resection through a more minimally invasive hemilaminectomy approach within 3 months of presentation.

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Section: Resultsmentioning

confidence: 99%

“…1,5,12,30,34,37,50,53,73 According to our meta-analysis, the calculated pooled estimate of the annual hemorrhage rate was 2.1% (95% CI 1.3%-3.3%) (Fig. 2).…”

Section: Clinical Outcomesmentioning

confidence: 99%

Section: Definition Of Variablesmentioning

confidence: 99%

mentioning

confidence: 99%

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Surgical outcomes and natural history of intramedullary spinal cord cavernous malformations: a single-center series and meta-analysis of individual patient data

Badhiwala¹,

Farrokhyar

Alhazzani

et al. 2014

SPI

118

View full text Add to dashboard Cite

show abstract

“…In such cases, resections required no separate myelotomy and the tumor could be entered directly. This applied to most angioblastomas, 6,38,44,57 some cavernomas, 35,36,55 and a few astrocytomas. Whenever the spinal cord had covered the intramedullary tumor completely, sensory functions suffered permanently to some degree.…”

Section: Postoperative Sensory Dysfunctionsmentioning

confidence: 99%

Treatment of intramedullary tumors: analysis of surgical morbidity and long-term results

Klekamp

2013

SPI

115

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Object Surgery of intramedullary tumors is established as the treatment of choice for these challenging lesions. This study presents a detailed analysis of risk factors for surgical morbidity and data on long-term results for intramedullary tumors. Methods Among 1317 patients with tumors of the spinal canal treated between 1980 and 2012, 278 patients with intramedullary tumors are presented. A total of 225 of these patients underwent 246 operations for treatment of 250 tumors. The mean patient age was 41 ± 17 years (range 3 weeks to 83 years). Patients underwent follow-up through outpatient visits and questionnaires with a mean follow-up of 41 ± 53 months. Tumors were subdivided into 3 groups: displacing tumors (Type A, n = 162), infiltrating tumors (Type B, n = 80), and nonproliferating tumors (Type C, n = 8). A gross-total resection (GTR) was attempted for every tumor except for Type C lipomas. Participating surgeons were divided into 3 groups according to the number of operations they performed. Short-term results were determined for individual symptoms and the modified McCormick Scale, whereas tumor recurrence rates were calculated with Kaplan-Meier statistics. Results Overall, 83.3% of Type A tumors underwent GTR compared with 22.5% of Type B and none in Type C. Gross-total resection rates increased throughout the study period and correlated significantly with surgical experience. A worsened neurological state after surgery was seen in 61% of patients. This deterioration was transient in 41.5% and was a common observation after GTR. Permanent morbidity (19.5%) was lowest after GTR and correlated significantly with surgical experience and the preoperative neurological state. Further analysis showed that patients with tumors of thoracic levels, tumor hemorrhages, and malignant and recurrent tumors were at a higher risk for permanent morbidity. In the long term, tumor recurrence rates for ependymomas and benign astrocytomas correlated significantly with the amount of resection. Long-term morbidity affected 3.7% with a postoperative myelopathy related to cord tethering at the level of surgery and 21.9% in form of neuropathic pain syndromes. The rate of postsurgical cord tethering could be lowered significantly by using pia sutures after tumor resection. Neuropathic pain syndromes were more common after surgery for tumors with associated syringomyelia or those located in the cervical cord. Conclusions Intramedullary tumors should be surgically treated as soon as neurological symptoms appear. Gross-total resection is possible for the majority of benign pathologies. Cervical tumors are associated with higher GTR and lower permanent morbidity rates compared with thoracic tumors. Surgery on intramedullary tumors should be performed by neurosurgeons who deal with these lesions on a regular basis as considerable experience is required to achieve high GTR rates and to limit rates of permanent morbidity.

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Microsurgical anatomy of the denticulate ligaments and their relationship with the axilla of the spinal nerve roots

et al. 2013

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The denticulate ligaments (DL), 20 or 21 pairs of meningeal extensions, spread from the lateral aspect of the spinal cord to the internal aspect of the spinal dura mater. The aim of this study is to define the specific relationship of the DL with adjacent axilla of the spinal nerve roots and to investigate the anatomical features of the DLs and their variations. The topographical anatomy of the DLs and their relationships with the adjacent axilla of the spinal nerve roots was examined on 16 formalin-fixed adult cadaveric spinal cords. The distances from the dural attachment of the DL to the axilla of the superior and inferior spinal nerve roots were measured bilaterally at every spinal level. Also the distances from the dural attachment of the DL to the lateral aspect of the spinal cord were measured bilaterally. Cervical DLs showed a triangular shape, while in the thoracic segment the ligament changes the shape to "Y." Also the most caudal DL was identified to be at the L1-2 level. Our study revealed that the distances from the dural attachment of the DL to the superior and inferior spinal nerve root axilla were different at the cervical, upper thoracic and the lower thoracic segments. Both distances to the superior and inferior spinal nerve root axilla were shown to increase from cervical to lower thoracic segments. This study provides a detailed anatomy of the DLs and their relationship with the adjacent spinal nerve root axilla.

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Clinical presentation and surgical management of intramedullary spinal cord cavernous malformations

Cited by 49 publications

References 11 publications

Surgical outcomes and natural history of intramedullary spinal cord cavernous malformations: a single-center series and meta-analysis of individual patient data

Surgical outcomes and natural history of intramedullary spinal cord cavernous malformations: a single-center series and meta-analysis of individual patient data

Treatment of intramedullary tumors: analysis of surgical morbidity and long-term results

Microsurgical anatomy of the denticulate ligaments and their relationship with the axilla of the spinal nerve roots

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