Surgical management of long intramedullary spinal cord tumors

Object Spinal cord tumors represent approximately 10–20% of primary central nervous system tumors. Only 20–30% of primary intradural tumors are intramedullary. The incidence of longitudinally extensive tumors involving the cervical, thoracic, and lumbar spine is very low (<1% of intramedullary lesions); hence, little literature exists on the management of this entity. Materials and methods We retrospectively reviewed all patients undergoing surgical resection of longitudinally extensive intramedullary spinal cord tumors involving the majority of the spinal cord between 1990 and 2002. Clinical, radiographic, operative, and outcome variables were retrospectively recorded and reported. Results Thirteen patients (eight male, five female) were included in the study. Mean age was 15 years (range, 3–45) at the time of the initial resection. Gross total resection was achieved in eight cases and subtotal resection in five cases. Pathology revealed astrocytoma in six cases (two pilocytic, four grade II), gangliogliomas in four cases, oligodendroglioma in two cases (one anaplastic), and lipoma in one case. One (8%) patient died from progression of anaplastic oligodendroglioma, and two (15%) underwent reoperation for recurrent tumor (ganglioglioma, grade II astrocytoma). With a mean of 3.4 years (range, 1–12) after surgery, the modified McCormick score (MMS) had worsened in only two (15%) patients, improved in three (23%) patients, and remained stable in seven (54%) patients compared to preoperative MMS. Five (38%) patients required fusion for progressive spinal deformity. Conclusion Gross total resection of holocord and longitudinally extensive intramedullary spinal cord tumors can be achieved with preservation of long-term neurological function in many cases. Serial imaging is recommended to guide subsequent resection for tumor recurrence and stabilization of progressive spinal deformity.     

Spinal deformity after resection of cervical intramedullary spinal cord tumors in children

Objective Progressive spinal deformity after cervical intramedullary spinal cord tumor (IMSCT) resection requiring subsequent fusion occurs in many cases among pediatric patients. It remains unknown which subgroups of patients represent the greatest risk for progressive spinal deformity. Materials and methods The data for 58 patients undergoing surgical resection of cervical IMSCT at a single institution were retrospectively collected and analyzed for development of progressive spinal deformity requiring fusion. The association of all clinical, radiographic, and operative variables to subsequent progressive spinal deformity as a function of time was assessed via Kaplan–Meier plots and Log-rank and Cox analyses. Results Mean age at the time of surgery was 11 ± 6years. Eleven (19%) patients required subsequent fusion for progressive spinal deformity at a median [interquartile range (IQR)] of 4 (2–6) years after IMSCT resection. Five (36%) of 14 patients with preoperative scoliosis or loss of lordosis developed postoperative progressive spinal deformity compared to only 6 (13%) of 44 patients with normal preoperative sagittal and coronal balance, p = 0.06. Patients <13years of age were more than three times more likely to develop postoperative progressive deformity, p = 0.05. Decompression spanning both the axial cervical spine (C1–C2) and the cervico–thoracic junction (C7–T1) increased the risk for progressive spinal deformity fourfold, p = 0.04. Number of spinal levels decompressed, revision surgery, radiotherapy, involvement of C1–C2 or C7–T1 alone in the decompression, or any other recorded variables were not associated with progressive postoperative spinal deformity. Conclusion Patients possessing one or more of these characteristics should be monitored closely for progressive spinal deformity after surgery.     

脊髓髓内肿瘤的手术治疗

目的：探讨各种病理类型的脊髓髓内肿瘤临床和影像学的鉴别诊断，肿瘤囊腔及其空洞的形成机理，脊髓前动脉在病理状态下的作用及各种肿瘤的手术切除技巧。方法：系统分析了经显微手术切除的１０４例（１１６个）髓内肿瘤，包括室管膜瘤，星形细胞瘤，血管网状细胞瘤等十余种病理类型的临床资料，并进行了动物脊髓血管闭塞模型的研究。结果：全组无手术死亡率，亦无手术致残者。绝大多数病人得到满意疗效，并保证了患者良好的术后存活质量。结论：对于绝大多数髓内肿瘤，显微外科手术治疗是目前最根本的治疗方法。强调早期治疗及对不同肿瘤采取相应的微创性手术技巧。对于那些疯狂侵润性生长的恶性肿瘤，要考虑一定剂量的常规放射治疗。     

显微手术治疗脊髓髓内肿瘤

目的探讨脊髓髓内肿瘤的显微手术治疗效果。方法回顾性分析经显微手术治疗的27例脊髓髓内肿瘤病人的临床资料。结果肿瘤全切除13例,次全切除10例,大部分切除4例。术后1月症状明显改善21例,稳定3例,加重3例。本组无死亡病例。术后随访6-24个月,复发2例;按McCormick脊髓功能状态分级：Ⅰ级17例,Ⅱ级6例,Ⅲ级3例,Ⅳ级1例。结论MRI是诊断脊髓髓内肿瘤的首选方法,显微手术切除脊髓髓内肿瘤是一种有效的手段。     

Outcome of children with primary intramedullary spinal cord tumors

The influence of clinical and treatment factors on the outcome of children with primary intramedullary spinal cord tumors (PST) was evaluated by reviewing the records of 26 children diagnosed during the 15-year period 1970–1984. Five-year survival was 39%, but 5-year event-free survival (EFS) was only 14%. Eighteen-month EFS was 53% (9/17) among children with low-grade astrocytoma, 100% (2/2) with ependymoma, and 0 of 7 with anaplastic astrocytoma or ganglioglioma. There was no significant difference in the 18-month EFS by location of tumor, duration of symptoms, or extent of surgical removal. Five of 9 children with locally recurrent PST had a second operation, and 4 were alive a median of 56 months later. PST disseminated to the leptomeninges or the III ventricle in 5 children: 2 at diagnosis, 2 as the first sign of disease relapse, and 1 after local recurrence. Given the poor outcome of our children, different methods of treatment for children with tumors in this location should be evaluated.Presented in part at the 14th Annual Meeting of the Child Neurology Society, Memphis, Tennessee, October 1985     

Cervical spinal cord intramedullary teratoma

We present the case of a 62-year-old patient suffering from the presence of a cervical spinal cord intramedullary teratoma and treated operatively. The purpose of this case report is to describe the highly unusual localization of the intramedullary teratoma associated with other vertebral malformations. A review of the literature is also presented.     

颈髓髓内血管母细胞瘤的诊断与治疗

目的 探讨颈髓髓内血管母细胞瘤的诊断与治疗。方法 分析19例患者的MRI表现，及其手术治疗的效果。结果 这类肿瘤在MRI上可分为三型：A.空洞型，肿瘤大小不等，且继发延、脊髓空洞；B.囊肿型，为囊内小的附壁结节；C.实体型，为巨大的实体性肿瘤。所有患者均经手术全切除肿瘤，并经病理证实为血管母细胞瘤。术后患者神经系统状态好转者18例，加重1例。结论 颈髓MRI能对颈髓髓内血管母细胞瘤作出定位、定性诊断，并可将其分型，以利选择不同的手术方法；诊断时，还需与胸廓出口综合征和颈椎病相鉴别。认为颈髓髓内、即使累及延髓的血管母细胞瘤宜行积极手术治疗；手术方法随肿瘤类型不同而各异，最为重要是：需沿正确的界面分离，并应在离断供血动脉后切除肿瘤。     

脊髓髓内胶质瘤的显微神经外科手术处理

目的总结脊髓髓内胶质瘤显微神经外科手术治疗的经验。方法1999年至2005年共手术治疗脊髓髓内胶质瘤71例,男39例,女32例,年龄4~68岁(平均38.1岁),病程2个月~9年;肿瘤直径占脊髓横断面的60%~90%,长度跨越4~11个椎体;临床表现按McCormick神经功能分级:Ⅰ级11例,Ⅱ级49例,Ⅲ级8例,Ⅳ级3例。早期42例采用传统椎板切除术,后期29例采用整块切除棘突及椎板后再回植重建的方法进入椎管,在显微镜下沿脊髓后正中裂切开脊髓显露肿瘤并分块切除。结果手术全切肿瘤59例(83%),大部分切除12例(17%)。术后病理诊断:室管膜瘤51例(72%),星形细胞瘤19例(27%),恶性小圆细胞瘤1例(1%)。术后近期症状较术前加重或出现新的神经损害症状者40例(56%),症状改善或无变化者31例(44%)。随访6个月~6年,52例(73.2%)恢复正常工作或学习,13例(18.3%)可自理生活,6例(8.5%)不能自理生活;肿瘤复发2例。患者功能预后与术前神经功能分级密切相关,术前神经损害症状越轻,术后恢复越好。结论显微神经外科手术切除脊髓髓内胶质瘤是目前最有效的治疗措施,最佳手术时机是在患者尚未发生严重神经损害症状之前。     

脊髓髓内畸胎瘤的诊断及手术治疗

目的探讨12例髓内畸胎瘤的临床表现及手术治疗效果。方法分析12例髓内畸胎瘤的临床症状及影像学表现，并行显微外科手术治疗，其中颈及颈胸段脊髓内4例，胸髓内2例，圆锥部6例。结果髓内畸胎瘤患者脊椎平片多见脊柱骨性畸形，MRI检查肿瘤多为混杂信号影，术中见肿瘤呈囊实性，与正常脊髓组织无明显分界，肿瘤全切困难，可次全切除，术后肌力障碍恢复良好。结论脊柱平片及MRI对髓内畸胎瘤有定性及定位意义，手术切除是有效的治疗手段。     

A case report of "spinal cord apoplexy" elicited by metastatic intramedullary thyroid carcinoma

A 31-year-old man presented with acute onset of paraplegia. The patient's history was significant for thyroid carcinoma that had been treated 2 years earlier by thyroidectomy. A magnetic resonance imaging scan showed an enhancing intramedullary lesion at T7-8. Patient underwent surgical treatment and a tumor with hematoma was resected via posterior midline myelotomy. Postoperatively, the patient's motor weakness was improved to grade 3. The lesion showed typical histologic features consistent with papillary thyroid carcinoma. Early diagnosis and microsurgical resection can result in improvement in neurological deficits and quality of life of patients with an ISCM.     

Pediatric intramedullary spinal cord tumors Critical review of the literature

The objective of this review was to analyze the literature on the management of intramedullary spinal cord tumors to determine whether enough information was available for treatment guidelines to be established. Using standard computerized search techniques, databases containing medical literature were queried for keywords related to intramedullary spinal cord tumors, beginning in 1966. Of the 445 articles published in English and with potential relevance, only 75 articles were included in the final analyses. Based on the strength of their recommendations for the treatment of this controversial condition, articles were divided into class I, class II and class III data. There were no class I studies related to any aspect of the treatment of intramedullary spinal cord tumors. Based on this critical review of literature, gross total removal of an ependymoma confirmed by immediate postoperative magnetic resonance imaging and adjunctive treatment for high-grade tumors using radiotherapy, with or without chemotherapy, can be recommended as standards of therapy. With the strength of a guideline, radiotherapy should be withheld after gross total removal of intramedullary ependymomas and radical resection of low-grade intramedullary astrocytomas. The use of intraoperative ultrasonography and evoked potentials, important surgical adjuncts, can also be considered guidelines. The radical resection of intramedullary low-grade astrocytomas is an option. Received: 15 October 1998     

脊髓髓内肿瘤的显微外科治疗

目的 总结脊髓髓内肿瘤的治疗经验.方法 回顾性分析36例经显微手术治疗的脊髓髓内肿瘤病人的临床资料,术中超声辅助定位5例.结果 室管膜瘤17例,低级别星形细胞瘤(WHO I ～II级)8例,高级别星形细胞瘤(WHO Ⅲ～Ⅳ级)3例,血管母细胞瘤3例,海绵状血管瘤2例,脂肪瘤、转移瘤、畸胎瘤各1例.室管膜瘤全切率82.4%,低级别星形细胞瘤为50.0%,高级别星形细胞瘤为33.3%,血管母细胞瘤、海绵状血管瘤和转移瘤均全切,脂肪瘤和畸胎瘤次全切.术后随访3个月,根据McCormick脊髓功能状态分级:I级23例,II级7例,Ⅲ级3例,Ⅳ级3例.结论 显微手术切除脊髓髓内肿瘤是目前最有效的治疗措施.术中超声有助于术中肿瘤定位,减少手术创伤.     

显微手术切除加椎管重建治疗髓内室管膜瘤七例

目的探讨经显微手术切除加椎管重建治疗髓内室管膜瘤的临床疗效和预后。方法总结我科7例采用显微镜下切除肿瘤,复位椎板复合体行椎管重建治疗髓内室管膜瘤临床资料。结果 6例肿瘤手术完全切除,症状好转4例,随访未见复发及脊柱生理弯曲变形。结论微手术切除加椎管重建治疗髓内室管膜瘤效果令人满意,且能够防止脊柱生理弯曲变形。     

Intramedullary spinal cord tumors in children

Introduction Pediatric intramedullary spinal cord tumors are rare and make up only a small percentage of all central nervous system neoplasms.Discussion These neoplasms are predominantly benign histologically, regardless of size, with a large percentage being astrocytomas or gangliogliomas. Ependymomas, which are common in adults, are relatively uncommon in children. Contemporary management of these tumors has generated much controversy. These neoplasms occur primarily in the cervical region, with pain or a motor deficit as the chief complaint. Surgery on these neoplasms can safely be performed using modern surgical adjuncts such as the ultrasonic aspirator, contact laser and neurophysiological monitoring. A radical resection of these tumors results in a good long-term outcome, since the majority are histologically benign. Adjuvant radiation therapy should only be administered for high-grade or malignant tumors.Conclusion The majority of spinal cord tumors are benign; however, malignant tumors have a dismal outcome and surgery in these children should be limited to a conservative debulking. An attempt should be made for radical surgery in hope of avoiding radiation and chemotherapy for the benign tumors. Spinal deformity is a concern in these patients since 35% of children may require a stabilization procedure.     

SLT接触式激光显微手术治疗脊髓髓内肿瘤随机对照研究

目的研究应用接触式激光显微手术治疗髓内肿瘤的疗效。方法对我院1998年3月-2003年4月期间入院所有脊髓髓内肿瘤患者随机分为A组和B组。其中A组接受常规显微手术,B组接受接触式激光器配合显微手术。制定严格的纳入和排除标准。术后采用美国脊髓损伤协会ASIA评分标准评分,评分时间分别为术后3个月、6个月、12个月。采用SPSS统计软件统计分析。结果A组30例,肿瘤全切11例(36.67%);近全切除14例(46.67%),大部切除5例(16.67%)。B组25例,肿瘤全切16例(64.00%);近全切除8例(32.00%)。大部切除1例(4.00%)。对两组治疗前后ASIA评分进行统计分析,术后3个月与术前评分差异有统计学意义(P<0.001)。结论⑴接触式激光可以精确地切除和汽化髓内肿瘤,减少副损伤。⑵接触式激光器配合显微手术与单纯使用显微手术相比增加了脊髓髓内肿瘤的切除率和术后功能好转率。⑶术后6个月内脊髓功能恢复良好,6个月后病情趋于稳定。     

电磁刀在脑和脊髓肿瘤显微手术中的应用及效果分析

目的 分析电磁刀在显微神经外科切除脑和脊髓肿瘤手术中的应用和效果。方法 应用该法切除82例常见脑和脊髓肿瘤，比较不同切割模式的作用。输出功率和刀头选择，总结电磁刀的适应证。结果 脑膜瘤全切率为95%。垂体瘤为85%，听神经瘤为80%。胶质瘤为88%。脊膜瘤和神经鞘瘤为100%。无明显人为神经和重要血管损伤。结论 应用电磁刀配合显微手术能够明显提高脑和脊髓肿瘤的全切率。并能减少重要神经和血管的损伤。     

Early rehabilitation improves neurofunctional outcome after surgery in children with spinal tumors简

To investigate the effect of early rehabilitation on neurofunctional outcome after surgery in children with spinal tumors, this study reviewed the medical charts and radiographic records of 70 pediatric patients(1–17 years old) who received spinal tumor surgical removal. The peddiatric patients received rahabilitation treatment at 4(range, 2–7) days after surgery for 10(range, 7–23) days. Results from the Modified McCormick Scale, Functional Independence Measure for Children, American Spinal Injury Association Impairment Scale and Karnofsky Performance Status Scale demonstrated that the sensory function, motor function and activity of daily living of pediatric children who received early rehabilitation were significantly improved. Results also showed that tumor setting and level localization as well as patients' s clinical symptoms have no influences on neurofunctional outcomes.     

脊髓髓内神经鞘瘤的诊断与治疗

目的 探讨脊髓髓内神经鞘瘤的诊断和显微外科治疗。方法 回顾性分析2005~2015年显微手术治疗的13例脊髓髓内神经鞘瘤患者的临床资料。结果 13例患者的肿瘤均获得完整切除。术后随访6个月~3年;术后2例肌力较术前出现暂时性减退,术后3个月恢复至术前水平,6个月恢复正常;1例截瘫患者肌力由术前Ⅰ级恢复至术后Ⅲ级,6个月恢复至Ⅴ-级,2年后肌力恢复正常,大小便障碍恢复正常;所有患者疼痛症状术后完全缓解;3例术后出现深感觉障碍,6个月后基本恢复正常;7例遗留有载瘤神经支配区的麻木;其余患者症状均较术前有明显改善;所有患者MRI复查未见肿瘤复发。结论 脊髓髓内神经鞘瘤与脊髓关系密切,临床症状较重,影像学特点没有明显特异性,显微镜下精细操作与预后密切相关。     

显微手术治疗颈髓髓内肿瘤

报道显微手术治疗５８例颈髓髓内肿瘤。获全肿瘤切除者５０例，占８６．２％；术后神经系统状态改善者４５例，占７７．６％。表明颈髓髓内肿瘤适宜作肿瘤全切除，手术时机选在患者处于中度神经系统障碍时为好；描述了不同种类肿瘤的手术方法，认为激光手术对脂肪瘤切除最有帮助。提出了术中注意事项和肿瘤全切除的判断标准；阐述了术前放疗的危害性；对治疗后脊髓变细也作了简要讨论。     

神经电生理监测技术在脊髓髓内肿瘤切除术中的应用

目的探讨神经电生理技术联合监测对预防脊髓髓内肿瘤切除术中脊髓神经功能损伤的意义。方法回顾性分析26例脊髓髓内肿瘤的病例资料,均行手术切除治疗,术中应用体感诱发电位(SEP-P40)和运动诱发电位(MEP-ABP)监测。结果术后2周随访脊髓神经功能JOA评分改善10例,不变13例,下降3例。JOA评分改善者,手术前后SEP-P40潜伏期、波幅改变及MEP-ABP潜伏期改变均具有统计学意义(P0.01)。JOA评分不变者,手术前后SEP-P40潜伏期、波幅改变及MEP-ABP潜伏期改变均无统计学意义(P0.05)。结论脊髓髓内肿瘤切除术中使用神经电生理联合监测能及时反映神经功能变化,术中电生理指标变化与病人术后神经功能改变一致。联合监测可提高术中操作的安全性,能避免或减少并发症。