Article
Intramedullary spinal cavernomas: Assessment of pre-operative clinical and radiographic parameters and neurological outcome in a single-center case series of 27 patients
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Published: | June 9, 2017 |
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Objective: Due to repetitive hemorrhage into the spinal cord the spontaneous course of intramedullary spinal cavernomas often leads to progressive neurological deterioration. On the other hand, surgical removal of an intramedullary lesion, despite modern techniques of microsurgery and neuromonitoring, bears considerable risks. Aim of the study was to identify critical preoperative factors that help to predict long-term neurological outcome.
Methods: A series of 27 consecutive patients with intramedullary spinal cavernomas over the past 12 years was retrospectively evaluated. Preoperative demographic and clinical variables (history of hemorrhage, previous treatments, neurological status) were assessed. In addition to radiographic properties (cavernoma location, central vs. superficial, lesion size) the surgical strategy (timing of surgery, approach, myelotomy vs. superficial evacuation) were evaluated. Pre- and postoperative neurological status was graded according to ASIA classification and rate of improvement (for motor and bladder function) was assessed separately.
Results: Within the cohort mean age was 46 + 12 years and female to male ratio 2.5:1. In the majority of cases (78%) a clear history of previous hemorrhage was present with multiple events in 33%. Cavernoma location was cervical (n=10), thoracic (n=16) and at the conus level in 1 case. Central or ventral location within the myelon was identified in 7 cases. In 45% of the cases surgical therapy was initiated within 6 months of the symptom onset. Complete removal was intended in all cases, although 2 patients had recurrent cavernomas (7%). Overall 12 patients showed significant clinical improvement and none exhibited worsening of symptoms at follow-up (6-12 months). Postoperative high-grade neurological deficit (ASIA A-C) without any improvement was identified in 3 cases; all of them had long-term, pre-existing severe neurological deficits (p<0.005 Chi2).
Conclusion: The presented data support our strategy of early surgical intervention in intramedullary spinal cavernomas. Neither timing of surgery (e.g. early after symptom onset), cavernoma size, location within the myelon, nor the necessity for myelotomy seem to be associated with unfavorable neurological outcome after surgery, whereas chances for neurological improvement in patients with long-term, high-grade myelopathy are little.