eMedicine Specialties > Neurosurgery > Neoplasm

Intramedullary Spinal Cord Tumors: Follow-up

Author: Alfred T Ogden, MD, Assistant Professor, Department of Neurological Surgery, Columbia University Medical Center
Coauthor(s): Nicholas Wetjen, MD, Pediatric Neurosurgery Fellow, University of Utah, Primary Children's Hospital; Thomas L Francavilla, MD, Chief of Neurosurgery Section, Department of Surgery, Brookwood Medical Center
Contributor Information and Disclosures

Updated: Apr 9, 2009

Outcome and Prognosis

Histology

Prognosis regarding the likelihood of a surgical cure is dependent upon histology.  Surgical series of ependymomas report recurrence rates of 0-9%, with anywhere from 2-10 years of follow-up. Factors associated with recurrence include histological anaplasia and piece-meal resection. 

For hemangioblastomas, complete surgical resection of sporadic cases is usually curative. Patients with VHL are of course always at risk of developing new lesions and must have their entire neuroaxis imaged periodically. 

Regarding astrocytoma, the literature is confused and often contradictory regarding the role of surgery, radiation, and prognosis in general. Undoubtedly, some of the differences in outcomes stems from differences in patient populations, specifically pediatric cases versus adult ones. Clearly, the prognosis for astrocytoma is worse than for ependymoma because many astrocytomas are infiltrative and impossible to resect completely. For high-grade lesions such as anaplastic astrocytoma and glioblastoma, the prognosis is clearly poor, with aggressive surgical resection having a debatable role in prolonging survival.

Severity of preoperative neurologic deficit

Neurologic morbidity is associated with preoperative functional status. Individuals with mild-to-moderate deficits may improve following surgical removal, while those with advanced neurologic compromise generally have no worthwhile improvement. This emphasizes the need for early intervention and close follow-up.3

Age

Advancing age (>60 y) is a negative prognostic factor.

Completeness of resection

Total removal of a benign tumor may result in long-term control or cure.

Location of lesion

Higher morbidity is associated with surgical removal of upper thoracic and conus lesions.

Size of lesion

Tumors spanning several levels may produce a corkscrew growth pattern that requires extensive dissection of the spinal cord in order to expose the tumor.

Arachnoid scarring and cord atrophy

These are negative prognostic factors for ependymomas.

Syrinx

The presence of a syrinx suggests a noninfiltrative lesion and carries a better prognosis.

Future and Controversies

Whereas the value of total excision of ependymomas is clear, the value of radical resection of astrocytomas is less certain. If an easily defined plane around the tumor can be followed and complete removal achieved, management is rather straightforward. However, if an ill-defined plane is present, the risk-to-benefit ratio for aggressive removal is unclear.

The role of radiotherapy in the management of slowly growing tumors is also controversial. Total excision of ependymomas does not warrant further treatment. This also may be true of many astrocytomas, particularly pilocytic astrocytomas. In cases of residual or recurrent tumor, clear clinical indications have not been established. Reoperation, radiation, and watchful waiting with serial examinations and imaging are all viable options.4,5

Intraoperative electrophysiologic monitoring is thought to be useful, but its efficacy is unproven. Although MRI greatly facilitates diagnosis of these lesions, pressure to control health care costs may delay diagnostic testing of mildly symptomatic patients.

Currently, no satisfactory modality is available to affect the relentless course of malignant astrocytomas. Novel therapies need to be developed. Stereotaxic radiosurgery has found a place in the management of intracranial tumors. With anticipated future developments, spinal radiosurgery may have a role in management. Developmental tumors can be quite adherent to the spinal cord. Given the slow growth rates of these tumors, the role of radical surgery to remove all traces of the tumor is not advocated by most clinicians.

Development of neuroprotective agents for use during surgery warrants further study.

Management of these potentially debilitating and treacherous lesions has come a long way in the last 100 years. Advances in imaging and surgical technique have led to removal of many tumors, with high success and low morbidity. However, the relative rarity of the tumor, along with its slow growth characteristics, makes the accumulation of large patient series difficult.

Presently, in many situations, the clinician can only care for patients harboring intramedullary spinal cord tumors using an incomplete knowledge base regarding the optimal management.

 


More on Intramedullary Spinal Cord Tumors

Overview: Intramedullary Spinal Cord Tumors
Workup: Intramedullary Spinal Cord Tumors
Treatment: Intramedullary Spinal Cord Tumors
Follow-up: Intramedullary Spinal Cord Tumors
Multimedia: Intramedullary Spinal Cord Tumors
References
[ CLOSE WINDOW ]

References

  1. Lee M, Rezai AR, Abbott R, et al. Intramedullary spinal cord lipomas. J Neurosurg. Mar 1995;82(3):394-400. [Medline].

  2. Kothbauer K, Deletis V, Epstein FJ. Intraoperative spinal cord monitoring for intramedullary surgery: an essential adjunct. Pediatr Neurosurg. May 1997;26(5):247-54. [Medline].

  3. Cristante L, Herrmann HD. Surgical management of intramedullary spinal cord tumors: functional outcome and sources of morbidity. Neurosurgery. Jul 1994;35(1):69-74; discussion 74-6. [Medline].

  4. Sgouros S, Malluci CL, Jackowski A. Spinal ependymomas--the value of postoperative radiotherapy for residual disease control. Br J Neurosurg. Dec 1996;10(6):559-66. [Medline].

  5. Jyothirmayi R, Madhavan J, Nair MK, et al. Conservative surgery and radiotherapy in the treatment of spinal cord astrocytoma. J Neurooncol. Jul 1997;33(3):205-11. [Medline].

  6. Epstein FJ, Farmer JP, Freed D. Adult intramedullary astrocytomas of the spinal cord. J Neurosurg. Sep 1992;77(3):355-9. [Medline].

  7. Epstein FJ, Farmer JP, Freed D. Adult intramedullary spinal cord ependymomas: the result of surgery in 38 patients. J Neurosurg. Aug 1993;79(2):204-9. [Medline].

  8. Greenwood J Jr. Surgical removal of intramedullary tumors. J Neurosurg. Feb 1967;26(2):276-82. [Medline].

  9. Hoshimaru M, Koyama T, Hashimoto N, et al. Results of microsurgical treatment for intramedullary spinal cord ependymomas: analysis of 36 cases. Neurosurgery. Feb 1999;44(2):264-9. [Medline].

  10. Lee M, Epstein FJ, Rezai AR, et al. Nonneoplastic intramedullary spinal cord lesions mimicking tumors. Neurosurgery. Oct 1998;43(4):788-94; discussion 794-5. [Medline].

  11. Malis LI. Intramedullary spinal cord tumors. Clin Neurosurg. 1978;25:512-39. [Medline].

  12. McCormick PC, Torres R, Post KD, et al. Intramedullary ependymoma of the spinal cord. J Neurosurg. Apr 1990;72(4):523-32. [Medline].

  13. Ogden, AT and McCormick, PC. Intradural Spinal Tumors. In: Bernstein, M and Berger, MS. Neuro-oncology: The Essentials. 2. New York: Thieme; 2008:36: 379-390.

  14. Sandler HM, Papadopoulos SM, Thornton AF Jr, et al. Spinal cord astrocytomas: results of therapy. Neurosurgery. Apr 1992;30(4):490-3. [Medline].

  15. Stein BM, McCormick PC. Intramedullary neoplasms and vascular malformations. Clin Neurosurg. 1992;39:361-87. [Medline].

  16. Stein BM, McCormick PC. Spinal intradural tumors. In: Wilkins RH, Rengachary SS, eds. Neurosurgery. New York, NY: McGraw-Hill; 1996:1769-89.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

spinal cord, intramedullary spinal tumors, intramedullary spinal cord tumor, intrinsic spinal tumors, intrinsic spinal tumor, spinal cord tumors, spinal cord tumor, intramedullary tumors, intramedullary tumor, intradural spinal tumors, intradural spinal tumor, intramedullary, spinal cord, tumors, tumor, spine tumors, spine tumor, spinal tumors, spinal tumor, spinal 

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Alfred T Ogden, MD, Assistant Professor, Department of Neurological Surgery, Columbia University Medical Center
Alfred T Ogden, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, and Congress of Neurological Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Nicholas Wetjen, MD, Pediatric Neurosurgery Fellow, University of Utah, Primary Children's Hospital
Nicholas Wetjen, MD is a member of the following medical societies: American Association of Neurological Surgeons and Congress of Neurological Surgeons
Disclosure: Nothing to disclose.

Thomas L Francavilla, MD, Chief of Neurosurgery Section, Department of Surgery, Brookwood Medical Center
Thomas L Francavilla, MD is a member of the following medical societies: American Association of Neurological Surgeons and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Duc Hoang Duong, MD, Professor, Chief Physician, Departments of Neurological Surgery and Neuroscience, Epilepsy Center, Charles Drew University of Medicine and Science
Duc Hoang Duong, MD is a member of the following medical societies: American Neurological Association, Congress of Neurological Surgeons, and North American Skull Base Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Ryszard M Pluta, MD, PhD, Associate Professor, Neurosurgical Department Medical Research Center, Polish Academy of Sciences at Warsaw, Poland; Senior Researcher, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, NIH
Ryszard M Pluta, MD, PhD is a member of the following medical societies: Congress of Neurological Surgeons and Polish Society of Neurosurgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

Allen R Wyler, MD, Former Medical Director, Northstar Neuroscience, Inc
Allen R Wyler, MD is a member of the following medical societies: American Academy of Neurological and Orthopaedic Surgeons, American Association of Neurological Surgeons, and Society of Neurological Surgeons
Disclosure: Nothing to disclose.

RELATED EMEDICINE ARTICLES
 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.