Intramedullary Spinal Cord Lesions: A Single-Center Experience

Abstract

Objective: Spinal cord tumors constitute a small part of spinal surgery owing to their rarity. This retrospective study describes their current management.

Methods: Forty-eight patients were treated for an intramedullary tumor between 2014 and 2020 at a single institution. Patients' files were retrospectively studied. We detailed clinical status according to neurological deficit and ambulatory ability using the modified McCormick Scale, radiological features like number of levels, associated syringomyelia, surgical technique with or without intraoperative electrophysiological monitoring, pathological findings, and postoperative outcome.

Results: The median age of this population was 43 years, including 5 patients under 18 years. The median delay before first neurosurgical contact was 3 months after the first clinical complaint. Treatment was gross total resection in 43.8%, subtotal resection in 50.0%, and biopsy in 6.2%. A laminectomy was performed for all the patients except 2 operated using the laminoplasty technique. Pathological findings were ependymoma in 43.8%, hemangioblastoma in 20.8%, and pilocytic astrocytoma in 10.4%. Six patients were reoperated for a tumor recurrence less than 2 years after the first surgical resection. One patient was reoperated for a postoperative cervical kyphosis.

Conclusion: Intramedullary tumors are still a challenging disease and they are treated by various surgical techniques. They must be managed in a specialized center including a trained surgical, radiological, electrophysiological, and pathological team. Arthrodesis must be discussed before performing extensive laminectomy to avoid postoperative kyphosis.

Keywords: Astrocytoma; Ependymoma; Hemangioblastoma; Intramedullary tumors.

Fig. 1.

Ependymoma (World Health Organization grade II) in a 57-year-old woman. (A, C) Sagittal and axial T2-weighted images reveal a heterogeneous expansile intramedullary mass in the cervical spine, with intratumoral cysts (white arrow) and hemosiderin cap sign (white arrowhead) at the inferior margins of the mass. Surrounding edema is present associated with syringohydromyelia (black arrowhead). (C) Axial T2-weighted image confirms the central location in the spinal cord. (B, D) Sagittal and axial contrast-enhanced T1-weighted images show intratumoral enhancement (black arrow) at C5–6 levels.

Fig. 2.

Not all expansile intramedullary lesions are neoplastic. Case 1: Perimedullary arteriovenous fistula. (A, C) Sagittal and axial T2-weighted images reveal an extensive centromedullary T2-hyperintense spinal cord edema from T7 to the conus medullaris responsible for enlargement of spinal cord. (B) Sagittal contrast-enhanced T1-weighted image shows intramedullary heterogeneous enhancement of conus medullaris (white arrows). Case 2: Central nervous system cavernomatosis with multiple spinal cavernomas. Sagittal and axial T2-weighted gradient-recalled echo sequences (B, D) are more sensitive than T2-weighted spin-echo (SE) sequences (A, C) to detect hemosiderin, showing prominent blooming at C4 and T7 levels (white arrow). Cavernomas are usually nonenhancing intramedullary lesions (not shown). Axial T2-weighted SE sequence (C) reveals typical hypointense rim (white arrowhead). Case 3: Inflammatory neuromyelitis optica. Sagittal T2-weighted images (A) reveal expansile T2-hyperintense myelitis from C2 to C7 with heterogeneous enhancement on sagittal contrast-enhanced T1-weighted image (B).

Fig. 3.

(A) Anaplastic ependymoma grade 3 MYCN amplified – (HES, × 20): highly cellular tumor with perivascular pseudorosettes, nuclear atypia, and brisk mitotic activity (arrows). (B) Extensive tumor necrosis (HES, × 10). (C) High ki-67 labeling (× 2.5).