Neurosurg Rev (2012) 35:85–93
DOI 10.1007/s10143-011-0345-2
ORIGINAL ARTICLE
Comparative analysis on the diagnosis and treatments
of multisegment intramedullary spinal cord tumors
between the different age groups
Zhen-yu Wang & Jian-jun Sun & Jing-cheng Xie &
Zhen-dong Li & Chang-cheng Ma & Bin Liu &
Xiao-dong Chen & Hung-I Liao & Tao Yu & Jia Zhang
Received: 12 September 2010 / Revised: 26 March 2011 / Accepted: 1 May 2011 / Published online: 6 August 2011
# Springer-Verlag 2011
Abstract Multisegment intramedullary spinal cord tumors
(MSICT) are a special type of spinal cord tumor. Up to now, no
comparative clinical study of MSICT has been performed
according to different age groups. Seventy-seven patients
underwent microsurgery for MSICT. As grouped with two
different methods, the parametric and nonparametric data of
MSICT and patients were comparatively analyzed using
statistically correlative methods. Forty-eight patients were
males and 29 were females, ranging in age from 4 to 64 years
(mean, 32.9 years). Among the six groups, being divided
with intervals of 10 years, the whole difference in the initial
symptoms of patients (Z=17.4, P=0.004) and in the
histological classification of tumors (Z=12.5, P=0.03) was
statistically significant, respectively. Neurodevelopmental
tumor and benign glioma predominated in adolescents and
decreased in frequency into adulthood where ependymoma
became more predominant. In the 25 years old grouping
method, there were 27 adolescent and 50 adult patients. The
All of our clinical studies were permitted by the patients and the
Ethics Committee of Peking University Third Hospital.
Electronic supplementary material The online version of this article
(doi:10.1007/s10143-011-0345-2) contains supplementary material,
which is available to authorized users.
Z.-y. Wang : J.-j. Sun (*) : J.-c. Xie : Z.-d. Li : C.-c. Ma :
B. Liu : X.-d. Chen : T. Yu : J. Zhang
Department of Neurosurgery, Peking University Third Hospital,
No. 49 Huayuan North RoadHaidian District Beijing 100191,
People’s Republic of China
e-mail: sunjj2008@gmail.com
H.-I. Liao
Department of Orthopedics, Peking University Third Hospital,
Beijing, People’s Republic of China
difference in initial symptoms of patients (Z=−2.08, P=0.04)
was statistically significant between the two groups. Pain
with motor weakness and gait deterioration predominated in
adolescents and decreased in frequency into adulthood where
sensory disturbances became more predominant.
Keywords Spinal cord . Intramedullary tumor .
Multisegments . Years . Initial symptoms . Histological
classification
Introduction
Multisegment intramedullary spinal cord tumors (MSICT)
are a special type of spinal cord tumor. Intramedullary
tumor length occupying more than two vertebral bodies is
considered as a MSICT [18]. Recently, numerous clinical
researches were performed in this field. Many scholars
emphasized that it is necessary for the early surgical
removal of the tumor and the removal must be as complete
as possible [17–19].
In our previous studies, many cases were analyzed and
discussed including multisegment intramedullary benign
spinal cord tumors and multisegment intramedullary astro-
cytomas [18, 19]. It is thought that the growth of the spinal
column is finalized once people reach adulthood or an age
of 25 years old and older, which is around the age of bone
ossification [4]. Up to now, no comparative clinical study of
MSICT has been performed in different age groups. Our
effort is to find differences in the histological classification,
location, long diameter, extent of MSICT removal, initial
symptoms, gender, neurological function, and prognosis of
patients in different age groups. This comparative analysis
was performed on 77 consecutive cases with MSICT who
86
underwent microsurgery in the neurosurgery inpatient
department of Peking University Third Hospital.
Materials and methods
This was an analytical study using clinical records. Ethics
approval was obtained from the Research Ethics Board of
Peking University Third Hospital to conduct this study. All
subjects were unrelated individuals, and patients or guard-
ians provided written informed consent.
Patients
A consecutive series of 78 patients diagnosed with MSICT
occupying three or more vertebral bodies were admitted in
the neurosurgery inpatient department and 77 patients
underwent microsurgical treatment between Jan. 2002 and
Dec. 2009 [18, 19]. Basic demographic data, clinical and
radiological presentation, and intraoperative observations
were evaluated. Preoperative neuroimaging including mag-
netic resonance imaging (MRI) was performed in all cases.
Spinal angiography was performed if the MRI suggested a
possible vascular lesion.
Group
The patients with MSICT were divided into six groups with
intervals of 10 years. The parametric and nonparametric
data in different patient groups were collected prospectively.
In addition, when 25 years old and older were considered as
an adult standard, 77 patients were divided into adolescent
and adult groups. The parametric and nonparametric data of
MSICT and patients were comparative analyzed using
statistically correlative methods within the two different
grouping methods.
Surgical techniques
Seventy-seven patients underwent operation at our institu-
tion with an exception of one 13-year-old patient who
refused to accept an open surgery. The operation followed
the standard procedures for intramedullary spinal cord
tumors. Laminectomy, laminoplasty, and laminectomy with
reinsertion of lamina were performed as exposure methods
over the region of the tumor on the basis of preoperative
neurodiagnostic testing. After a midline dural incision, the
operating microscope was brought into view. A midline
myelotomy was then performed and pia traction was
obtained using sutures to the dura. The resection was then
modified based on the tumor dissection plane and the
severity of the infiltration seen on the preoperative MRI and
intraoperative microscopy. Intraoperative neurophysiologic
Neurosurg Rev (2012) 35:85–93
monitoring was used. The pia mater was not normally
reattached at the end of the resection [18].
The extent of tumor removal was categorized into four
different classes according to intraoperative observations
and postoperative enhanced MRI. Cases with total resection
and without residual tumors on postoperative MRI were
classified as class 1, resection of around 80% to 90% of
tumors was defined as class 2, and resection of around 60%
to 80% of tumors was defined as class 3. All other
procedures, including decompression and biopsy of the
tumors, were classified as class 4. The cross section with
the longest diameter of tumor was measured under
microscope intraoperatively. Diameters less than 5.0 cm
were classified as class 1, between 5.1 and 10.0 cm as class
2, between 10.1 and 15.0 cm as class 3, and more than
15.0 cm as class 4.
Location and histological classification of tumors
The location of intramedullary spinal cord tumors was
determined based on enhanced MRI scans. The locations
were classified as medulla–cervical, cervical, cervicothora-
cic, thoracic, thoracolumbar, and lumbar (including lumbo-
sacral) regions. Affected segments of the spinal cord were
recorded. Based on the postoperative hematoxylin and
eosin and immunohistochemical stainings, MSICT were
classified as ependymoma, benign gliomas (including
astrocytoma I–II and oligodendrocytoma), vascular tumors
(including hemangioblastomas and cavernous angioma),
neurodevelopmental tumors (including lipoma, epidermoid
cyst, and teratoma), malignant glioma, and neurogenic
tumors (including neurinoma and cyst).
Evaluation of neurological functions
The improved Japanese Orthopaedic Association (IJOA)
scoring system was used to evaluate preoperative and
postoperative neurological function of patients. IJOA was
based on the JOA scoring system with the addition of
scoring stool function as either normal, slightly dysfunction-
al, severely dysfunctional, or incontinence. Short-term
prognosis was assessed by IJOA difference values equal to
the postoperative IJOA score minus the preoperative IJOA
score. Postoperative IJOA scores were evaluated 2 weeks
after the operation. The short-term prognosis of patients was
classified into five grades (<−4, −1 to −3, 0, 1–3, and >4)
based on the IJOA difference values. The clinical outcomes
were independently analyzed by a blind observer.
Postoperative management
Postoperatively, all patients received a routine flushing dose
of methylprednisolone (around 10mg/kg/day depending on
Neurosurg Rev (2012) 35:85–93 87

the different body weights) for 3 days and neurotrophic Results

drugs for at least 2 months. A neck collar or waistline brace
was used to stabilize body position and to prevent spinal
deformation. All patients received rehabilitation training at
local physical therapy centers [18, 19].
Follow-up
The postoperative follow-ups with enhanced MRI scans
were performed at 2 weeks and at 6 months. MRI was
repeated annually to find any disease progression in
cases without symptomatic changes. If patients were
experiencing symptomatic changes, then the MRI was
immediately performed. Disease progression was defined
as recurrence in cases of complete tumor removal and
regrowth in cases of incomplete tumor removal. The
present conditions of patients were evaluated according
to the neurological status and graded as improved,
unchanged, or deteriorated. All patients received follow-
up reviews until June 1, 2010.
Statistical analysis
Data analysis was performed using SPSS 17.0 (SPSS,
Chicago, IL, USA). Statistical analysis was performed
using the two-sample Kolmogorov–Smirnov t test or one-
way analysis of variance (ANOVA) test for the hospitalized
days, preoperative IJOA scores, affected tumor segments,
tumor’s long diameter, and postoperative IJOA scores
within the different age groups. Mann–Whitney test or
Kruskal–Wallis test was used to analyze the characteristics
of tumors (such as location, histological classification,
diameter grading, and extent of tumor removal) and other
factors of the patients (including gender, initial symptoms,
urine and stool function, IJOA difference values grading,
and limb weakness of patients). Data were expressed as the
mean±standard error. P values of less than 0.05 were
considered statistically significant. The initial symptoms
ratio of adolescent patients to adult patients was used to
determine the most common initial symptom of adolescent
patients.
Clinical factors of patients within different groups
Of the 77 patients, 48 were males (62.3%) and 29 were
females (37.7%). Age range was 4–64 years; average age was
32.9±15.57 years. The general conditions of patients in the six
10-year interval groupings are shown in Tables 1 and 2.
In the 25 years old grouping, 17 males and 10 females
were grouped in the adolescent group and 31 males and 19
females were grouped in the adult group. Mean age was
16.0±7.06 years old in the adolescent group and 42.0±
10.35 years old in the adult group (Tables 3 and 4).
Comparative analysis between the different groups
The differences in gender, limb weakness, and urine and
stool function of the patients were statistically insignificant
in the different age groups within the two different grouping
methods (Tables 1, 2, 3 and 4). Average hospitalized days
were 21.5±5.23 days. The difference of hospitalized days
was statistically insignificant in the different age groups
within the two different grouping methods.
The most common location of tumors was the cervical
region (29.9%, 23 out of 77), followed by the cervico-
thoracic region (19.5%, 15 out of 77), the thoracolumbar
region (19.5%, 15 out of 77), the thoracic region (14.2%, 11
out of 77), the lumbar region (13.0%, 10 out of 77), and the
medulla–cervical region (3.9%, 3 out of 77). The difference
of locations was statistically insignificant in the different
age groups within the two different grouping methods. The
average affected segments of the spinal cord were 4.3±
1.41. The difference of the affected segments was statisti-
cally insignificant in the different age groups within the two
different grouping methods.
The averaged long diameter of tumors was 10.1±5.75 cm.
The difference of long diameter of tumors was statistically
insignificant in the different age groups within the two
different grouping methods. In addition, the long diameter
grading was statistically insignificant in the different age
groups within the two different grouping methods.

Table 1 Differences of parametric data in the different age group (x  SD; one-way ANOVA test)

Classification 1–9 years 10–19 years 20–29 years 30–39 years 40–49 years 50 ~ years F value P value

Hospitalized days 21±4.08 21.7±3.32 23±5.12 20.2±4.89 20.9±5.12 21.9±7.49 0.54 0.75
Preoperative IJOA scores 15.3±2.36 13.7±3.57 14.8±3.97 12.4±4.87 14.6±3.01 13.1±4.76 0.97 0.44
Postoperative IJOA scores 16.7±2.50 14.7±2.78 15.9±3.51 13.2±4.97 15.0±2.34 13.1±5.0 1.73 0.14
Affected tumor segments 4.3±0.95 4.8±1.79 4.2±1.3 4.6±1.82 4±1.29 3.9±0.54 0.67 0.65
Tumor’s long diameter 11.6±3.92 9.4±3.8 10.8±6.56 12.1±7.22 8.6±5.94 7.4±2.59 1.38 0.24
IJOA difference values 1.4±2.88 1±1.58 1.1±2.39 0.7±1.36 0.4±1.76 −0.1±3.17 0.67 0.65
88 Neurosurg Rev (2012) 35:85–93

Table 2 Differences of nonpara-

metric data in the different age Classification 1–9 10–19 20–29 30–39 40–49 50 ~ Z value P value
groups (years, n; Kruskal–Wallis
test) Gender 1.68 0.89
Male 4 7 10 10 9 8
Female 3 2 7 8 4 5
Limb weakness 6.36 0.28
Normal 3 0 4 4 1 2
Weak 4 9 13 14 12 11
Urine and stool function 2.37 0.8
Normal 2 2 7 6 6 6
Slightly dysfunctional 1 4 4 2 2 3
Severely dysfunctional 2 2 3 5 4 1
Incontinence 2 1 3 5 1 3
Location 6.68 0.25
Medulla–cervical 0 0 1 1 0 1
Cervical 1 1 4 5 5 7
Cervicothoracic 2 3 6 1 2 1
Thoracic 1 2 3 1 1 3
Thoracolumbar 3 2 0 7 2 1
Lumbar (including lumbosacral) 0 1 3 3 3 0
regions
Histological classification 12.5 0.03
Ependymoma 0 1 8 6 4 10
Benign gliomas (including astrocytoma 3 3 4 3 3 1
I–II and oligodendrocytoma)
Vascular tumors ( including 1 0 2 0 1 1
hemangioblastomas and cavernous angioma)
Neurodevelopmental tumors (including 3 4 2 5 1 0
lipoma, epidermoid cyst, and teratoma)
Malignant glioma 0 1 0 4 2 1
Neurogenic tumors (including 0 0 1 0 2 0
neurinoma and cyst)
The extent of tumor removal 9.97 0.08
Total resection 3 3 11 5 4 10
Resection of around 80% to 90% of tumors 1 4 3 3 2 1
Resection of around 60% to 80% of tumors 0 0 1 5 5 0
Decompression and biopsy of the tumors 3 2 2 5 2 2
IJOA difference values classification 3.6 0.61
≤−4 2 1 2 0 1 1
−1 to −3 3 5 8 10 4 4
0 1 1 4 5 6 5
1–3 1 2 3 3 2 1
≥4 0 0 0 0 0 2
Diameter grading 5.13 0.4
≤5.0 cm 1 0 2 3 4 3
5.1–10.0 cm 1 7 10 7 5 8
10.1–15.0 cm 5 1 3 4 3 2
≥15.0 cm 0 1 2 4 1 0
Initial symptoms 17.4 0.004
Gait deterioration 2 0 2 0 0 0
Limb weakness 1 2 6 1 2 2
Pain 3 5 7 10 4 1
Sensory disturbance 1 1 2 7 7 10
Sphincter dysfunction 0 1 0 0 0 0

Class 1 resection for tumor was obtained in 36 (46.8%) difference in the extent of tumor removal was statistically
cases, class 2 resection in 14 (18.2%) cases, class 3 in 11 insignificant in the different age groups within the two
(14.2%) cases, and class 4 in 16 (20.8%) cases. The different grouping methods.
Neurosurg Rev (2012) 35:85–93
Table 3 Differences of paramet-
ric data between adolescent and Classification
adult patients with MSICT
grouped by 25 years old stan- Hospitalized days
dard (two-sample Kolmogorov–
Smirnov test) Preoperative IJOA scores
Postoperative IJOA scores
Affected tumor segments
Tumor’s long diameter
IJOA difference values
Initial symptoms between the different groups
The most common initial symptom was pain (39.0%, 30 out
of 77), followed by sensory disturbance (36.4%, 28 out of
77), limb weakness (18.2%, 14 out of 77), gait deterioration
(5.2%, 4 out of 77), and sphincter dysfunction (1.2%, 1 out
of 77) (Tables 2 and 4) [18]. Age and initial symptoms have
prognostic significance (Z=17.4, P=0.004). Children, ado-
lescent, and younger patients tended to present with pain.
Older patients mostly presented with sensory disturbance
(Fig. 1).
In the 25 years old grouping method, the difference of
initial symptoms was statistically significant between the
adolescent group and the adult group (Z=−2.08, P=0.04).
The order of initial symptoms of adolescent patients from
the most common to the least common was gait deteriora-
tion (ratio was 1), pain (including pain with motor
weakness; ratio was 0.88), motor weakness (ratio was
0.75), and sensory disturbances (ratio was 0.17). There
were five patients who presented with pain with motor
weakness, aged 7, 15, 18, 19, and 26 years old, respective-
ly. If pain with motor weakness was singled out from pain
as a whole, then the order of initial symptoms would
change into pain with motor weakness (ratio was 4), gait
deterioration (ratio was 1), motor weakness (ratio was
0.75), simple pain (ratio was 0.67), and sensory disturban-
ces (ratio was 0.17).
Histological classification between the different groups
The most frequent histological classification of MSICT was
ependymomas (37.7%, 29 out of 77), followed by benign
gliomas (including astrocytoma I–II and oligodendrocy-
toma; 22.1%, 17 out of 77), neurodevelopmental tumors
(including lipoma, epidermoid cyst and teratoma; 19.5%,
15 out of 77), malignant glioma (10.4%, 8 out of 77),
vascular tumors (including hemangioblastomas and cavern-
ous angioma; 6.5%, 5 out of 77), and neurogenic tumors
(including neurinoma and cyst; 3.8%, 3 out of 77) (Tables 2
and 4). Age of patients and histological classification of
MSICT have prognostic significance (Z=12.5, P=0.03).
Neurodevelopmental tumor and benign glioma, mostly
89
Adolescent group (x  SD) Adult group (x  SD) t value P value
21.3±5.51 21.2±5.71 0.05 0.96
14.9±3.51 13.4±4.3 1.53 0.13
15.7±3.3 14.0±4.22 1.86 0.07
4.6±1.52 4.2±1.43 1.18 0.24
10.6±4.60 9.8±6.31 0.54 0.59
1.0±1.75 0.6±2.41 0.84 0.41
astrocytoma I–II, predominated in adolescents and de-
creased in frequency into adulthood, which then ependy-
moma became more predominant (Fig. 2).
Neurological function between the different groups
The preoperative IJOA scores of the patients were 13.9±
4.06, postoperative IJOA scores were 14.6±3.99, and IJOA
difference values were 0.7±2.20 (Tables 1, 2, 3 and 4). The
differences of the preoperative IJOA scores, postoperative
IJOA scores, and IJOA difference values were statistically
insignificant in the different age groups within the two
different grouping methods.
The difference of IJOA difference values grading was
statistically insignificant in the different age groups within
the two different grouping methods. Improvements of
neurological functions and its stabilities were seen in
patients younger than 40 years old. On the other hand, the
patients older than 40 years old presented with deterioration
of neurological functions and stabilities (Fig. 3).
Internal fixation and spinal stability
Universal Spine system internal fixation (USS) was per-
formed in two cases following a total resection of massive
long diameter ependymomas (the long diameter of the tumor
was more than 20 cm) involving the thoracolumbar region
[11].
Two adult patients with cervical ependymomas involving
more than five spinal segments developed cervical flexion
deformity 1 year after a laminectomy at both the axial
cervical spine (C1 or C2) and the cervicothoracic junction.
We believed that the deformity was probably due to the
physical requirements of their occupations. Rectification of
an unhealthy posture and enhancement of the cervical
hypokinesis using exercises may prevent the cervical
vertebra from deformity in these patients [18, 19].
Long-term follow-up
The mean follow-up period was 44.2±25.68 months (rang-
ing from 5 to 103 months). Compared to the preoperative
90 Neurosurg Rev (2012) 35:85–93

Table 4 Difference of nonparametric data between adolescent and Table 4 (continued)

adult patients with MSICT grouped by 25 years old standard (Mann–
Classification Adolescent Adult Z value P value
Whitney test)
group (n) group (n)
Classification Adolescent Adult Z value P value
group (n) group (n) Initial symptoms −2.08 0.04
Gait deterioration 2 2
Gender −0.11 0.91 Limb weakness 6 8
Male 17 31 Pain 14 16
Female 10 19 Sensory disturbance 4 24
Limb weakness −1.56 0.12 Sphincter dysfunction 1 0
Normal 7 7
Weak 20 43
Urine and stool function −0.28 0.78
Normal 8 21
neurological status, the overall postoperative status pre-
Slightly dysfunctional 9 7
sented at the final follow-up review improved in 84.4% of
Severely dysfunctional 4 13
all patients (n=65), unchanged in 11.7% (n=9), and
Incontinence 6 9
deteriorated in 3.9% (n=3 with malignant gliomas). After
Location −0.73 0.47
Medulla–cervical 0 3 rehabilitation training, obvious improvement of neurologi-
Cervical 5 18 cal function was obtained in most adult patients with
Cervicothoracic 10 5 ependymomas, benign glioma, or vascular tumors in
Thoracic 4 7 6 months.
Thoracolumbar 5 10 The neurological function condition improved postoper-
Lumbar (including 3 7 atively in most adolescent patients and deteriorated slightly
lumbosacral) regions in only four patients (two cases with ependymomas). The
Histological classification −0.93 0.36 adolescent patients with neurological function deterioration
Ependymoma 7 22
conditions often experience recovery and even normal
Benign gliomas (including 7 10
astrocytoma I–II and living conditions after 2 months postoperatively. In contrast,
oligodendrocytoma) the neurological function conditions deteriorated postoper-
Vascular tumors (including 3 2 atively in most adult patients (ten cases, seven cases with
hemangioblastomas and
cavernous angioma) ependymomas) and even experience apparent deterioration
Neurodevelopmental 8 7 in two adult patients. The deterioration of neurological
tumors (including lipoma, function of adult patients recovered slowly in about half a
epidermoid cyst, and
teratoma) year or even experienced failure to recover.
Malignant glioma 1 7
Neurogenic tumors (including 1 2 Cases of malignant gliomas
neurinoma and cyst)
The extent of tumor removal −0.97 0.36
Total resection 15 21 In this study, there were three cases of malignant glioma.
Resection of around 80% 5 9 The first case was a 14-year-old male with a glioblastoma
to 90% of tumors in the conus terminalis region who exhibited iliac and
Resection of around 60% 1 10 femoral bone metastases 5 months postoperatively. In
to 80% of tumors
Decompression and biopsy 6 10
addition to the metastases, a lateral cerebral ventricle
of the tumors seeding was present and ultimately the patient died of
IJOA difference values −1.51 0.13 cerebral herniation 16 months later. The second case was a
grading
≥4 3 4
30-year-old male patient with a subtotal removal of a grade
1–3 15 19
III–IV astrocytoma who exhibited in situ recurrence
0 5 17
8 months postoperatively. At the time of the second
−1 to −3 4 8 laminectomy, the tumor metastasized to the subarachnoid
≤4 0 2 space. Due to the deteriorating health condition, this patient
Diameter grading −1.24 0.22 ultimately died of pneumonia. The third case was a 35-year-
≤5.0 cm 2 11 old female patient with a cervical spinal cord regrowth of
5.1–10.0 cm 14 24 malignant glioma 3 months after a decompression surgery
10.1–15.0 cm 9 9 and biopsy. Five months after the surgery, this patient died
≥15.0 cm 2 6 of respiratory failure.
Neurosurg Rev (2012) 35:85–93
Fig. 1 The changing figure of initial symptoms of patients with
MSICT between different age stage
Discussion
MSICT in the younger adolescent group were predomi-
nately benign glioma, mostly astrocytoma I–II and neuro-
developmental tumor. In addition to our conclusion, Houten
et al. [5] also presumed that astrocytomas predominated in
younger children and decreased in frequency into adulthood
where ependymomas became more predominant.
Astrocytoma, mostly low-grade tumor, was the predom-
inant histological type in the adolescent patients with
intramedullary spinal cord tumors and could be completely
removed with ease [3, 10]. In addition, postoperative
neurological functional state was improved or stable in
75–90% of adolescent patients [1, 13]. Sandler et al. [16]
considered that age was an effective influencing factor for
the prognosis of patients with intramedullary astrocytoma.
Based on the differences in color and texture between the
benign gliomas and normal spinal cord intraoperatively, the
pseudoboundaries were determined. From the center of
intramedullary tumor to the periphery, the tumor tissue was
removed layer by layer until the normal white matter was in
view. If the measurements of intraoperative somatosensory-
evoked potential (SEP) and motor-evoked potential (MEP)
monitoring showed deteriorating neurological function or
pseudoboundaries could not be identified clearly, the
resection of tumor should be terminated [1, 13].
Furthermore, multisegment neurodevelopmental tumors
(including cystic tumors, such as epidermoid cyst, dermoid
cyst, and cystic teratoma) were also a predominant tumor in
the young adolescent patients, mostly seen in males [11, 12,
19]. In some cases, the tumor tissues were closely adhered
Fig. 2 The changing figure of histological classification of MSICT
between different age stage
91
Fig. 3 The changing figure of IJOA difference values grading of
patients with MSICT between different age stage
to the normal spinal cord tissue. For examples, cases with
adipose tissue growing between normal white matter tissues
and cases with adhesion of unyielding cyst wall with the
adjacent neurological structures or the penetrating growth
surrounding spinal marrow. In order to avoid neurological
dysfunction, the closely adhered tumor tissues should,
therefore, not be removed by force [16]. The main purpose
of the surgery for these tumors was not a complete removal
but a decompression on the adjacent neurological structures
[17]. Hence, total or subtotal resection was obtained only in
66.7% of patients with neurodevelopmental tumors [19].
MSICT in the adult group were predominately ependy-
moma. Intramedullary ependymomas originated from the
central canal of spinal cord, which was found to be 15–
19.7% in all spinal cord tumors. The age of onset of
intramedullary ependymoma was within 30–50 years old
[7, 18]. The boundaries between tumor body and normal
spinal cord tissue were distinct and separable. Therefore,
total or subtotal resection was obtained in 94.7% of
intramedullary ependymomas [9, 15, 18, 19].
No matter if its benign gliomas, neurodevelopmental
tumors, or ependymomas, it was imperative that tumors
resection had been performed in time. Most scholars
believed that it is crucial for an early diagnosis and an
early open surgery for removing intramedullary tumors.
The less severe the preoperative symptoms and signs of a
patient, the better the recovery could be obtained for the
patients after an operation. Patients can even recover back
to normal neurological states [3, 10, 12, 13, 15, 16].
Improvement of neurological functions and its stabilities
were seen in patients younger than 40 years old. This result
might be due to better plasticity in the spinal cord tissues of
the younger patients, which could result in a relatively
better prognosis in younger patients with MSICT [20]. New
et al. [14] thought that younger patients with traumatic or
nontraumatic spinal cord injury were more likely to regain
walking in a short-term prognosis.
Pain with motor weakness and gait deterioration pre-
dominated in adolescents and decreased in frequency into
adulthood where sensory disturbances became more pre-
dominant. Houten et al. [5] concluded that pain was the
92
most frequent presenting symptom of intramedullary spinal
cord tumors and often precedes the development of other
symptoms such as weakness, gait deterioration, torticollis,
sensory disturbance, and sphincter dysfunction. Chang et
al. [2] found that preoperative sensory abnormality was
observed in 93% of adult patients with ependymoma. As
easily confused with growing pains, early pain complaints
of adolescent patients may be neglected. Only if subtle
changes in gait or more frequent falls were noticed by their
parents, adolescent patients will then visit the doctor. The
pain from intramedullary spinal cord tumors could not have
been distinguished from growing pains by neither the
parents nor the doctors. Therefore, MRI scan screening
should be performed regularly for adolescents complaining
of constant pain that does not dissipate.
The patients who presented with benign gliomas in
which total resection were easily performed obtained a
better prognosis. However, in patients who presented with
malignant gliomas, total resections were difficult to perform
and suffered a relatively worse prognosis with higher
recurrence rates (about 50%). In the study of Kim et al.
[8], they reported that only 39% of benign gliomas obtained
a total resection, while only 20% of malignant gliomas
obtained a total resection. In addition, the study of Huddart
et al. [6] reported that distant metastases occurred in 50–
60% of patients with malignant glioma.
In summary, benign glioma, mostly astrocytoma I–II,
and neurodevelopmental tumor predominated in younger
adolescents and decreased in frequency into adulthood
where ependymoma became more predominant. Pain with
motor weakness and gait deterioration predominated in
adolescents and decreased in frequency into adulthood
where sensory disturbances became more predominant.
Due to the small sample size in our data, the results of
the statistical correlations and analyses might have a
decrease in its statistical power. Nevertheless, the statistical
results were sufficient to draw a conclusive statement about
the MSICT characteristics between different age groups.
Acknowledgement This work was supported by the Science
Foundation for The Excellent Youth Scholars of Ministry of Education
of China (BSD-09-6-11) and Science Foundation for The Excellent
Youth Scholars of Peking University Third Hospital (74496-01). The
authors thank Dr. Simon Glynn (from the Department of Neurology,
University of Pennsylvania School of Medicine) for the revision and
comments on the manuscript and Ms. Isabelle Liu (from the
Washington University in St. Louis School of Medicine) for the final
careful English-language editing.
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Comments
Jörg Klekamp, Quakenbrück, Germany
Surgery on intramedullary tumors has come a long way since von
Eiselsberg’s first successful operation on such a neoplasm in 1907. He
observed a period of neurological deterioration before the patient
made a good recovery. Such gratifying results were exceptional in
those times when the surgeon’s major concern was saving the patient’s
life rather than his neurological function. Throughout the past decades,
Neurosurg Rev (2012) 35:85–93
every article on these tumors emphasized the need for an early
diagnosis and an early operation as surgical morbidity was and still is
directly related to the patient’s preoperative neurological function.
With modern imaging techniques, we are in the fortunate position now
to diagnose patients early. With modern microsurgical techniques and
intraoperative neurophysiological monitoring, the preservation of
function has become the rule rather than the exception if surgery is
performed by experienced neurosurgeons. Wang et al. present their
analysis of 77 multilevel intramedullary spinal cord tumors. Apart
from well-established differences in the literature concerning the
predominating tumor histologies in children and adults, the authors
found lower surgical morbidities in younger patients both in terms of
immediate postoperative function as well as potential recovery from a
postoperative deterioration. These are important informations for
preoperative patient counseling. Almost all patients experience some
permanent loss of sensory function after an operation on a multilevel
tumor. This may have significant consequences for coordination of
movements. Preservation of motor functions alone may not be enough
to preserve the patient’s walking abilities. Spinal ataxia is difficult to
rehabilitate in elderly patients in particular. Regarding intraoperative
neurophysiological monitoring, almost every paper focuses exclusive-
ly on the preservation of motor-evoked potentials. Many colleagues
consider attempting to preserve sensory-evoked potentials a meaning-
less undertaking. I do not agree with such a view. To try to preserve as
much sensory function as possible lowers postoperative morbidity.
Furthermore, with exposure and removal of such a tumor, the posterior
part of the spinal cord with its sensory pathways is manipulated before
the anterior parts containing the motor tracts are reached. The surgeon
can learn intraoperatively how to handle an individual tumor looking
at SEP reactions. If SEPs are preserved, the chances to preserve MEPs
as well will rise for certain.
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102:309–468
Jacques Brotchi, Brussels, Belgium
The authors bring interesting data in their comparative analysis on
the diagnosis and treatments of MSICT between the different age
groups. They point out differences in symptoms, histology, and
prognosis. Nevertheless, I have several constructive criticisms, which
may be summarized as follows:
– Lumbosacral tumors are not intramedullary lesions. Most are
myxopapillary ependymomas arising from the filum and they
should be included as true intramedullary tumors.
– If a midline myelotomy is the perfect approach for most
ependymomas and astrocytomas [1, 2], that approach is not
recommended for vascular tumors (hemangioblastomas, caverno-
mas). Most hemangioblastomas are subpial and should cautiously
be separated from normal spinal cord through careful division of
the pia all around the lesion [3, 4]. A myelotomy is surely not
indicated.
– Astrocytoma may successfully remove in around 40% of cases.
93
They cannot be completely removed with ease. This is in
opposition with the literature [2, 5]. The infiltrating nature of
most astrocytoma lesions makes total removal impossible without
an unacceptable loss of neurological function [6].
– I am astonished to read that the overall postoperative status
presented at the final follow-up review was improved in 84.4% of
all patients (n=65), unchanged in 11.7% (n=9), and deteriorated
in 3.9% (n=3 with malignant gliomas). We know from the
literature that the quality of the results closely depends on the
preoperative neurological status. In large published series, it is
said that more than 50% of patients are stabilized. Furthermore,
in experienced hands, the rate of worsening runs from 5% to 20%
in intramedullary low-grade gliomas according to the preopera-
tive neurological status (McCormick grades I to III) [7]. Here, the
authors report 3.9% worsening encountered in malignant gliomas
only. It is surprising and in disagreement with classical data of the
literature [7–10].
– My last comment concerns laminoplasty. It is true that, in China,
many patients are poor and unable to cover the cost of screws and
plates. But I wish to say that, in my practice, I have made several
laminoplasties in children with very cheap silk sutures at the time
we had not the small plates and screws in titanium. If we go back
to the original papers from pediatric neurosurgeons, laminoplasty
was made with silk sutures [11].
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