Therapeutic strategies and challenges in the management of craniospinal tumours in pregnancy: a 10-year retrospective tertiary centre study, systematic review, and proposal of treatment algorithms

Objectives: The study aims to evaluate therapeutic strategies in the management of craniospinal tumours in pregnant patients and the factors that influence the management along with their influence on maternal & foetal outcomes. Materials and Methods:A retrospective single-centre cohort study was performed at a tertiary neurosurgical referral centre. Pregnant patients referred to neuro-oncology multidisciplinary meeting (MDM) with craniospinal tumour were included. Ten-year patient data were collected from hospital records and neuro-oncology MDM outcomes. A systematic review was performed on the available literature in PubMed as per PRISMA guidelines. Results:Thirty-three patients were identified with a mean age of 31 years. 91%(n=30) had cranial lesions and 9%(n=3) had spinal lesions. Most of the patients had WHO Grade I/II tumours. 33.3% underwent surgery when pregnant whilst in 24.2% this was deferred until after the due date. 27.2% patients did not require surgical intervention and were followed up with serial imaging in the MDM. Left Lateral/park bench position was the preferred position for the spinal and posterior fossa lesions. Systematic review identified 26 eligible articles. Treatment algorithms are proposed addressing the therapeutic strategy for management of cranio-spinal tumours during pregnancy and the challenges for maternal and foetal outcomes were tabulated. Conclusions:Craniospinal tumours presenting in pregnancy are challenging. The surgical management needs to be tailored individually and as part of a multidisciplinary team approach. Maternal and foetal outcomes are to be considered during patient counselling.

Paediatric Spinal Tumours: Profile and Treatment Outcome in A Nigerian Tertiary Institution

Introduction Paediatric spinal tumours are rare, accounting for 1-10% of all childhood central nervous system tumours. There is a paucity of information on spinal tumours in Sub-Saharan Africans. This is particularly so in the Nigerian paediatric population where neuro-oncologic data is limited. Indeed, there is no previously published work on the profile of paediatric spinal tumours in the Nigerian neurosurgical literature. The authors aim to document the profile of paediatric spinal tumours in a Nigerian tertiary institution and to contribute to the available data on paediatric central nervous system tumours in West Africa. Methods We retrospectively evaluated data on paediatric patients who underwent surgery for spine tumours over a 20-year-period at our institution. Results A total of 12 patients were managed for paediatric spine tumours during the study period. These had a male: female ratio of 1:1.4 and their ages ranged between 3 and 18 years (mean: 12.83 ± 4.75 years). The highest incidence (6/12) was seen in the 15-18 years age group. The mean duration of symptoms was 10.2 months. More than half (7/12) of the patients presented with symptoms with duration of at least 6 months. Motor deficit was present in all patients at presentation. Two-thirds of the tumours were in the thoracic region, 1 was located in the cervical region, while the remaining 3 tumours were cervicothoracic. The tumour was extradural in location in 8 of our patients and intramedullary in the remaining 4. Astrocytoma (intramedullary in all cases) was the most predominant histological tumour type in (3/12) in our series. Postoperative neurological improvement occurred in 7 of the patients while 5 remained the same. There was no permanent postoperative neurological deterioration or perioperative mortality. Conclusion Paediatric spinal tumours mostly affected older children in our study group and were predominantly astrocytic in nature. The most common tumour location was extradural, involving mostly the thoracic spinal level. The preoperative neurological status correlates with the postoperative functional outcome. Therefore, the need for early diagnosis and treatment of these tumours cannot overemphasized.

Lessons Learnt in Health Management: Paediatric Spinal Tumours: A 6-year Retrospective Review from Central India

Background: From the management perspective, rare medical conditions do not attract enough attention, though their management can often be resource intensive. Increased awareness among health professionals can lead to early diagnosis of cases and prevention of complications leading to improved outcomes. Paediatric spinal tumours are rare disease entities with an annual incidence of approximately 1 per 1 million children. The profile of spinal tumours in the paediatric population is significantly different than that in adults. In this study we retrospectively analyse a heterogenous variety of paediatric spinal tumours which were treated at our institution over the last 6 years, with the goal of contributing to existing knowledge of this relatively rare disease entity. Methods: This retrospective study includes paediatric patients (under 18 years of age) who underwent surgery for primary spinal tumours from 2014 to 2019. The medical records were reviewed retrospectively and the information regarding clinical presentation, tumour location, operative findings, and postoperative status and functional outcome were analysed. The modified McCormick grade was used to assess the neurological status. Patients with spinal metastasis or incomplete medical records were excluded from the study. Results: Of 74 patients with primary spinal tumours operated at our centre between 2014 to 2019, a total of 8 patients (5 males and 3 females) who met the inclusion criteria were identified for the present study. The mean age of the patients included was 12.1±5.3 and the median follow-up period was 24 months. An improvement in the neurological status, as assessed by the modified McCormick grade, was seen in 37.5% of the patients. Three of the patients received adjuvant radiotherapy, post-surgical resection. A unique feature of this series was the wide variety of cases encountered, as each case had a different histopathological diagnosis, despite being limited by its sample size. Conclusion: Primary paediatric spinal cord tumours are rare, and surgical resection remains the treatment of choice. Adjuvant therapy is warranted in cases of high-grade lesions or recurrences. Through this study, we realised that due to its relative rarity and low incidence, a lack of public awareness can often lead to disproportionately increased morbidity and mortality. Prospective multi-centric studies can provide tools to help develop future management strategies for improved survival rates and reduced complications.

Malignant idiopathic intracranial hypertension revealed a hidden primary spinal leptomeningeal medulloblastoma

Frequently the cause of raised intracranial pressure remains unresolved and rarely is related to spinal tumours, moreover less to spinal medulloblastoma without primary brain focus. An 18-year-old woman had a 3-month history of headache and impaired vision. Neurological examination revealed bilateral sixth cranial nerve palsies with bilateral papilloedema of grade III. No focal brain or spine lesion was found on imaging. Consecutive lumbar punctures showed high opening pressure and subsequent increasing protein level. Meningeal biopsy was negative. At one point, she developed an increasing headache, vomiting and back pain. Spine MRI showed diffuse nodular leptomeningeal enhancement with the largest nodule at T6–T7. Malignant cells were detected in cerebrospinal fluid. She underwent laminectomy with excisional biopsy, and pathology showed medulloblastoma WHO grade IV. She was treated with chemotherapy and craniospinal irradiation and made a good recovery.

Feasibility Of Radiation Dose Planning Guided Surgical Resection In Spinal Tumours

The objective of high dose stereotactic radiotherapy regardless of application is to treat the malignancy while minimizing the radiation dose to the surrounding healthy tissue. In the context of spinal tumours this paradigm is difficult since the rigid dose tolerance of the spinal cord precludes optimal dose coverage of the epidural disease. To achieve adequate coverage spine separation surgery is performed, increasing the distance from the spinal cord to the malignancy and facilitating adequate radiation treatment planning. This approach has been validated with delivery of maximum tolerable dose and local control rates over 90%. The objective of this dissertation is to establish the feasibility of intraoperative, dose guided, spine separation surgery. In the current clinical context, spine separation surgery is performed prior to radiation treatment planning and contours are placed based on postoperative resected tumour volumes. The extent of surgical resection is not dictated by the dosimetric constraints of the spinal cord and relies solely on the clinical expertise of the operating neurosurgeon. Further, though a skilled surgeon can perform precise tumour debulking with or without the aid of millimetre resolution neuronavigation devices, determination of surgical debulking progress with accuracy comparable to treatment delivery cannot be recognized without intraoperative imaging. To achieve this goal, we introduced pre-surgical dosimetric planning with tracked high frequency micro-ultrasound imaging into the operating theatre to inform the surgeon of the surgical progress while considering the dosimetric objectives. In this dissertation, we assessed the dosimetric advantage of spine separation surgery on a millimetre by millimetre basis in a retrospective simulation study. Feasibility of intraoperative navigation with submillimetre resolution was established by quantifying the application accuracy of surgical navigation in the context of cranial and spinal surgery. Accuracy quantification was performed, assessing our revolutionary optical topographical imaging system and benchmarked versus existing commercially available neuronavigation systems. Finally, to establish feasibility of radiation dose planning guided surgical resection we integrated a high frequency micro-ultrasound system into the operating theater during spine separation surgery. Thus, by implementing sub-millimetre high frequency micro-ultrasound imaging and neuronavigation, incremental gains towards establishing the feasibility of in traoperative dose planning by iteratively updating the extent of tumour resection were recognized.

Feasibility Of Radiation Dose Planning Guided Surgical Resection In Spinal Tumours

The objective of high dose stereotactic radiotherapy regardless of application is to treat the malignancy while minimizing the radiation dose to the surrounding healthy tissue. In the context of spinal tumours this paradigm is difficult since the rigid dose tolerance of the spinal cord precludes optimal dose coverage of the epidural disease. To achieve adequate coverage spine separation surgery is performed, increasing the distance from the spinal cord to the malignancy and facilitating adequate radiation treatment planning. This approach has been validated with delivery of maximum tolerable dose and local control rates over 90%. The objective of this dissertation is to establish the feasibility of intraoperative, dose guided, spine separation surgery. In the current clinical context, spine separation surgery is performed prior to radiation treatment planning and contours are placed based on postoperative resected tumour volumes. The extent of surgical resection is not dictated by the dosimetric constraints of the spinal cord and relies solely on the clinical expertise of the operating neurosurgeon. Further, though a skilled surgeon can perform precise tumour debulking with or without the aid of millimetre resolution neuronavigation devices, determination of surgical debulking progress with accuracy comparable to treatment delivery cannot be recognized without intraoperative imaging. To achieve this goal, we introduced pre-surgical dosimetric planning with tracked high frequency micro-ultrasound imaging into the operating theatre to inform the surgeon of the surgical progress while considering the dosimetric objectives. In this dissertation, we assessed the dosimetric advantage of spine separation surgery on a millimetre by millimetre basis in a retrospective simulation study. Feasibility of intraoperative navigation with submillimetre resolution was established by quantifying the application accuracy of surgical navigation in the context of cranial and spinal surgery. Accuracy quantification was performed, assessing our revolutionary optical topographical imaging system and benchmarked versus existing commercially available neuronavigation systems. Finally, to establish feasibility of radiation dose planning guided surgical resection we integrated a high frequency micro-ultrasound system into the operating theater during spine separation surgery. Thus, by implementing sub-millimetre high frequency micro-ultrasound imaging and neuronavigation, incremental gains towards establishing the feasibility of in traoperative dose planning by iteratively updating the extent of tumour resection were recognized.

Surgery treatment of primary spinal tumors

To analyze the results of the surgical treatment of primary spinal tumors, based on the appropriate ASIA scales, SINS, Bilsky, considering the location of tumors in various segments of the vertebral column, a retrospective analysis of 43 patients with primary benign and malignant spinal tumours was performed. The results of treatment depending on the histological type of tumors and the possibility of radical removal of tumors within healthy tissues have been studied. It has been established that with timely radical surgical treatment it is possible to prevent neurological complications, improve existing neurological disorders, restore normal anatomical relationships in the affected spinal segment, and create a reliable, rigid stabilization of the spine, which in turn allows prolonging patients’ lives.

Revision surgery for instrumentation failure after total en bloc spondylectomy: a retrospective case series

Background: There have been several reports of instrumentation failure after 3-column resections such as total en bloc spondylectomy (TES) for spinal tumours; nevertheless, clinical outcomes of revision surgery for instrumentation failure after TES are seldom reported. Therefore, this study assessed the clinical outcomes of revision surgery for instrumentation failure after TES. Methods: This study employed a retrospective case series in a single centre and included 61 patients with spinal tumours who underwent TES between 2010 and 2015 and followed for >2 years. Instrumentation failure rate, back pain, neurological deterioration, ambulatory status, operation time, blood loss, complications, bone fusion after revision surgery, and re-instrumentation failure were assessed. Data were collected on back pain, neurological deterioration, ambulatory status, and management for patients with instrumentation failure, and we documented radiological bone fusion and re-instrumentation failure in cases followed for >2 years after revision surgery. Results: Of the 61 patients, 26 (42.6%) experienced instrumentation failure at an average of 32 (range, 11−92) months after TES. Of these, 23 underwent revision surgery. The average operation time and intraoperative blood loss were 204 min and 97 ml, respectively. Including the six patients who were unable to walk after instrumentation failure, all patients were able to walk after revision surgery. Perioperative complications of reoperation were surgical site infection (n = 2) and delayed wound healing (n = 1). At the final follow-up, bone fusion was observed in all patients. No re-instrumentation failure was recorded. Conclusion: Bone fusion was achieved by revision surgery using the posterior approach alone.