Spinal Cord Cavernoma—Operative Strategy and Results in 30 Patients

Abstract

Background Many case reports and small series addressing the surgical management of spinal cord cavernoma have been published. However, only few larger series that would allow identifying operative strategies exist. After having treated 30 patients, we feel encouraged to report our experiences.

Methods A total of 30 patients (13 men and 17 women) were mainly admitted to our institution because of sensory deficits (83.3%), paresis (33.3%), and bladder dysfunction (26.6%). Magnetic resonance imaging revealed a spinal cavernoma mostly in the thoracic region (63.3%). All patients underwent surgery. The relation between pial surface and cavernoma guided the choice of approach and the myelotomy site.

Results After laminectomy/laminoplasty, median myelotomy was done in 16.7% to reach a medially located cavernoma. In 60.0%, myelotomy was located at the dorsal root entry zone, for which a (partial) hemilaminectomy was sufficient. The laterality of the location guided the bony approach in the remaining 23.3% with exophytic cavernoma. Immediately after surgery, neurological worsening was seen in 56.7%, an improvement in 10.0% and an unchanged neurological status in 33.3%. During the follow-up, the rate of neurological worsening dropped to 10.0%, the improvement rate increased to 50.0%. In 40.0% of the patients, the symptoms remained unchanged or returned to preoperative status.

Conclusion The exact localization in relation to the pial surface guides the approach and area of myelotomy. In the majority of patients limited approaches are sufficient for successful cavernoma removal. In our series anterior approaches had not been necessary.

Keywords

spinal cord cavernoma - surgical techniques - approach

• References

• 1 Hadlich R. A case of cavernous “malformation” of the spine with special emphasis on new theories of the genetics of this cavernous tumor. Virchows Arch 1903; 172: 429-441
• 2 Odom GL, Woodhall B, Margolis G. Spontaneous hematomyelia and angiomas of the spinal cord. J Neurosurg 1957; 14 (2) 192-202
• 3 Cosgrove GR, Bertrand G, Fontaine S, Robitaille Y, Melanson D. Cavernous angiomas of the spinal cord. J Neurosurg 1988; 68 (1) 31-36
• 4 Deutsch H, Jallo GI, Faktorovich A, Epstein F. Spinal intramedullary cavernoma: clinical presentation and surgical outcome. J Neurosurg 2000; 93 (1, Suppl) 65-70
• 5 Graziani N, Bouillot P, Figarella-Branger D, Dufour H, Peragut JC, Grisoli F. Cavernous angiomas and arteriovenous malformations of the spinal epidural space: report of 11 cases. Neurosurgery 1994; 35 (5) 856-863 , discussion 863–864
• 6 Harrison MJ, Eisenberg MB, Ullman JS, Oppenheim JS, Camins MB, Post KD. Symptomatic cavernous malformations affecting the spine and spinal cord. Neurosurgery 1995; 37 (2) 195-204 , discussion 204–205
• 7 Kivelev J, Niemelä M, Hernesniemi J. Outcome after microsurgery in 14 patients with spinal cavernomas and review of the literature. J Neurosurg Spine 2010; 13 (4) 524-534
• 8 Cohen-Gadol AA, Jacob JT, Edwards DA, Krauss WE. Coexistence of intracranial and spinal cavernous malformations: a study of prevalence and natural history. J Neurosurg 2006; 104 (3) 376-381
• 9 Jallo GI, Freed D, Zareck M, Epstein F, Kothbauer KF. Clinical presentation and optimal management for intramedullary cavernous malformations. Neurosurg Focus 2006; 21 (1) e10
• 10 Kim LJ, Klopfenstein JD, Zabramski JM, Sonntag VK, Spetzler RF. Analysis of pain resolution after surgical resection of intramedullary spinal cord cavernous malformations. Neurosurgery 2006; 58 (1) 106-111 , discussion 106–111
• 11 Labauge P, Bouly S, Parker F , et al; French Study Group of Spinal Cord Cavernomas. Outcome in 53 patients with spinal cord cavernomas. Surg Neurol 2008; 70 (2) 176-181 , discussion 181
• 12 Lu DC, Lawton MT. Clinical presentation and surgical management of intramedullary spinal cord cavernous malformations. Neurosurg Focus 2010; 29 (3) E12
• 13 Steiger HJ, Turowski B, Hänggi D. Prognostic factors for the outcome of surgical and conservative treatment of symptomatic spinal cord cavernous malformations: a review of a series of 20 patients. Neurosurg Focus 2010; 29 (3) E13
• 14 Kharkar S, Shuck J, Conway J, Rigamonti D. The natural history of conservatively managed symptomatic intramedullary spinal cord cavernomas. Neurosurgery 2007; 60 (5) 865-872 , discussion 865–872
• 15 Sandalcioglu IE, Wiedemayer H, Gasser T, Asgari S, Engelhorn T, Stolke D. Intramedullary spinal cord cavernous malformations: clinical features and risk of hemorrhage. Neurosurg Rev 2003; 26 (4) 253-256
• 16 Zevgaridis D, Medele RJ, Hamburger C, Steiger HJ, Reulen HJ. Cavernous haemangiomas of the spinal cord. A review of 117 cases. Acta Neurochir (Wien) 1999; 141 (3) 237-245
• 17 Gross BA, Du R, Popp AJ, Day AL. Intramedullary spinal cord cavernous malformations. Neurosurg Focus 2010; 29 (3) E14
• 18 Simard JM, Garcia-Bengochea F, Ballinger Jr WE, Mickle JP, Quisling RG. Cavernous angioma: a review of 126 collected and 12 new clinical cases. Neurosurgery 1986; 18 (2) 162-172
• 19 Santoro A, Piccirilli M, Frati A , et al. Intramedullary spinal cord cavernous malformations: report of ten new cases. Neurosurg Rev 2004; 27 (2) 93-98
• 20 Vishteh AG, Zabramski JM, Spetzler RF. Patients with spinal cord cavernous malformations are at an increased risk for multiple neuraxis cavernous malformations. Neurosurgery 1999; 45 (1) 30-32 , discussion 33
• 21 Bian LG, Bertalanffy H, Sun QF, Shen JK. Intramedullary cavernous malformations: clinical features and surgical technique via hemilaminectomy. Clin Neurol Neurosurg 2009; 111 (6) 511-517
• 22 Vishteh AG, Sankhla S, Anson JA, Zabramski JM, Spetzler RF. Surgical resection of intramedullary spinal cord cavernous malformations: delayed complications, long-term outcomes, and association with cryptic venous malformations. Neurosurgery 1997; 41 (5) 1094-1100 , discussion 1100–1101
• 23 Labauge P, Laberge S, Brunereau L, Levy C, Tournier-Lasserve E. Hereditary cerebral cavernous angiomas: clinical and genetic features in 57 French families. Société Française de Neurochirurgie. Lancet 1998; 352 (9144) 1892-1897
• 24 Fontaine D, Lot G, George B. Intramedullary cavernous angioma. Resection by oblique corpectomy. Surg Neurol 1999; 51 (4) 435-441 , discussion 441–442
• 25 Spetzger U, Gilsbach JM, Bertalanffy H. Cavernous angiomas of the spinal cord clinical presentation, surgical strategy, and postoperative results. Acta Neurochir (Wien) 1995; 134 (3-4) 200-206
• 26 Nishikawa M, Ohata K, Ishibashi K, Takami T, Goto T, Hara M. The anterolateral partial vertebrectomy approach for ventrally located cervical intramedullary cavernous angiomas. Neurosurgery 2006; 59 (1, Suppl 1) ONS58-ONS63 , discussion ONS58–ONS63
• 27 Matsuyama Y, Sakai Y, Katayama Y , et al. Surgical results of intramedullary spinal cord tumor with spinal cord monitoring to guide extent of resection. J Neurosurg Spine 2009; 10 (5) 404-413
• 28 Lunardi P, Acqui M, Ferrante L, Fortuna A. The role of intraoperative ultrasound imaging in the surgical removal of intramedullary cavernous angiomas. Neurosurgery 1994; 34 (3) 520-523 , discussion 523
• 29 Anson JA, Spetzler RF. Surgical resection of intramedullary spinal cord cavernous malformations. J Neurosurg 1993; 78 (3) 446-451
• 30 Cristante L, Hermann HD. Radical excision of intramedullary cavernous angiomas. Neurosurgery 1998; 43 (3) 424-430 , discussion 430–431