Neurosurg Rev (2001) 24:1–5
© Springer-Verlag 2001
REVIEW
Uta Schick · Gerhard Marquardt · Rüdiger Lorenz
Intradural and extradural spinal metastases
Received: 6 July 2000 / Accepted: 22 August 2000
Abstract Intradural spinal metastases are uncommon. The outcome of surgical treatment of intra- and extramedullary intradural metastases is considered to be poor, with rapid clinical deterioration. The question of optimal treatment remains controversial. We present an overview of the clinical outcome and surgical treatment of 220 spinal metastases carried out in our centre from 1980 to 1999, with particular emphasis on 11 intradural metastases. Clinical history, signs, surgical approach, outcome, and radiological reports were obtained by review of patient charts. Secondary spinal tumours most often originated from carcinomas of the breast, lung, kidney, gastrointestinal tract, and prostate. In 12% of cases, no primary tumour could be found. Drop metastases of intracranial pathology appeared in 3%. Intradural metastases were seen in 11 patients and formed a very heterogeneous group with predominance of melanoma, lymphoma, and medulloblastoma. Functional recovery and survival time were worse in intradural metastases than in extradural metastases, and the patients were younger. Treatment of metastases is designed to relieve pain and preserve or restore neurological function palliatively. Intradural metastases are a devastating condition with usually fatal outcome. Selected patients who undergo aggressive surgical treatment may have substantially increased survival. Keywords Intradural metastases · Spinal neoplasms · Surgical treatment
U. Schick (✉) Clinic of Neurological Surgery, University of Leipzig, Johannisallee 34, 04103 Leipzig, Germany e-mail:
[email protected] Tel.: +49-0341-97-12000 G. Marquardt · R. Lorenz Clinic of Neurological Surgery, Johann Wolfgang Goethe University, Schleusenweg 2–16, 60528 Frankfurt am Main, Germany
Introduction Tumours that metastasise to the vertebrae and epidural tissues are commonly seen, but dissemination to the spinal cord is considered rare. When intradural spinal metastases do occur, they are often in the setting of rapidly progressive neurological deficit, disseminated primary tumour, and very limited life expectancy [3–4, 6]. Recommended treatment has been radiation and corticosteroids, especially for intramedullary metastases, and surgery played only a small role [12, 14]. Only a few larger series report about surgical treatment of single cases of intradural metastases [3–4, 6, 9–13]. We present a retrospective review of our series of 220 spinal metastases, with special regard to 11 intradural metastases.
Patients and methods The series included 220 patients with spinal metastases, all of whom underwent surgery from 1980 to 1998. The population was composed of 110 men and 110 women. Follow-up was available for 9.3±22.2 months. Mean age was 58.9±17.2 years. Neurological status The mean duration of symptoms was 3.5 months. Pain was the earliest and most prominent feature in 80.5% of patients. We found 32.6% to be in reduced general health. Our clinical scoring system in a modified version according to Cheshire [2] relates to motor power, gait disturbance, and bladder function, and scores range from 1 to 6: 1 signifies no abnormal neurological signs, 2 discrete impairment, 3 significant motor and/or sensory impairment with total ambulation and normal bladder function, 4 greater motor and sensory loss and ambulation with aids and/or neurogenic bladder, 5 severely limited ambulation and neurogenic bladder and severe weakness, and 6 no useful motor function. These neurological grades were applied to the patients retrospectively. Only 9.9% were classified as 1, 9.5% as 2, and 17.2% as 3. The largest proportion (32.5%) was graded as 4, 18.1% as 5, and 12.7% were already 6, the worst category.
2 Table 1 Case reports of 11 patients with intradural metastases, all of whom underwent operation. Outcome: + improved, = unchanged, – worse (IM intramedullary, EM extramedullary) Patient no.
Age (years)
Sex
Histology
Location
Level
Surgery
Resection
Outcome
1 2 3 4 5 6 7 8 9 10 11
11 31 36 47 48 48 54 56 58 67 74
M F M M F F F M F F F
Medulloblastoma Medulloblastoma Synoviobl. carcinoma PNET Esophageal carcinoma Lymphoma Bronchial carcinoma Ependymoma Lymphoma Melanoma Melanoma
EM EM IM IM EM IM IM EM EM IM IM
L5 C2 D1–D2 C7–D2 D1–D2 C2 C1–C3 C2–D2 D12–L3 D10–L1 C4
Hemilaminectomy Laminectomy Laminectomy Laminectomy Laminectomy Laminectomy Laminectomy Hemilaminectomy Laminectomy Laminectomy Laminectomy
Total Subtotal Subtotal Subtotal Total Biopsy Subtotal Subtotal Biopsy Total Total
= = + + – = – + = = =
Location The vast majority of metastases were purely extradural (94.5%); 34.4% were epidural and had a large paravertebral section involving bone and soft tissue outside the spinal canal. Intradural metastases were seen in 11 patients (5.0%). Six of these had intramedullary metastases. Magnetic resonance imaging (MRI) has been available since March 1987 for outpatients and May 1991 for inpatients. Of all patients, 19.5% had no MRI and were diagnosed by CT and/or myelography. Statistics Information about clinical history, signs, surgical approach, and outcome was obtained retrospectively by reviewing patient charts and radiological reports. Statistical evaluation of the results was carried out using the chi-squared test to indicate differences between two samples, and Wilcoxon’s matched pairs test was used to evaluate the differences between two measurements of the same sample. Probability values lower than 0.05 indicated a significant difference.
Table 2 Neurological grades of patients. Scores: 1 no deficit, 2 discrete neurological impairment, 3 significant impairment with total ambulation and normal bladder, 4 greater deficit with ambulation with aids and/or neurogenic bladder, 5 severely limited ambulation and neurogenic bladder, 6 no useful motor function Patient no.
Preoperative
Postoperative
Follow-up
1 2 3 4 5 6 7 8 9 10 11
3 3 5 4 4 4 3 3 4 3 4
3 3 4 3 5 4 4 2 4 3 4
3 3 4 3 6 4 4 1 4 3 6
Neurological status and outcome
Results Intradural metastases occurred in 11 cases (four male, seven female) with a mean age of 48.18 years; six were intramedullary and five were extramedullary (Table 1). The cervical region was the most common site (n=4), with extension to the thoracic spine in two further cases. The second predilection was the thoracic region (n=3). One tumour was located thoracolumbarly and one was lumbar. Surgery All patients were operated via a dorsal approach, generally a laminectomy, and, in two cases, hemilaminectomy. Four tumours could be totally removed, five subtotally, three were intramedullary with an unclear cleavage plane (nos. 3, 4, and 7), one had a large extension over eight spinal levels (no. 8), and one was ingrown in scar tissue after prior operation. Two were only biopsied (Table 1). These two lymphomas did not respond adequately to chemotherapy after 1 month and histology had to be verified.
Five patients showed only slight neurological deficits preoperatively (score of 3), five showed marked deficits (score of 4), and one had severe deficits (score of 5) (Table 2). Duration of symptoms varied from 1 to 16 months (mean 5.72 months) (Table 3). The period between diagnosis of primary tumour and appearance of metastases ranged from 1 to 288 months in case of an ependymoma. Two tumours were first diagnosed shortly before operation of spinal metastases and in one, metastasis of a malignant melanoma, no primary tumour could be found. All four patients with medulloblastoma, ependymoma, and primitive neuroectodermal tumour (PNET) had had craniotomy of the posterior fossa in the past but no signs of local tumour recurrence at presentation with spinal metastases. One patient with synovioblastoma of the hip underwent operation for right parietal intracranial haemorrhage within a metastasis 8 months before appearance of intramedullary thoracic metastases. Postoperatively, only two patients showed neurological deterioration. Six remained unchanged and three demonstrated an improvement of neurological signs (Table 2). Nine patients died within the following 5 months (mean 3.0 months). Only three survived (mean 20 months) and
3 Fig. 1 MRI reveals an intramedullary metastasis from malignant melanoma in the form of a tumour nodule at C4 and extradural metastases in the vertebral bodies of C4–C6 Fig. 2 MRI shows multiple contrast-enhanced intradural drop metastases in a 52-yearold man with a history of ependymoma II around the fourth ventricle 24 years ago
Table 3 Case reports with duration of symptoms, diagnosis of primary tumour in months before operation of spinal metastases, adjuvant therapy pre- and postoperatively, survival in months after operation, and follow-up in survivors Patient no. 1 2 3 4 5 6 7 8 9 10 11
Duration of symptoms (months)
Diagnosis of primary tumour (months)
Chemotherapy
Radiation
Preop
Postop
Preop
6 1 1 1 2 13 4 9 16 9 1
36 3 16 11 24 1 11 288 1 0 0
+
+
+
Survival (months) Postop
27 +
+
+ +
+ + +
+
+
+ +
+ +
are still being followed up as outpatients (Table 3). In the total series of 220 patients, 10% died within the first 6 months after surgical treatment of spinal metastases and 46% within 1 year (Table 3).
Follow-up (months)
+ +
3 2 2 5 4 1
+ + +
9 24 2 5
(P
