R J Groen, H A van Alphen
Operative treatment of spontaneous spinal epidural hematomas: a study of the factors determining postoperative outcome.
Neurosurgery. 1996 Sep;39(3):494-508; discussion 508-9.
Abstract/Text
OBJECTIVE: We clarify the factors affecting postoperative outcomes in patients who have suffered spontaneous spinal epidural hematomas.
METHODS: We review 330 cases of spontaneous spinal epidural hematomas from the international literature and three unpublished cases of our own. Attention was focused on sex, age, medical history, mortality, size and position of the hematoma, vertebral level of the hematoma, preoperative neurological condition, operative interval, and postoperative result.
RESULTS: Sex, age, and size and position of the hematoma did not correlate with postoperative outcome. Mortality correlated highly with cervical or cervicothoracic hematomas, especially in patients with cardiovascular disease and those undergoing anticoagulant therapy. Incomplete preoperative sensorimotor deficit correlated highly with favorable outcomes (P < 0.0005), and recovery was significantly better when decompression was performed in < or = 36 hours in patients with complete sensorimotor loss (P < 0.05) and in < or = 48 hours in patients with incomplete sensorimotor deficit (P < 0.005).
CONCLUSION: The critical factors for recovery after spontaneous spinal epidural hematoma are the level of preoperative neurological deficit and the operative interval. The vertebral level of the hematoma did not correlate with postoperative results, which suggests that local compression, rather than vascular obstruction, is the main factor in producing neurological deficit.
國保倫子、金景成、井須豊彦：脊髄硬膜外血腫、脊椎脊髄ジャーナル、2014:27:656-662.
Leonardo Rangel-Castilla, Jonathan J Russin, Hasan A Zaidi, Eduardo Martinez-Del-Campo, Min S Park, Felipe C Albuquerque, Cameron G McDougall, Peter Nakaji, Robert F Spetzler
Contemporary management of spinal AVFs and AVMs: lessons learned from 110 cases.
Neurosurg Focus. 2014 Sep;37(3):E14. doi: 10.3171/2014.7.FOCUS14236.
Abstract/Text
OBJECT: Spinal arteriovenous fistulas (AVFs) and arteriovenous malformations (AVMs) are rare, complex spinal vascular lesions that are challenging to manage. Recently, understanding of these lesions has increased thanks to neuroimaging technology. Published reports of surgical results and clinical outcome are limited to small series. The authors present a large contemporary series of patients with spinal AVFs and AVMs who were treated at Barrow Neurological Institute in Phoenix, Arizona.
METHODS: Retrospective detailed review of a prospective vascular database was performed for all patients with spinal AVFs and AVMs treated between 2000 and 2013. Patient demographic data, AVF and AVM characteristics, surgical results, clinical outcomes, complications, and long-term follow-up were reviewed.
RESULTS: Between 2000 and 2013, 110 patients (57 male and 53 female) underwent obliteration of spinal AVFs and AVMs. The mean age at presentation was 42.3 years (range 18 months-81 years). There were 44 patients with AVFs and 66 with AVMs. The AVM group included 27 intramedullary, 21 conus medullaris, 12 metameric, and 6 extradural. The most common location was thoracic spine (61%), followed by cervical (22.7%), lumbar (14.5%), and sacral (1.8%). The most common presenting signs and symptoms included paresis/paralysis (75.5%), paresthesias (60%), pain (51.8%), bowel/bladder dysfunction (41.8%), and myelopathy (36.4%). Evidence of rupture was seen in 26.4% of patients. Perioperative embolization was performed in 42% of patients. Resection was performed in 95 patients (86.4%). Embolization alone was the only treatment in 14 patients (12.7%). One patient was treated with radiosurgery alone. Angiographically verified AVF and AVM obliteration was achieved in 92 patients (83.6%). At a mean follow-up duration of 30.5 months (range 1-205 months), 43 patients (97.7%) with AVFs and 57 (86.4%) with AVMs remained functionally independent (McCormick Scale scores ≤ 2). Perioperative complications were seen in 8 patients (7%). No deaths occurred. Temporary neurological deficits were observed in 27 patients (24.5%). These temporary deficits recovered 6-8 weeks after treatment. Recurrence was identified in 6 patients (13.6%) with AVFs and 10 (15.2%) with AVMs.
CONCLUSIONS: Spinal AVFs and AVMs are complex lesions that should be considered for surgical obliteration. Over the last several decades the authors have changed surgical strategies and management to achieve better clinical outcomes. Transient neurological deficit postoperatively is a risk associated with intervention; however, clinical outcomes appear to exceed the natural history based on patients' ability to recover during the follow-up period. Due to the recurrence rate associated with these lesions, long-term follow-up is required.
Matthias Reitz, Till Burkhardt, Eik Vettorazzi, Frank Raimund, Erik Fritzsche, Nils Ole Schmidt, Jan Regelsberger, Manfred Westphal, Sven Oliver Eicker
Intramedullary spinal cavernoma: clinical presentation, microsurgical approach, and long-term outcome in a cohort of 48 patients.
Neurosurg Focus. 2015 Aug;39(2):E19. doi: 10.3171/2015.5.FOCUS15153.
Abstract/Text
OBJECT Intramedullary spinal cavernoma (ISC) is a rare entity and accounts for approximately 5%-12% of all spinal vascular pathologies. The purpose of the present study was to examine the influence of clinical presentation, localization, and different surgical approaches on long-term outcome in patients treated for ISC. METHODS The authors performed a retrospective single-center study of 48 cases of ISC treated microsurgically over the past 28 years. Analyzed factors included preoperative clinical history, microsurgical strategies, neurological outcome (American Spinal Injury Association [ASIA] grade, Epstein and Cooper grade), and the occurrence of postoperative spinal ataxia. Univariate analysis was performed to identify factors influencing long-term outcome. RESULTS Preoperatively, 18.8% of all patients experienced a slow, progressive decline in neurological function and 33.3% suffered repetitive episodes of acute neurological deterioration over a time frame of months to years. Moreover, 16.7% noted the sudden onset of a severe neurological deficit, whereas 25% experienced the sudden onset of symptoms with a subsequent gradually progressive decline in neurological function. On long-term follow-up after treatment (mean ± SD, 79.3 ± 35.2 months), 70.8% of patients showed no change in neurological function, 6.3% suffered from a decline, and 22.9% improved neurologically. Thoracolumbar localization (p = 0.043), low preoperative Epstein and Cooper grade for the lower extremities (p < 0.001), and a low preoperative ASIA grade (p < 0.001) were identified as factors associated with an unfavorable outcome (ASIA Grade A-C). The rate of spinal ataxia related to surgical approach was 16.7%. CONCLUSION Postoperative neurological function in ISC patients is determined by the preoperative neurological status. On long-term follow-up after microsurgical treatment, 93.7% of patients presented with a stable or improved condition (ASIA grade); thus, definite microsurgical treatment should be considered as long as patients present with only mild symptoms after the diagnosis of symptomatic ISC.
岩波明生、石井賢、中村雅也：髄内出血をきたす脊髄腫瘍、脊椎脊髄ジャーナル、2014: 27:679-685.
