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Spinal Cord Tumors Cases Over The Past 10 Years At Srinagarind Hospital

การรักษาผู้ป่วยเนื้องอกไขสันหลัง 10 ปีที่ผ่านมาของโรงพยาบาลศรีนครินทร์

Kritsakorn Jingjit (กฤษกร จริงจิตร) 1




วัตถุประสงค์: รายงานการเกิดเนื้องอกไขสันหลัง จำแนกทางชนิดของพยาธิวิทยาเนื้องอกไขสันหลังตลอดระยะเวลาสิบปีของผู้ป่วยในโรงพยาบาลศรีนครินทร์และเปรียบเทียบข้อมูลนี้กับรายงานอื่น ๆ

วิธีการศึกษา : ผู้ป่วยเนื้องอกไขสันหลังที่ได้รับผ่าตัดตั้งแต่ช่วงปี ค.ศ. 2005-2015 ซึ่งได้รับการลงทะเบียนในฐานข้อมูลของโรงพยาบาลศรีนครินทร์ โดยเก็บข้อมูลได้แก่ อายุในช่วงเวลาของการผ่าตัด  เพศ  ระดับกระดูกสันหลังของเนื้องอกไขสันหลัง  อาการทางคลินิกและการวินิจฉัยทางพยาธิวิทยา

ผลการศึกษา : จากผู้ป่วยทั้งหมดจำนวน75 ราย ในการศึกษาส่วนใหญ่เป็นเพศหญิง 42 ราย(ร้อยละ56) อายุเฉลี่ยในการผ่าตัดเป็น 42.96 ปี ได้รับการวินิจฉัยทางพยาธิวิทยารวม 44 ราย เป็น schwannoma (ร้อยละ59) 3 ราย เป็น meningioma (ร้อยละ4) 10 ราย เป็น ependymoma (ร้อยละ13) ependymoma 3 ราย เป็น myxopapilly  (ร้อยละ4) 3 รายเป็น neurofibroma (ร้อยละ4) และ 6 ราย เป็นastrocytoma (ร้อยละ8) และอื่น ๆ  จำนวน 6 ราย (ร้อยละ8) (cavernoma, ganglioglioma, leiomyoma, lipoma, hemangioblastoma) ระยะเวลาเฉลี่ยตั้งแต่เริ่มมีอาการจนถึงได้รับการวินิจฉัยเป็น 12.44 เดือน อาการแสดงที่พบมากที่สุดของเนื้องอกไขสันหลังหลักคืออาการปวดร้าวไปที่แขนและ/หรือขา (ร้อยละ 45) ชา (ร้อยละ25) ปวดตามแนวแกนหลัง (ปวดคอหรือหลัง) (ร้อยละ13.3) อ่อนแรง (ร้อยละ13.3 ) ร้อยละ 5.3 ของผู้ป่วยมีความผิดปกติของการปัสสาวะตามลำดับ

สรุป:   ผลการศึกษานี้เป็นการรายงานผู้ป่วยเนื้องอกเส้นประสาทไขสันครั้งแรกผู้ป่วยผ่าตัดที่ได้รับเหล่านี้ในโรงพยาบาลศรีนครินทร์ซึ่งข้อมูลทางด้านอายุ  เพศ ลักษณะทางพยาธิวิทยา ระดับกระดูกสันหลังของเนื้องอกและอาการแสดงของผลการศึกษาพบความคล้ายคลึงกับรายงานจากประเทศอื่น ๆ ในเอเชีย

 

Purpose : To clarify the relative frequency of various histo-pathological spinal cord tumors and their features over the past 10 years in Srinagarind hospital and to compare this data with other reports.

Methods :  Primary spinal cord tumor surgical cases from 2005 to 2015, which were registered in our affiliated hospital database were collected. We collected data of  age at the time of  the surgery, sex, anatomical locations, vertebral levels of the tumor, clinical presentation and pathological diagnosis in each case.

Result :  Of the 75 patients in our study, 33 (44 %) were males and 42 (56 %) were females. The mean age at surgery was 42.96 years. The pathological diagnoses included 44 schwannoma (59 %), 3 meningioma (4 %), 10 ependymoma (13 %), 3 myxopapillyependymoma(4%), 3 neurofibroma(4 %), and 6 astrocytoma (8 %). the other 8% of patients were diagnosed with other conditions (cavernoma, ganglioglioma, leiomyoma, lipoma, hemangioblastoma) (8%).  Median time until diagnosis was 12.44 months. The most common clinical presentation of primary spinal cord tumors was pain radiating out to the arm and/or leg (45%), numbness (25%), axial pain( 13.3%) (include neck pain and back pain), weakness (13.3%), Only 2 children presented with scoliosis.10.7%, and 5.3% of patients suffered from sphincter dysfunction and paraparesis, respectively.

Conclusion :   This is the first published data on primary spinal cord tumors describing the demographic characteristics, pathological features, anatomical locations, and vertebral levels of these surgically-treated tumors in Srinagarind hospital. The results were similar to those of reports from other Asian countries.

Introduction

            According to previous reports 1–13, primary spinal cord tumors account for about 4-16% of all tumors arising from the central nervous systems (CNS). Most intradural tumors arise from the cellular constituents of the spinal cord and filum terminale, nerve roots, or meninges. Metastatic involvement of the spinal intradural compartment is rare. Because of variation in population sizes studied and classification of tumors, the frequencies of different spinal cord tumors vary among these reports.

          The aims of this study are to review surgically treated cases of primary spinal cord tumors, and to clarify the relative frequencies of these tumors in Srinagarind hospital as classified by clinical manifestation, histological types, anatomical locations and the vertebral levels at which they were found. By describing features of spinal cord tumors in Srinagarind hospital, we can determine the similarities and differences of spinal cord tumors in populations from other countries (such as pathology, race and sex) and suggest the roles that environmental, genetic, and hormonal factors may play in the etiology of spinal cord tumors.

Materials and Methods

          Khon Kaen University’s Srinagarind has database in which it registers all spinal surgeries performed there. From this database, we collected cases with primary spinal cord tumors that were treated surgically between January 2005 and December 2015. We excluded metastatic and spinal bone tumors from this study. The study protocol was approved by Khon Kaen University’s Committee on HE591147in Human Research. In each case, we collected data of age at the time of  surgery, sex, anatomical location of tumors, symptoms, duration, vertebral level location (cervical, cervicothoracic, thoracic, thoracolumbar, lumbar, lumbosacral and sacral) and pathological diagnosis.

Results

Patient demographics

         

          There were 75 patients with primary spinal cord tumors surgically treated during the period of this study. Of the 75 patients, 42 (56 %) were females and 33 (44 %)were males. The mean age at surgery was 42.96 years (range, 3 years to 72 years, Fig. 1). When stratified by patient age in 10-year intervals, the patient groups aged 41–50  years and 51–60 years encompassed the largest number of patients with primary spinal cord tumors.; Only 1.3 % of patients were over 70 years of age. The vertebral levels of the tumors were evenly distributed (Fig.2).  The largest number of primary spinal cord tumors were at the cervical (35%) and thoracic (28%) levels. ; Only one of the cases was multiple lesion, due to Neurofibromatosis type2. The pathological diagnoses of the primary spinal cord tumors are shown in Table 1.

 

Figure 1 Age and sex distributions of patients with primary spinal cord tumors

 

Figure 2 Vertebral level distribution of primary spinal cord tumors

 

Table1 Primary spinal cord tumors by histology and sex

Pathology

Number

(% of total)

Male

Female

Schwannoma

44 (59)

20

24

Ependymoma

10 (13)

3

7

Astrocytoma

6 (8)

2

4

Meningioma      

3 (4)

2

1

Myxopapillary ependymoma

3 (4)    

1

2

Neurofibroma   

3 (4)

1

2

Others  

6 (8)

4

2

Total    

75 (100)

33

   42     

Figure 3 Percentage of primary spinal cord tumors

Table 2 Vertebral level distribution of each type of tumor

Tumor type

Cervical

Cervicothoracic

Thoracic

Thoracolumbar

Lumbar

Lumbrosacral

Multiple

Total

Schwannoma

18

0

12

6

6

1

1

44

Astrocytoma

0

1

3

2

0

0

0

6

Ependymoma

2

3

1

3

1

0

0

10

Meningioma

3

0

0

0

0

0

0

3

Myxopapillary ependymoma

0

0

1

2

0

0

0

3

Neurofibroma

1

0

0

0

2

0

0

3

Others

2

0

4

0

0

0

0

6

Total

26

4

21

13

9

1

1

75

 

Histological types of tumor

          Histological examination of primary spinal cord tumors revealed the most common type to be Schwannoma (59%),  followed by ependymoma (13%), astrocytoma (8%), meningioma (4%), myxopapillary ependymoma (4%), meurofibroma (4%) and others(8%)

          Of the 44 patients with Schwannomas, the tumors occurred mainly at the cervical level of 18 and thoracic levelof 12 (Table 2). They were typically diagnosed after the age of 30, and the peak incidence for Schwannomas was found from 41 to 50 years of age (Fig. 4).

 

Figure 4 The characteristics of Schwannomas. Age and sex distributions

 

          There were 10 patients with ependymomas, and3 myxopapillary ependymomas. the others were astrocytoma, meningioma, neurofibroma and the others (cavernoma, ganglioglioma, leiomyoma, lipoma, hemangioblastoma). The vertebral level distribution of each type of tumor are shown inTable. 2

Presenting signs and symptom

 

 

Figure 5  Characteristic of  clininal presentation

 

          Median time to diagnosis were 12.44 months. The most common clinical presentation of a primary spinal cord tumor was pain radiating out to the arm and/or leg (45%), numbness (26%), pain ( 13.3%) (include neck pain and back pain), weakness (13.3%), Only 2 children presented with scoliosis (Fig.5).10.7%, and 5.3% of patients presented with sphincter dysfunction and paraparesis, respectively.

 

 

Table 3 Number of patients with bowel and bladder symptoms

Bowel/bladder

Number of patients

%

Bladder

8

10.7

Both

13

17.3

No

54

72.0

Total

75

100.0

 

 

          There were 8 (10.7%)patients with bladder dysfunction and, 13(17.3%) with bowel and bladder disturbance. 54 (72%) of patients had normal function of bowel and bladder (Table 3). The largest number of patients with primary spinal cord tumors had motor weakness (paraplegia) and Only 4 (5.3%) patients suffered from total paraparesis (Table 4).

 

Table 4 Percentage of Motor power

 

Motor power

Frequency

%

No active movement

4

5.3

Muscle contraction

5

6.7

Movement thru ROM w/o gravity

12

16.0

Movement thru ROM against gravity

16

21.3

Movement against some resistance

27

36.0

Movement against full resistance

11

14.7

Total

75

100.0

Table 5 Incidence of primary spinal cord tumors by series

 

Reference

Country

Number of case

Date

Schwannoma (%)

Meningioma (%)

Neuroepithelial tumor (%)

Ardehali14

Iran

108

1962-1986

40.7

33.3

16.7

Lalitha and Dastur16

India

326

Before 1980

39.9

25.5

20.9

Shuangsh and Panyatha11

Thailand

120

1956-1973

65.8

14.2

12.5

Cheang et al.15

Taiwan

92

1988-1995

52.2

15.1

10.9

Wen-Qing, et al.13

China

2,245

Before 1982

49.4

14.7

11.4

Cheng2

China

1,549

Before 1982

49.5

13.2

10.7

Suh, et al12

Korea

141

1997-1998

39.7

25.5

19.1

 

Discussion

          This study evaluated the primary spinal cord tumors presented at Srinagarind hospital. Our study uses a spinal surgery registry to retrospectively analyze primary spinal cord tumor cases and collect detailed data about patients’ age at surgery, sex, anatomical location of tumors, vertebral level of tumors, clinical presentation and pathological diagnosis.

The incidence rate of primary spinal cord tumors in our study compared with other reports out of Asia. Also similar to other reports, nerve sheath cell tumor (Schwannoma) 2, 11-15were most frequent(Table 5). The mean age at surgery was 42.96 years. The median time until diagnosis was 12.44 months, Pain was the most common presenting symptom  and may manifest asradicular pain, back pain and neck pain. Motor disturbance was the  next most common presenting symptom followed by sensory loss. Sphincter disturbance was the least common presenting symptom.

          Primary treatment of primary spinal cord tumors is surgical resection and predictors of outcome include preoperative functional status (limited to no neurologic deficit predicts a better outcome), histologic grade of the tumor (lower grade predicts improved chance of survival)

 

Conclusions

          This is the first published research on primary spinal cord tumors describing the demographic characteristics, pathological features, anatomical locations, and vertebral levels of these surgically-treated tumors in Srinagarind hospital. The results were similar to those of reports from other Asian countries. Schwannoma were most frequent.

          Early recognition of the signs and symptoms of primaryspinal cord tumors facilitates early diagnostic evaluationand treatment, potentially minimizes neurologic morbidity, and improves clinical outcome.

 

Disclosure

          No potential conflicts of interest relevant to this article were reported.

 

 

References

1. Char G, Cross JN, Persaud V. Tumors of the central-nervous-system analysis of 476 cases observed at the University-Hospital-of-the-West-Indies. West Indian Med J 1987; 36: 140-9.

2. Cheng MK. Spinal cord tumors in the People’s Republic of China: a statistical review. Neurosurgery1982; 10: 22–4.

3. Chi JG, Khang SK. Central nervous system tumors among Koreans—a statistical study on 697 cases. J Korean Med Sci1989; 4: 77–90.

4. Elia-Pasquet S, Provost D, Jaffre A, Loiseau H, Vital A, Kantor G, et al.. Incidence of central nervous system tumors in Gironde, France. Neuroepidemiology 2004; 23: 110–7.

5. Fogelholm R, Uutela T, Murros K. Epidemiology of central nervous system neoplasms. A regional survey in CentralFinland. Acta Neurol Scand 1984; 69: 129–36.

6. Helseth A, Mork SJ, Johansen A, Tretli S. Neoplasms of the central nervous system in Norway.IV.A population-based epidemiological study of meningiomas. APMIS 1989; 97: 646–54.

7. Johannesen TB, Angell-Andersen E, Tretli S, Langmark F, Lote K. Trends in incidence of brain and central nervous systemtumors in Norway, 1970-1999. Neuroepidemiology 2004; 23: 101–9.

8. Kaye AH, Giles GG, Gonzales M. Primary central nervoussystem tumours in Australia: a profile of clinical practice from theAustralian Brain Tumour Register. Aust N Z J Surg 1993; 63: 33–8.

9. Liigant A, Asser T, Kulla A, Kaasik AE. Epidemiology ofprimary central nervous system tumors in Estonia. Neuroepidemiology 2000; 19: 300–11.

10. Preston-Martin S. Descriptive epidemiology of primarytumors of the spinal cord and spinal meninges in Los AngelesCounty, 1972-1985.  Neuroepidemiology 1990; 9: 106–11.

11. Shuangsh S, Panyatha R. Neural neoplasms in Thailand—study of 2,897 cases. Neurology 1974; 24: 1127–34.

12. Suh YL, Koo H, Kim TS, Chi JG, Park SH, Khang SK, et al. Tumors of the central nervous system in Korea—amulticenter study of 3221 cases. J Neurooncol 2002; 56: 251–9.

13. Wen-qing H, Shi-ju Z, Qing-sheng T, Jian-qing H, Yu-xia L,Qing-zhong X, et al. Statistical analysis ofcentral nervous system tumors in China. J Neurosurg 1982; 56: 555–64.

14. Ardehali MR. Relative incidence of spinal canal tumors. Clin Neurol Neurosurg 1990; 92: 237–43.

15. Cheang CM, Hwang SL, Hwong SL. An analysis ofintraspinal tumors in south Taiwan. Kaohsiung J Med Sci 1997; 13: 229–36.

16. Lalitha VS, Dastur DK. Neoplasms of the central nervoussystem—histological types in 2237 cases. Indian J Cancer 1980; 17: 102–6.

 

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