Intramedullary Spinal Cord Glial Tumours: Management Philosophy and Surgical Outcome

Abstract

Intramedullary tumours of the spinal cord account for 2–4% of CNS neoplasms and about 20–25% of all intraspinal tumours [1]. Intramedullary tumours compromise about one third of spinal neoplasms in adults [2]. Astrocytomas and ependymomas account for more than 80% of intramedullary tumours in most series [3]. Until recently their management remained unclear mainly because of the debate regarding the nature and extent of surgery and the relative risks of surgery and radiotherapy in the treatment of these lesions. In many series patients were treated before the advent of modern diagnostic tools and surgical adjuncts and the approach used to be biopsy, dural decompression and radiation therapy based on the assumption that carrying extensive removal of tumours from within the cord was not feasible without inflicting additional neurological insult. As a result the optimal management of this entity remained unclear. With the advent of magnetic resonance imaging and a number of surgical tools such as the operating microscope, ultrasound, ultrasonic tissue aspirator and the laser the diagnosis and management of these lesions have become more easier and safer. Despite these modern advances intramedullary surgery remains a formidable undertaking. However the earlier pessimistic outlook has paved way to optimism over the years ever since the first successful removal of an intramedullary tumour by Von Eiselberg [4]. Greenwood [5,6], Rand [7], Vasergill [8], Stein [9] all were strong proponents in favour of surgery. The most vocal proponent for aggressive surgery in recent years has been Epstein [10–13].