Clinical Profile and Outcome of Surgical Management of Spinal Tumours in Abuja.

Introduction

Spine tumours comprise tumours affecting the spinal cord and spinal column. These tumours are classified anatomically into intramedullary tumours, intradural extramedullary tumours, and extramedullary tumours.[ 1 ] They are either primary or secondary (metastatic) tumours. Primary spinal cord tumours are rare making up about 3% of all primary CNS tumours.[ 2 , 3 ] The most common intramedullary tumours are astrocytoma and ependymomas. Meningiomas and nerve sheath tumours constitute the majority of intradural extramedullary tumours.[ 1 , 4 ] Most spine tumours are, however, extradural tumours, of which majority are metastatic tumours commonly from lungs, breast, prostate tumours, and renal cell carcinoma. Metastatic spine tumours (MST) affect 20–40% of cancer patients and are symptomatic in about 10%–20% of them.[ 1 , 5 , 6 ] There is an increase in incidence of metastatic tumour due to improved management of primary cancers with introduction of targeted therapies resulting in improved survival for virtually all malignant tumours.[ 5 , 6 ]

Clinical presentation of these tumours depends on their locations and rapidity of their growth progression. Pain and motor deficit are the commonest mode of presentation.[ 6 , 7 , 8 , 9 , 10 ] Few patients are diagnosed during screening for metastasis in patients with known cancers.

Depending on the location and nature of the tumour, surgical interventions are carried out for tumour excision, biopsy for histology, spinal fixation in case of instability, and spinal cord decompression.[ 11 , 12 , 13 ]

There have been remarkable advances in the surgical treatment of both benign and malignant tumour of the spine. For benign spine tumours, the goal of surgery is to achieve gross total tumour excision as a curative measure, and this is achievable with use of standard microsurgical techniques in majority of cases.[ 4 ] Treatment goals for MST are palliative aiming at preservation or restoration of neurological function, improved pain control, and maintenance of spinal stability in a setting of local tumour control.[ 5 ] Introduction of spine stereotactic radiosurgery (SSRS), less invasive surgical techniques including separation surgery, percutaneous pedicle screw instrumentation, and cement augmentation among others have improved health-related quality of life and survival of patients with MST. Invariably, these measures tend to render scoring systems such as Tomita score[ 14 ] and Tokuhashi[ 15 ] revised score of little value in the current era of metastatic spine tumour treatment.[ 11 , 16 , 17 ]

Management of spinal tumours in Nigeria has recorded some improvement in recent time but like other developing countries, it still lags behind the advancement in developed world. There are few published works on surgical management of spine tumour in Nigeria. The study was designed to evaluate the clinical presentations, surgical interventions, pathological diagnosis, and outcome spinal tumour in our institution.

Subjects and Methods

This study was a retrospective review of all patients managed by the authors for spinal tumours at our institution over 41 months (June 2021–November 2024). The study was carried out at the Neurosurgery Department of National Hospital Abuja, a tertiary health care centre at the capital city of Nigeria as a departmental audit. The patients’ clinical, radiology, surgery, and histology records were retrieved from the hospital electronic medical records and theater operation records with the assistance of the Head of the hospital Medical Record Department. Patients without a histological diagnosis were excluded from the study; hence, a purposive sampling technique was used. The neurological status of patients was assessed pre- and postsurgery using the American Spinal Injury Association (ASIA) impairment scale[ Figure 1 ].[ 18 ] Data on demographics, clinical presentation, tumour location, type of surgery, postoperative outcome, and histology were recorded in a predesigned study pro forma. The data were entered into IBM Statistical Package in for Social Sciences Version 31 spread sheet and analysed. Univariate analyses were carried out and results were compared with findings of similar results in other part of worlds. The study is a retrospective review; hence, ethical approval was not required by the ethics committee of the National Hospital Abuja [ Figure 1 .

Results

A total of 180 spine surgeries for various indications were conducted during the study period, out of which 34 patients had histologically confirmed spinal tumours representing 18.9% of all spinal surgeries. There were 16 males and 18 females (male: female ratio 1:1.1). Patients’ ages ranged from 14 to 90 years [ Table 1 ]. All patients presented with pain while 27 (79.4%) patients presented with motor deficits and 15 (44.1%) patients had sensory deficits. Fifteen (44.1%) patients present with ASIA-C, 10 (29.4%) present with ASIA-A [ Table 2 ]. Majority of the patients 23 (67.6%) presents between 6 and 12 months of onsets of symptoms, 4 (11.8%) patients for less than 6 months, and 7 (20.6%) had symptoms for more than 1 year before presentation. The thoracic spine was most frequently affected 17 (50%), followed by the cervical spine 7(20.6%) [ Table 3 ]. Half of the tumours were extradural, while 10 (29.4%) were intradural extramedullary [ Figure 2 ]. Metastatic tumours 10 (29.4%) and multiple myeloma 6 (17.6%) were the most common histological diagnoses [ Table 3 ]. Prostate carcinoma 10 (30%) and breast cancer 7 (20.0) were the most common primary source of metastasis while the primary source was unknown in 7 (20%) patients [ Figure 3 ]. Spinal meningioma 5 (14.7%) and Schwannoma 5 (14.7%) were the most common primary tumours.

Seventeen patients (50.0%) had laminectomy alone, 10 (29.4%) patients had laminectomy and transpedicular fixation and posterior lateral fusion while 3 (8.8%) patients underwent cervical corpectomy and fusion surgeries. Gross total tumour excision was achieved in 13 (38.2%) patients wish consisted of patients with meningioma and most of the patients with spinal schwannoma [ Table 4 ]. Most of the patients with metastasis had debulking surgery [ Table 5 ]. Half of the patients had neurological improvement postsurgery with increase in ASIA scale of at least one grade above the preoperative grade, while 30% remained unchanged, and 20% deteriorated.

Figures 4 , 5 , 6 , 7 shows illustrative images of the patients.

Discussion

This study report on 34 cases of spinal tumour operated over a 3-year period which represented 18.9% of all spine procedures done. The result shows an apparent increase in the average number of spine tumour surgeries than previously reported from other centres in Nigeria. A total of 39 cases and 59 cases, respectively, were reported over a 10-year period in southeastern and southwestern part of Nigeria.[ 8 , 9 ] The percentage of spinal surgeries for tumour (19%) was higher than the 8.9% reported by chikani in southeastern Nigeria .[ 8 ] These findings may be due to increased availability of diagnostic imaging (MRI and CT scan) and better awareness by patients and primary doctors leading to improved referral to spine surgeons. The demographic characteristics of our patients are like previous reports. Spinal tumour affects different age groups (mean 51 years) and gender. We found a slightly more female been operated like report by Adeolu in southern Nigeria but different from report from eastern part of the country.[ 8 ] Other studies have previously reported different sex predominant. In Taiwan, male predominant was reported in metastatic disease while female dominant was reported for spinal meningioma.[ 19 ] These differences in sex predominance may be reflection of pattern primary origin of MSTs,[ 19 ] differences in health seeking behaviours different genders of the study population and other reasons that should be a subject of further research.

All our patients present with pain with motor deficit been present in 79% at presentation. Most of these patients present with poor neurologic grade (ASIA A-C in 84% and ASIA-C,44%). This clinical presentation was probably due to late presentation as 80% of the patients present after 6 months of onset of symptoms. Various authors have reported different mode of presentation of patients with spinal tumours. Adeolu et al .,[ 9 ] report 58% of the patients presented at least 6 months of symptoms onset with motor deficit of 97% while Arora[ 7 ]reported an average duration of symptoms of 16.17 months with predominant motor deficit of 70.27% and poor neurologic status in 71.17%. Neurologic status at presentation has been found to impact significantly on outcome of management.[ 7 ]

The thoracic spine (50%) was the most affected segment of the spine followed by cervical (21%). The thoracic spine as the most common segment involved was reported in Ibadan 65%, Enugu 43.6%, Taiwan 51.4%, India 34%, and Brazil 37%.[ 3 , 7 , 8 , 9 , 19 ] This is attributable to the long segment of the thoracic spine and peculiar nature of vascular supply to the spine in the region.

Half of the tumours were extradural, and majority were metastatic adenocarcinoma (29%). The prostate (30%) and the breast (20%) were the most common primary origins of metastases. Meningioma (14.7%) and schwannoma (14.7%) were the commonest primary tumour. These findings were consistent with previous reports from Nigeria and other parts of the world.[ 1 , 8 , 9 ] In a review from Taiwan, the lung was the commonest primary site whereas Lung metastasis only account for 10% of metastasis in our series.[ 19 ] These differences could be attributed to cigarette smoking habit of the study population. The Prostate, breast, lungs, and renal cell carcinoma have been reported as forming the majority of spine metastasis in different studies.[ 5 ] The primary origin of metastases was not known in 20% of our patients. This percentage is lower than 31% reported by Chikani et al . in Nigeria, though still within the 0.4%–38% reported in the literature.[ 20 ] It is higher than 4.8% reported by Tsai et al .[ 19 ] in Taiwan. The decline in proportion of unknown cases reflects improved pathological diagnosis occasioned by advance diagnostic imaging (CT, MRI, and PET scans) and availability of trained personnel. One adolescent (2.9%) of our patient was managed for osteo osteoma (OO) of the cervical spine a rare benign bony tumour. OO is reported to comprise 6% of spinal lesions.[ 21 ]

All our surgical interventions were by open method due to lack of facility for minimal access surgery. Half of the patients had laminectomy alone, while 29.4% had laminectomy and pedicle screws instrumentation surgeries. Spinal fixation using spinal process wiring (17.8%) was the main fixation method reported in Ibadan.[ 9 ] Gross total tumour resection was achieved in 38.2%, most of these comprise patients with primary benign tumour such as meningioma, schwannoma and OO. Limited and guided intervention was carried out for metastatic. Many patients with metastatic disease had decompression of the spinal cord and tumour debulking. Few of these patients had additional fixation due to instability occasioned because of tumour infiltration and extend of decompression. There has been major advancement in the care of cancer patients. The use of targeted therapies in cancer care and advanced diagnostic imaging such as MRI and PET scan with resultant improvement in survival and quality of life of patients has led to increase incidence of MSD.[ 5 , 22 ] Many of the interventions like SSRS, minimally invasive procedures which are now the main approached to managing metastatic spinal tumours are currently not available in our centre. However, these patients were managed in conjunction with oncologists for external beam radiotherapy and chemotherapy where appropriate following histologic diagnosis. Surgery resulted in neurological improvement in half of our patients while 20% of the patients deteriorated probably due to disease progression. These outcome finding is in tandem with other reports in Nigeria and other parts of the world.[ 3 , 7 , 8 , 9 , 23 ]

Conclusion

Pain control and restoration of neurological deficits were the main reasons for surgical intervention in our patients. Majority of the patients had metastatic spine disease requiring palliative interventions. Gross total resection was achieved in 38% of cases. All surgeries were by open posterior approach with more than half of the patients having laminectomies with or without instrumented fusion. Surgery resulted in significant improvement in outcome. There is need to improve therapeutic intervention especially for patient with MST with introduction of SSRS, MISS, and separation surgery as currently practised in many advanced centres.

Conflicts of interest

There are no conflicts of interest.

1 Kumar N Tan WLB Wei W Vellayappan BA An overview of the tumors affecting the spine-inside to out Neurooncol. Pract 2020 7 i10 7 33299569 10.1093/nop/npaa049 PMC7705529

2 Grimm S Chamberlain MC Adult primary spinal cord tumors Expert Rev Neurother 2009 9 1487 95 19831838 10.1586/ern.09.101

3 Santos Júnior EC Dantas F Caires ACV Cariri GA Reis MTD Botelho RV Evaluation of surgically treated primary spinal cord tumors in a single Brazilian Institution: A case series study of 104 patients Cureus 2022 14 e23408 35475084 10.7759/cureus.23408 PMC9023327

4 Kilinc F Setzer M Marquardt G Keil F Dubinski D Bruder M Functional outcome and morbidity after microsurgical resection of spinal meningiomas Neurosurg Focus 2021 50 E20 10.3171/2021.2.FOCUS201116 33932928

5 Barzilai O Fisher CG Bilsky MH State of the art treatment of spinal metastatic disease Neurosurgery 2018 82 757 69 29481645 10.1093/neuros/nyx567

6 Sciubba DM Petteys RJ Dekutoski MB Fisher CG Fehlings MG Ondra SL Diagnosis and management of metastatic spine disease. A review J Neurosurg Spine 2010 13 94 108 20594024 10.3171/2010.3.SPINE09202

7 Arora RK Kumar R Spinal tumors:Trends from Northern India Asian J Neurosurg 2015 10 291 7 26425159 10.4103/1793-5482.162707 PMC4558806

8 Chikani MC Messi M Okwunodulu O Mezue W Ohaegbulam S Ndubuisi C Pattern of presentation and surgical management of spine tumors in Southeast Nigeria over a 10-year period Niger J Clin Pract 2020 23 1167 71 32788497 10.4103/njcp.njcp_41_19

9 Adeolu AA Oyemolade TA Salami AA Adigun TA Malomo AO Akang EA Features and outcome of surgical management of spinal tumors in a cohort of Nigerian patients World Neurosurg 2015 84 1090 4 26074431 10.1016/j.wneu.2015.05.081

10 Oyemolade TA Balogun JA Badejo OA Malomo AO Shokunbi MT Idowu OK Clinical profile and outcome of surgical management of intramedullary spinal cord tumours: A single center study in a developing country World Neurosurg X 2023 20 100228 37456686 10.1016/j.wnsx.2023.100228 PMC10344788

11 Barzilai O Sahgal A Rhines LD Versteeg AL Sciubba DM Lazary A AO Spine Knowledge Forum Tumor Patient-reported and clinical outcomes of surgically treated patients with symptomatic spinal metastases: Results from epidemiology, process, and outcomes of spine oncology (EPOSO), a prospective, multi-institutional and International study Neurosurgery 2024 95 1148 57 38832791 10.1227/neu.0000000000002989 PMC11449425

12 Yoshihara H Yoneoka D Trends in the surgical treatment for spinal metastasis and the in-hospital patient outcomes in the United States from 2000 to 2009 Spine J 2014 14 1844 9 24291034 10.1016/j.spinee.2013.11.029

13 Bakar D Tanenbaum JE Phan K Alentado VJ Steinmetz MP Benzel EC Decompression surgery for spinal metastases: A systematic review Neurosurg Focus 2016 41 E2 10.3171/2016.6.FOCUS16166 27476844

14 Tomita K Kawahara N Kobayashi T Yoshida A Murakami H Akamaru T Surgical strategy for spinal metastases Spine 2001 26 298 306 11224867 10.1097/00007632-200102010-00016

15 Tokuhashi Y Matsuzaki H Oda H Oshima M Ryu J A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis Spine 2005 30 2186 91 16205345 10.1097/01.brs.0000180401.06919.a5

16 Dhamija B Batheja D Balain BS A systematic review of MIS and open decompression surgery for spinal metastases in the last two decades J Clin Orthopaedics Trauma 2021 22 101596 10.1016/j.jcot.2021.101596 PMC8488238 34631409

17 Echt M Stock A De la Garza Ramos R Der E Hamad M Holland R Separation surgery for metastatic epidural spinal cord compression: Comparison of a minimally invasive versus open approach Neurosurg Focus 2021 50 E10 10.3171/2021.2.FOCUS201124 33932918

18 Roberts TT Leonard GR Cepela DJ Classifications in brief: American Spinal Injury Association (ASIA) impairment scale Clin Orthop Relat Res 2017 475 1499 504 27815685 10.1007/s11999-016-5133-4 PMC5384910

19 Tsai CY Tsai TH Su YF Surgical treatment of intraspinal tumors in Southern Taiwan: The 30-year experience of a single institution J Clin Neurosci 2020 75 52 4 32241643 10.1016/j.jocn.2020.03.035

20 Aizenberg MR Fox BD Suki D McCutcheon IE Rao G Rhines LD Surgical management of unknown primary tumors metastatic to the spine J Neurosurg 2012 16 86 92 10.3171/2011.9.SPINE11422 21981272

21 Shu M Ke J The surgical management of osteoid osteoma: A systematic review Front Oncol 2022 12 933640 10.3389/fonc.2022.935640 PMC9355277 35936708

22 Yaari LS Novack L Shemesh S Sidon E Haviv B Sheinis D Patient outcomes and survival following surgery for spinal metastases J Spinal Cord Med 2021 44 204 11 31050608 10.1080/10790268.2019.1610602 PMC7952068

23 Yee TJ Saadeh YS Strong MJ Ward AL Elswick CM Srinivasan S Survival, fusion, and hardware failure after surgery for spinal metastatic disease J Neurosurg Spine 2021 34 665 72 33513569 10.3171/2020.8.SPINE201166