A Comparison of Laminectomy and Hemilaminectomy Approaches for Resection of Spinal Schwannomas and Meningiomas

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A Comparison of Laminectomy and Hemilaminectomy Approaches for Resection of Spinal Schwannomas and Meningiomas

https://doi.org/10.21203/rs.3.rs-4685546/v1

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Background: Spinal schwannomas and meningiomas are the most common spinal cord benign tumors in adults and total excision is the goal of the treatment. The traditional surgical approach is performed by total laminectomy, but recently unilateral hemilaminectomy has been recognized as a valuable surgical alternative.

We report the clinical results of patients affected by spinal schwannoma and meningioma in whom total laminectomy or unilateral hemilaminectomy were performed.

Material and Methods: A retrospective study of patients who underwent resection of spinal meningioma or schwannoma by laminectomy or unilateral hemilaminectomy approaches in our Institute from January 2013 to January 2023 was made. The baseline data of these patients, operative approach and postoperative outcome were compared.

Results: The study was performed on 41 patients with mean age of 62.5 ±14.6 years. Our series included 24 (59%) cases of schwannomas and 17 (41%) cases of meningiomas, with a prevalent location in the thoracic spine. The average schwannomas volume was 3,6 ±2,7 cm³, whereas the average meningiomas volume was 1.1 ±0.5 cm³. Total excision was achieved in all cases. Operative time of schwannomas was longer (p=0.001) respect to meningiomas with higher intra-operative blood loss (p=0.000). Total laminectomy approach was performed in 24 out of 41 patients (59%) and unilateral hemilaminectomy approach in 17 out of 41 (41%) patients. Unilateral hemilaminectomy was associated with shorter postoperative bed rest (p=0.003), shorter hospitalization (p=0.028) and lower postoperative pain (p=0.02) respect to total laminectomy.

Conclusions: Both spinal schwannomas and spinal meningiomas in various size can be safely and effectively treated with unilateral hemilaminectomy approach. This approach grants more advantages compared with standard total laminectomy, including shorter postoperative bed rest, shorter hospitalization and reduced postoperative pain.

spinal schwannomas

spinal meningiomas

laminectomy

hemilaminectomy

spinal intradural extramedullary tumors

Intradural extramedullary (IDEM) tumors account the 80% of all intraspinal tumors in adults. Schwannomas are the most common IDEM tumors (30% of cases), followed by meningiomas (25% of cases) (1). These tumors are benign lesions and gross total resection is the treatment of choice with an excellent functional outcome and very low recurrence rate (2,3,4,5,6,7).

The traditional surgical approach includes total laminectomy extending to levels above and below the tumour (8). This approach provides a wide working area, but it is associated with significant tissue trauma and postoperative pain, instability and/or deformity especially after multilevel laminectomy (9,10). Nowadays thanks to the concept of minimally invasive surgery, there is an increasing interest to reduce the amount of bone and ligament removal in spinal surgery especially for degenerative disease (11,12,13,14). Recently these techniques have been applied successfully in the treatment of spinal intradural tumors (15,16,17,18) but still today the best surgical approach is debated.

In this paper, we report the results of a surgical series of patients affected by spinal schwannomas and meningiomas who underwent surgical resection by laminectomy or hemilaminectomy comparing the clinical results between the two approaches.

We retrospectively reviewed our surgical series of consecutive patients with IDEM tumors who underwent surgical resection via total laminectomy or via unilateral hemilaminectomy in our Institute between January 2013 and January 2023. The diagnosis was obtained by contrast-enhanced magnetic resonance imaging (MR) and it was confirmed by histopathological examination.

Baseline medical data were collected. Clinical symptoms were reviewed using patients’ medical charts. Preoperative and postoperative neurological status were assessed by the American Spinal Injury Association (ASIA) Impairment Scale (19). All patients underwent spinal MR preoperatively and during follow up. Tumor size was measured on contrast-enhanced T1-weighted MR imaging using the widest diameter in three planes and tumor volume was calculated (ellipsoid methods volume= D1xD2xD3/2). Operative and perioperative details recorded included the extent of resection, operative time, amount of blood loss, need for transfusion, length of postoperative bed rest and hospitalization. We also collected 1-month postoperative back pain through Numeric Pain Rating Scale (NRS score) (20). Additionally, postoperative complications were recorded. All methods and procedures were carried out in accordance with current clinical guidelines and regulations. The study was conducted in accordance with the Declaration of Helsinki and Ethical approval was waived by our local ethics committee in view of the retrospective nature of the study and all the procedures being performed were part of the routine care. Informed consent was obtained before each surgical procedure from all subjects or their legal guardians.

Statistical analysis: Values are presented as mean ± standard deviation (SD) for continuous variables and as numbers and percentages for categorical variables. Student’s t test, Chi-squared test, Mann-Whitney test and binary logistic regression analysis were used, as appropriate. Results were considered statistically significant for p value ≤0.05. Statistical analysis was performed by the software package SPSS, version 25.0 (Chicago, IL, USA).

We included 41 consecutive patients affected by spinal schwannoma and meningioma who underwent surgical resection with a follow up of maximum 10 years and minimum 1 year. Our study population consisted of 17 males and 24 females with a mean age of 62.5±14.6 years (range from 33 to 87 years) (Table 1).

The clinical onset and the type of the tumors are reported in Table 1. In our surgical series of schwannomas, the average volume of schwannomas was 3,6 ±2,7 cm³, whereas the average volume of meningiomas was 1.1 ±0.5 cm³. We achieved the total excision in all patients. Compared with preoperative neurological dysfunction, after surgery there was a significant improvement in the neurological status (Table 1).

The total laminectomy was performed in 24 out of 41 patients (59%) while unilateral hemilaminectomy was performed in 17 out of 41 patients (41%) (Table 1); hemilaminectomy was performed in 13 patients out of 24 affected by schwannoma and 4 patients out of 17 affected by meningiomas (Table 2). In our surgical series, postoperative complications were observed in 9 (21.9%) patients out of 41 and included CSF leakage in 4 cases (9.7%) with the need of spinal drainage for 1 week, wound infection in 4 cases (9.7%) with healing after antibiotic therapy. We also reported epidural hematoma in one patients that required re-operation. No deaths were recorded in the series.

The operative time was longer for resection of schwannomas than for resection of meningiomas (209.6±79.0 vs 132.4±46.6 minutes, respectively; p=0.001), as well as the intraoperative blood loss was higher in the schwannoma group (1.6 vs 1.5 g/dl, respectively; p=0.000). We noticed no differences between the two groups of tumors regard to postoperative complications, hospital stay and postoperative length bed rest (Table 2). In our surgical series, compared to total laminectomy, unilateral hemilaminectomy was associated with shorter length bed rest (77.8±33.3 vs 46.5±27.3 hours, respectively; p=0.003) and so with shorter hospital stay (11.9±4.8 vs 8.9±2.9 days, respectively; p=0.028). At 1month-follow up, the means NRS score was 4.29±1.9 in the group of laminectomy and 2.8±1.8 in the group of unilateral hemilaminectomy (p=0.02). Operative time was comparable between the total laminectomy and the unilateral hemilaminectomy groups (170.7±70.0 vs 187.3±87.4 minutes, respectively; p=0.503).

We found no differences between the two approaches groups in the intraoperative blood loss and incidence of postoperative complications (Table 3).

Surgery is the first choice treatment for spinal schwannoma and meningioma. The surgical goals are gross total tumor resection and the maintenance or restore neurological functions. Laminectomy offers a large exposure of the dorsal surface of the spinal cord and nerve roots with wide working area. However, total laminectomy is associated with tissue trauma and high intraoperative blood loss, prolonged postoperative bed rest and hospitalization (16,21,22,23). According to the “three column” concept of the spine proposed by Denis in 1983 (24), the preservation of the integrity of the posterior column muscles and ligaments is of great importance for the spinal stability and the sagittal balance (23). The rationale for unilateral hemilaminectomy, which is less invasive, is to preserve the supraspinous and interspinous ligaments, the paravertebral muscle of one side and posterior bony elements as much as possible (25). For this reason, unilateral hemilaminectomy has more benefits with regard to postoperative spinal stability comparing with total laminectomy (18,26,27). Nowadays hemilaminectomy is widely used in spinal degenerative diseases but Yasargil et al, with their experience in microneurosurgery, recommended hemilaminectomy for nearly any type of intradural tumors (29). Literature documents that this technique is associated with reduced postoperative pain, low intraoperative blood loss, earlier mobilization and shorter hospital stays (17,25,26,28). Furthermore several studies (15,16,17,18,26,27,28) reported that hemilaminectomy could be applied to spinal tumors without significant adverse effects and that it was even considered superior to the laminectomy in intradural extramedullary tumors. Some Authors have demonstrated that hemilaminectomy could also performed for the resection of partial intramedullary tumors with favourable results (29,30,31). Sun et al described a potential application of the hemilaminectomy in all lateral intradural lesions, whether located ventrally or laterally (32).

In our retrospective analysis, 24 spinal schwannomas with average tumor volume of 3,6 ±2,7 cm³ and 4 meningiomas with average tumor volume of 1,1 ±0,5 cm³ were totally resected by unilateral hemilaminectomy with favourable outcomes. Compared to total laminectomy, we documented that unilateral hemilaminectomy had shorter hospital stays, reduced length of postoperative bed rest and less postoperative pain with statistically significance. Our results, in line with the results of previous studies (16,17,18,25,26,27,28,31,32,33,34), demonstrated that this approach is useful and safe also for the resection of large spinal meningioma and schwannoma. In our series schwannomas had wider volume than meningiomas. This was due to the location of all meningiomas in the dorsal region where the diameter of the spinal canal is narrow respect to the lumbar spine. For this reason, meningiomas were diagnosed early respect to schwannomas, that was localized more frequently in the lumbar spine in a wide spinal canal. One possible disadvantage of unilateral hemilaminectomy for large tumors is the narrow surgical corridor formed by the spinous processes and ipsilateral facet joint with risks of dural and nerve root damage or incomplete tumor removal. However, in our experience and in accordance with some Authors (16,18,26,27,28,29,33,34), partial facetectomy, undercutt of the spinous process base, oblique tilting of the operating table and ipsilateral dural flap fixed to the muscle or fascia near the facet joint allow to visualize controlateral side of the spinal cord and to remove completely the tumor.

With this approach we create a wide working corridor for the total excision of the tumor, even large ones, with the assistence of the microscope.

Recently, Alvarez-Crespo et al reported that the average operative time for resection of spinal schwannomas was 293 minutes with the average intraoperative blood loss of 451.88 ml (35). In our surgical series, the operative time was 209.6±79 minutes with less intraoperative blood loss of 160 ml.

In this study we found that unilateral hemilaminectomy approach had at least equivalent or longer operative time compared to total laminectomy but may depends on neurosurgeons’ skill. Therefore, we suggest that unilateral hemilaminectomy should be used as a suitable option in spinal meningiomas and schwannomas removal, since one of the major benefit of this approach is the control of intraoperative blood loss that in case of schwannomas is mandatory.

The limitations of this study is the retrospective analysis and the small number of patients with the need of further studies.

Our study documents that unilateral hemilaminectomy approach for the resection of spinal schwannoma and meningioma offers several advantages compared to standard total laminectomy, including shorter postoperative bed rest, shorter hospital stays and less postoperative pain, allowing adequate vision of the surgical area and control of intra-operative bleeding. It is mandatory that neurosurgeon have adequate experience with unilateral hemilaminectomy approach in order to totally remove these tumoral lesions without injury of the spinal cord and nerve roots. More extensive randomized and prospective trials are necessary to elucidate the role of unilateral hemilaminectomy in the surgical management of spinal tumors.

Data Statement: The datasets used and analysed during the current study available from the corresponding author on reasonable request.

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Table 1 General characteristics of patients

Characteristics	Patients (n=41)
Sex male (n,%) female (n,%)	17 (41) 24 (59)
Age (years, mean±DS°)	62.5±14.6
Clinical signs pain (n,%) sensory deficit (n,%) motor deficit (n,%) bowel/urinary dysfunction (n,%)	22 (53.6) 18 (44.0) 11 (26.8) 3 (7.3)
Preoperative ASIA score * A (n,%) B (n,%) C (n,%) D (n,%) E (n,%)	- 1 (2.4) 12 (29.3) 26 (63.4) 2 (49)
Postoperative ASIA score * A (n,%) B (n,%) C (n,%) D (n,%) E (n,%)	- - 1 (2.4) 17 (41.5) 23 (56.1)
Type of Tumor schwannoma (n,%) meningioma (n,%)	24 (59) 17 (41)
Surgery Total laminectomy (n,%) Unilateral hemilaminectomy (n,%)	24 (59) 17 (41)

°DS: standard deviation

*ASIA score: American Spinal Injury Association Impairment Scale

Table 2 Characteristics of patients according to pathology

Characteristics	Meningiomas (n=17)	Schwannomas (n=24)	P value*
Tumor volume (cm³, mean ±DS°)	1.1±0.5	3.6±2.7	-
Type of surgery Total laminectomy (n,%) Unilateral hemilaminectomy (n,%)	13 (54.2) 4 (23.5)	11 (45.8) 13 (76.5)	-
Site of surgery cervical (n,%) thoracic (n,%) lumbar (n,%)	- 17 (100) -	4 (16.7) 11 (45.8) 9 (35.5)	-
Operative time (minutes, mean ±DS°)	132.4±46.6	209.6±79.0	*0.001*
Intraoperative blood loss (g/dl)	1.5	1.6	*0.000*
Bed rest time (hours, mean ±DS°)	59.1±25.4	68.9±39.5	0.372
Hospital stays time (days, mean ±DS°)	9.6±3.8	11.4±4.7	0.20
Postoperative complications wound infection (n,%) CSF leakage (n,%) Epidural bleeding (n,%)	3 (17.6) 2 (11.8) 1 (5.9)	1 (4.1) 2 (8.3) -	-

°DS: standard deviation

*P value significant ≤ 0.05

Table 3 Characteristics of patients according to surgical approach

Characteristics	Laminectomy (n=24)	Hemilaminectomy (n=17)	P value*
Site of surgery cervical (n,%) thoracic (n,%) lumbar (n,%)	1 (4.2) 20 (83.3) 3 (12.5)	3 (17.6) 8 (47.1) 6 (35.3)	- - -
Operative time (minutes, mean ±DS°)	170.7±70.0	187.3±87.4	0.503
Intraoperative blood loss (g/dl)	1.6	1.6	0.051
Bed rest time (hours, mean ±DS°)	77.8±33.3	46.5±27.3	*0.003*
Hospital stays time (days, mean ±DS°)	11.9±4.8	8.9±2.9	*0.028*
Postoperative complications wound infection (n,%) CSF leakage (n,%) Epidural bleeding (n,%)	2 (8.3) 4 (16.7) 1 (8.3)	2 (11.7) - -	0.725
1-month follow up NRS score ^§ (mean±DS°)	4.29±1.9	2.8±1.8	*0.02*

°DS: standard deviation

*P value significant ≤ 0.05

^§NRS score: Numeric Pain Rating Scale

No competing interests reported.

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A Comparison of Laminectomy and Hemilaminectomy Approaches for Resection of Spinal Schwannomas and Meningiomas

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