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Fluorescence-guided resection of intradural spinal tumors: a systematic review and meta-analysis
Ibrahem Albalkhi1,2, Areez Shafqat1, Othman Bin-Alamer3
1College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
Abstract:
Intradural spinal tumors present significant challenges due to involvement of critical motor and sensory tracts. Achieving maximal resection while preserving functional tissue is therefore crucial. Fluorescence-guided surgery aims to improve resection accuracy and is well studied for brain tumors, but its efficacy has not been fully assessed for spinal tumors. This meta-analysis aims to delineate the efficacy of fluorescence guidance in intradural spinal tumor resection. The authors performed a systematic review in four databases. We included studies that have utilized fluorescence agents, 5-aminolevulinic acid (5-ALA) or sodium fluorescein, for the resection of intradural spinal tumors. A meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A total of 12 studies involving 552 patients undergoing fluorescence-guided intradural spinal tumor resection were included. Meningiomas demonstrated a 98% fluorescence rate and were associated with a homogenous florescence pattern; however, astrocytomas had variable fluorescence rate with pooled proportion of 70%. There was no significant difference in gross total resection (GTR) rates between fluorescein and 5-ALA (94% vs 84%, p = .22). Pre-operative contrast enhancement was significantly associated with intraoperative fluorescence with fluorescein. Intramedullary tumors with positive intraoperative fluorescence were significantly associated with higher GTR rates (96% vs 73%, p = .03). Utilizing fluorescence guidance during intradural spinal tumor resection holds promise of improving intraoperative visualization for specific intradural spinal tumors. Meningiomas and ependymomas have the highest fluorescence rates especially with sodium fluorescein; on the other hand, astrocytomas have variable fluorescence rates with no superiority of either agent. Positive fluorescence of intramedullary tumors is associated with a higher degree of resection.
Insights
Fluorescence guidance improves visualization during spinal tumor surgery, particularly for meningiomas and ependymomas. Positive intraoperative fluorescence in intramedullary tumors correlates with higher gross total resection rates.
Area of Science:
- Neurosurgery
- Oncology
- Medical Imaging
Background:
- Intradural spinal tumors pose surgical challenges due to proximity to critical neural structures.
- Maximal tumor resection while preserving neurological function is paramount.
- Fluorescence-guided surgery (FGS) is established for brain tumors but less so for spinal tumors.
Approach:
- Systematic review and meta-analysis of 12 studies (552 patients) on FGS for intradural spinal tumors.
- Included studies utilized 5-aminolevulinic acid (5-ALA) or sodium fluorescein.
- Analysis followed PRISMA guidelines.
Key Points:
- Meningiomas showed a 98% fluorescence rate; astrocytomas had a 70% variable rate.
- No significant difference in gross total resection (GTR) rates between fluorescein and 5-ALA (94% vs 84%).
- Positive intraoperative fluorescence in intramedullary tumors was linked to higher GTR rates (96% vs 73%).
Conclusions:
- FGS enhances intraoperative visualization for select intradural spinal tumors.
- Meningiomas and ependymomas exhibit high fluorescence rates, especially with sodium fluorescein.
- Positive fluorescence in intramedullary tumors is associated with improved resection extent.
