J. Neurosurg Spine / Volume 2 / March, 2005 249 NTRAMEDULLARY spinal cord tumors are relatively rare neoplasms, accounting for only 2 to 4% of central ner- vous system glial tumors. 3,6,16,17,24 Intramedullary spinal cord tumors are less common in adults than in children 10 (20% of all intraspinal neoplasms in the former and 35% in the latter). 5,11,31,36 The optimal treatment of these lesions has been controversial in both populations. 3,44,46 Historically tra- ditional management has indicated (and continues to indi- cate) the following optimal treatment: 1) examination of a biopsy specimen; 2) dural decompression; and 3) radiation therapy. 15,19,33,37,41,42 The problem with the traditional man- agement paradigm has been that the lesions eventually pro- gress neurologically, with patients becoming disabled, suf- fering significant morbidities, and ultimately dying. 6,24,28,46 This traditional management paradigm is further confound- ed in elderly patients 47 in whom too often conservative management without definitive treatment is recommended, especially if there is already evidence of neurological dete- rioration. 19 The belief that the older-age patients suffer more postoperative deficits has led some clinicians to defer radical IMSCT resection. Our protocol, as originally ad- vanced by the senior author (F.J.E.) in 1980, has involved aggressive intraoperative neurophysiological monitoring– guided excision with attempted GTR. 6,7,10,11,21,22 Most IMSCTs are low-grade lesions for which resection can pro- vide a cure without the need for postoperative radio- or chemotherapy (and its associated morbidities, especially in the elderly). We initiated this study to investigate the role of aggressive resection in the older adult population ( 50 years of age) to assess neurological performance and long- term functional outcome. We report long-term outcome in this first large series of IMSCTs in adult patients older than 50 years of age. J Neurosurg Spine 2:249–255, 2005 Intramedullary spinal cord tumors in patients older than 50 years of age: management and outcome analysis RAJ K. SHRIVASTAVA, M.D., FRED J. EPSTEIN, M.D., NOEL I. PERIN, M.D., F.R.C.S., KALMON D. POST , M.D., AND GEORGE I. JALLO, M.D. Department of Neurosurgery, St. Luke’s Roosevelt Hospital Center; Institute of Neurosurgery and Neurology, Beth Israel Medical Center; Department of Neurosurgery, Mount Sinai Medical Center, New York, New York; and Division of Pediatric Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland Object. Intramedullary spinal cord tumors (IMSCTs) in the older-age adult population pose complex management issues regarding the extent of resection and functional outcome, especially in terms of quality of life. Historically, IMSCTs in the older adult population were treated with irradiation alone because it was assumed that functional recovery would be poor. The authors examined their IMSCT database and report the first large series of IMSCTs in patients older than 50 years of age. Methods. In this retrospective clinical and chart review there were 30 cases meeting inclusion criteria drawn from data- bases at three different institutions. A modified McCormick Scale was used to assess functional levels in all 30 patients pre- and postoperatively. The mean age of patients in this cohort was 59.8 years (range 50–78 years), and the mean fol- low-up period was 10.6 years (range 2–16 years). Ependymoma was the most common tumor (83%), and 55% were located in the thoracic spine. The most common pre- senting symptom was sensory dysesthesia, with rare motor loss. The prodromal period to treatment was 19.4 months. Based on the McCormick Scale score at last follow-up examination 67% of patients were clinically functionally the same, 9% were worse, and 24% were improved after surgery. There were two deaths due tumor progression (both malignant tumors) and one recurrence (anaplastic astrocytoma). All three patients in whom malignant astrocytomas were diagnosed underwent postoperative radiation therapy. Conclusions. In the population of patients older than age 50 years, thoracic ependymomas are the most common IMSCTs that present characteristically with sensory symptoms. The longer prodromal period in the older adult population may reflect the fact that their diagnosis and workup is inadequate. There was no significant increase in the length of stay in the neurosurgical ward. The authors recommend motor evoked potential–guided aggressive microsurgical resection, because the long-term outcome of benign lesions is excellent (good functional recovery and no tumor recurrence). KEY WORDS • astrocytoma • ependymoma • intramedullary • outcome • spinal cord I Abbreviations used in this paper: AA = anaplastic astrocytoma; GBM = glioblastoma multiforme; GTR = gross-total resection; MEP = motor evoked potential; IMSCT = intramedullary spinal cord tumor; LOS = length of stay; MR = magnetic resonance; PFS = progression-free survival; STR = subtotal resection.