Asian Spine Journal

Asian Spine Journal

Clinical Study Walking
Asian Spine Ability after Spinal
J 2023;17(2):355-364 Cord Tumor Resection 355
• https://doi.org/10.31616/asj.2022.0068

Early Phase Functional Recovery after Spinal

Intramedullary Tumor Resection Could Predict
Ambulatory Capacity at 1 Year after Surgery
Tetsuya Suzuki1, Osahiko Tsuji2, Masahiko Ichikawa1, Ryota Ishii3,
Narihito Nagoshi2, Michiyuki Kawakami1, Kota Watanabe2, Morio Matsumoto2,
Tetsuya Tsuji1, Toshiyuki Fujiwara4, Masaya Nakamura2
1
Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
2
Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
3
Department of Biostatistics, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
4
Department of Rehabilitation Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan

Study Design: This is a single-center retrospective cohort study with a university hospital setting.
Purpose: This study aims to evaluate the short-term course of physical function and walking ability after intramedullary spinal cord
tumor (ISCT) resection and predict walking independence 1 year after surgery.
Overview of Literature: Although several reports have shown the postoperative functional prognosis of spinal intramedullary tu-
mors with long-term follow-up, no reports have identified the predictors associated with the functional outcome at an early stage.
Methods: A total of 79 individuals who underwent ISCT resection at our institute between 2014 and 2019 were enrolled in the study,
whose preoperative walking state was independent ambulator regardless of cane support with the Functional Independence Measure
Locomotor Scale (FIM-L) score of ≥6. The FIM-L, the American Spinal Injury Association (ASIA) motor and sensory scores in the lower
extremities, and the Walking Index for Spinal Cord Injury II (WISCI II) were assessed for walking independence, lower-limb function,
and walking ability, respectively. These evaluations were performed at 4 time points: preoperatively, 1 week (1W), 2 weeks (2W), and
1 year after surgery.
Results: In the early phase after surgery, 71% and 43% of the participants were nonindependent ambulators at 1W and 2W, respec-
tively. Histopathology indicated that patients with solid tumors (ependymoma, astrocytoma, or lipoma) showed significantly lower
indices at 1W and 2W than those with vascular tumors (hemangioblastoma or cavernous hemangioma). Regarding tumor location,
thoracic cases exhibited poorer lower-limb function at 1W and 2W and poorer walking ability at 2W than cervical cases. According to
the receiver operating characteristic (ROC) analysis, 2 WISCI II points at 2W had the highest sensitivity (100%) and specificity (92.2%)
in predicting the level of walking independence at 1 year postoperatively (the area under the ROC curve was 0.99 (95% confidence
interval, 0.93–1.00).
Conclusions: The higher the lower-limb function scores in the early phase, the better the improvement in walking ability is predicted
1 year after ISCT resection.

Keywords: Intramedullary spinal cord neoplasms; Rehabilitation outcome; Ambulation; Prognosis

Received Feb 17, 2022; Revised May 4, 2022; Accepted May 31, 2022
Corresponding author: Osahiko Tsuji
Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
Tel: +81-3-5363-3812, Fax: +81-3-3353-6597, E-mail: [email protected]

ASJ
Copyright Ⓒ 2023 by Korean Society of Spine Surgery
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Asian Spine Journal • pISSN 1976-1902 eISSN 1976-7846 • www.asianspinejournal.org
 356 Tetsuya Suzuki et al. Asian Spine J 2023;17(2):355-364

Introduction reviewed. The clinical data for each patient was collected
through medical records in accordance with the institu-
Primary spinal cord tumors are among the rarest, ac- tion’s ethical guidelines. Among these cases, 161 patients
counting for about 2%–4%, tumors originating from the presented with cervical and thoracic ISCTs. All surgeries
central nervous system [1,2]. Among them, intramedul- for ISCT resection were performed via posterior approach
lary spinal cord tumors (ISCTs) have a low incidence of microscopically by the same skilled surgical team under
5%–15% of all spinal cord tumors. The majority (70%– general anesthesia with neuromonitoring. Exclusion crite-
85%) are gliomas, i.e., ependymomas and astrocytomas, ria included preoperative gait disorder (Functional Inde-
with a higher frequency of ependymomas in adults and, pendence Measure Locomotor Scale (FIM-L) score of 5 or
conversely, astrocytomas in children [3,4]. Other histo- less [11]), a history of brain disease or lower-limb injury,
logical tumors include hemangioblastoma and cavernous and postoperative complications that delayed the start of
hemangioma. There are risks of functional deterioration rehabilitation. The reason for excluding nonindependent
involved in surgical treatment for ISCT [5]. To mitigate preoperative ambulators was that preoperative physi-
the risk of postoperative neurological deterioration, earli- cal function had been reported to affect postoperative
er surgery before developing severe myelopathy is deemed function [7,8,12,13]. This study focused on the course of
necessary [6,7]. The objective of the surgery is to prevent physical function and walking ability after surgery and the
paralysis from worsening rather than improving it. effects of rehabilitation in independent preoperative am-
Several reports have examined the postoperative bulators. Consequently, 79 total independent ambulatory
functional prognosis of ISCTs [7-10]. However, they are preoperative cases (44 males and 35 females) were eligible
mainly long-term longitudinal studies, and the timing of for a series of follow-up and neurological examination for
functional evaluation is not constant. No reports have ex- 1 year postoperatively. The mean age was 46.8±16.2 years
amined the short-term course of physical function in the (range, 11–81 years) (Table 1).
early postoperative period. In recent years, the length of
stay in acute care hospitals has decreased. The hospitaliza- 2. Postoperative physical therapy program
tion period after ISCT surgery is also short (2–3 weeks).
Therefore, identifying the predictors associated with the On the first day after surgery, the bed angle was up to
functional outcome at an early stage is necessary. Physical 30°. The bed angle was then limited to 60° on the second
function and walking ability are particularly important postoperative day, and the wheelchair transfer began on
focal points for this. This study aimed to examine the the fourth postoperative day. To prevent rupture of the
short-term course of physical function and walking ability sutured dura and arachnoid maters, our standard postop-
in patients with ISCTs in the early postoperative period, erative course after spinal cord tumor resection is to grad-
which could predict the ambulatory state 1 year after sur- ually stand for 4 days instead of leaving the bed immedi-
gery and would be helpful for planning the postoperative ately. The practice in the rehabilitation room began 1 week
rehabilitation program with a long-term perspective. after surgery. Physical therapy in the rehabilitation room
consisted of range-of-motion exercises, muscle strength-
Materials and Methods ening, basic movement exercises, walking exercises, and
endurance training according to each patient. Treatment
1. Subjects frequency was 20–40 minutes a day, 5 days a week.

This study was approved by the Ethics Committee of 3. Outcome measures

the Keio University School of Medicine (approval no.,
20110142). We obtained written informed consent for the Postoperative functional status at 1 and 2 postoperative
use of patient data from each patient or their guardian, weeks was evaluated using the following measurements:
according to the hospital’s ethics guidelines. the American Spinal Injury Association (ASIA) lower
Approximately 432 consecutive patients who under- extremity motor score (ASIA-LEMS) [14] was used for
went spinal cord tumor resection surgery at Keio Univer- lower-limb motor function, the ASIA lower extremity sen-
sity Hospital between 2014 and 2019 were retrospectively sory score (ASIA-LESS) [14] below the L1 level for lower-
 Asian Spine Journal Walking Ability after Spinal Cord Tumor Resection 357

limb sensory function, the Walking Index for Spinal Cord Whitney U test was performed to compare them between
Injury II (WISCI II) [15] for walking ability, and the FIM- subjects. Fisher’s exact test was performed for walking
L score for walking independence [11]. WISCI II was de- independence at 2 weeks postoperatively. A univariate
veloped for patients with incomplete spinal cord injuries logistic regression was performed to predict walking in-
[16] and evaluated walking function on a 21-point scale dependence (independent ambulators defined as FIM-L
based on walking aids, orthotics, and physical assistance. score of ≥6) at 1 year postoperatively from the WISCI II
However, the definition of the grading of physical assis- score at 2 weeks after surgery. The optimal cutoff value of
tance is unclear. This is the part where those who do not the WISCI II score was calculated based on the Youden’s
need a walking aid but need physical assistance are rated index of the ROC curve. Then, the sensitivity and specific-
higher than those who need a walking aid but do not need ity were calculated using the optimal cutoff value. For sta-
physical assistance. Ditunno et al. [17] stated that WISCI tistical analysis, IBM SPSS ver. 25.0 (IBM Corp., Armonk,
II scores should not be dichotomized into dependent and NY, USA) was used, and the significance level was set at
independent levels of physical assistance. Therefore, to as- 5%.
sess for physical assistance for walking, FIM-L was used.
The FIM-L score is assigned on a 7-point scale based on Results
walking assistance: 1, full assistance; 2, maximum assis-
tance; 3, moderate assistance; 4, minimum assistance; 5, 1. Preoperative demographic data
monitoring; 6, modified independence (with equipment);
and 7, independence without equipment. In this study, an The baseline demographics of the 79 subjects who under-
independent ambulator was defined as FIM-L score of ≥6 went spinal ISCT resection surgery are summarized in
and nonindependent as FIM-L score of <5. Table 1. The study participants included those who walked
First, the above indices collected 1 and 2 weeks after independently before the surgery. Therefore, all of the
surgery were compared between independent and non- study participants had an FIM-L of at least 6 points and a
independent ambulators, whose walking ability was evalu- WISCI II of at least 19 points. The median score of ASIA-
ated 1 year postoperatively. Moreover, the above indices LEMS was 50 out of 50. The median score on ASIA-LESS
were compared using tumor histology and localization was 33 out of 36. Regarding tumor histology, 46 cases had
(cervical or thoracic spinal cord). For the grouping of solid tumors (43 gliomas and three lipomas), and 33 had
tumor histology, ependymoma, astrocytoma, and lipoma vascular tumors (23 cavernous hemangiomas and 10 he-
were classified as solid tumor group, and hemangioblas- mangioblastomas) (Table 2).
toma and cavernous hemangioma were classified as vas-
cular tumor group. We examined changes in walking abil-
Table 1. Preoperative characteristics of all participants
ity from 2 weeks to 1 year postoperatively in 78 patients
Characteristic Value
who could be assessed with FIM-L and WISCI II at 1 year
postoperatively. Then, the cutoff value for the discrimina- Age (yr) 46.8±16.2

tion of walking independence at 1 year postoperatively Sex

was calculated using the receiver operating characteristic Male 44
(ROC) curve from the WISCI II score at 2 weeks postop- Female 35
eratively. Height (cm) 163.7±8.9
Body weight (kg) 62.0±13.3
4. Statistical analysis ASIA-LEMS 50 (48–50)
ASIA-LESS 33 (27–36)
The normality of all data was confirmed using the his- FIM-L 7 (7–7)
togram. The clinical course of all subjects was analyzed, WISCI II 20 (20–20)
and the results were compared according to walking in- Values are presented as mean±standard deviation or median (first quartile–
dependence, tumor histology, and tumor location. The third quartile).
Wilcoxon signed rank test was performed to compare ASIA, American Spinal Injury Association; LEMS, lower extremity motor score;
LESS, lower extremity sensory score; FIM-L, Functional Independence Measure
continuous variables within a subject, while the Mann- Locomotor Scale; WISCI II, Walking Index for Spinal Cord Injury II.
 358 Tetsuya Suzuki et al. Asian Spine J 2023;17(2):355-364

Table 2. Histopathology and spinal location of tumor 2. ‌Walking independence and physical functions at 1
Histopathology Cervical Thoracic and 2 weeks after tumor resection
Solid tumor
Glioma 22 21
Fig. 1A–C shows the results for all participants at 1–2
weeks postoperatively. The percentage of nonindependent
Lipoma 0 3
ambulators decreased from 71% to 43% at 1–2 weeks
Vascular tumor
postoperatively. During this observation period, a sig-
Cavernous hemangioma 14 9
nificant improvement in lower-limb motor function was
Hemangioblastoma 4 6
observed, but no significant change was found in sensory
function. Then, the independent and nonindependent
ambulator groups 2 weeks after surgery were compared.
Table 3 demonstrated that independent ambulators 2

**p <0.001 **p <0.001 p =0.577

20 20 50 50
48
100
40 93 92
15
80
13 30
10 60
20
40
5
10 20
A 0 B 0 C 0
1 Week 2 Weeks 1 Week 2 Weeks 1 Week 2 Weeks

*p =0.029 p =0.101 *p= 0.002

20 50
48 50
17 100
40 92 99
15
80
30
10 60
8 20
40
5
10 20
D 0 E 0
F 0
Solid Vascular Solid Vascular Solid Vascular

*p =0.013 p =0.061 *p= 0.002

20 50
19 20 50 50
100 95
15 40 91
80
30
10 60
20
40
5
10 20
G 0 H 0 I 0
Solid Vascular Solid Vascular Solid Vascular
Fig. 1. Changes of Walking Index for Spinal Cord Injury II (WISCI II) and American Spinal Injury Association (ASIA)-lower extremity motor score (LEMS) and lower
extremity sensory score (LESS). (A–C) Results of all subjects. Comparison of solid and vascular tumor groups at 1 week (D–F) and 2 weeks (G–I) postoperatively.
*p <0.05. **p <0.01.
 Asian Spine Journal Walking Ability after Spinal Cord Tumor Resection 359

Table 3. Comparison of the independent walking group and non-independent walking group

Variables at 1 week after surgery Independent at 2 weeks (n=45) Non-independent at 2 weeks (n=34) p -valuea)

ASIA-LEMS 50 (46–50) 45 (30–49) <0.001

ASIA-LESS 27 (18–35) 18 (18–26) <0.001
WISCI II 19 (13–20) 3 (0–8) <0.001
Values are presented as median (first quartile–third quartile).
ASIA, American Spinal Injury Association; LEMS, lower extremity motor score; LESS, lower extremity sensory score; WISCI II, Walking Index for Spinal Cord Injury II.
a)
By Mann-Whitney U test.

Table 4. Comparison of solid tumor histological types and locations: results of Table 5. Comparison of solid tumor histological types and locations: compari-
solid and vascular tumor groups son of cervical and thoracic groups

Solid tumor (n=46) Vascular tumor (n=33) p -valuea) Cervical (n=40) Thoracic (n=39) p -valuea)

1 Week after surgery 1 Week after surgery

ASIA-LEMS 48 (39–50) 50 (45–50) 0.101 ASIA-LEMS 50 (45–50) 44 (36–50) 0.001
ASIA-LESS 18 (18–24) 28 (18–36) 0.002 ASIA-LESS 21 (18–36) 20 (18–28) 0.174
WISCI II 8 (0–18) 17 (8–20) 0.029 WISCI II 13 (8–20) 8 (1–19) 0.220
2 Weeks after surgery 2 Weeks after surgery
ASIA-LEMS 50 (41–50) 50 (49–50) 0.061 ASIA-LEMS 50 (46–50) 48 (39–50) <0.001
ASIA-LESS 18 (18–24) 28 (18–36) 0.002 ASIA-LESS 21 (18–36) 20 (18–28) 0.177
WISCI II 19 (10–20) 20 (19–20) 0.013 WISCI II 20 (19–20) 19 (10–20) 0.033
Values are presented as median (first quartile–third quartile). Values are presented as median (first quartile–third quartile).
ASIA, American Spinal Injury Association; LEMS, lower extremity motor score; ASIA, American Spinal Injury Association; LEMS, lower extremity motor score;
LESS, lower extremity sensory score; WISCI II, Walking Index for Spinal Cord LESS, lower extremity sensory score; WISCI II, Walking Index for Spinal Cord
Injury II. Injury II.
a) a)
By Mann-Whitney U test. By Mann-Whitney U test.

weeks after surgery showed significantly better lower- weeks postoperatively (Fig. 1D–I).
limb and sensory functions evaluated by ASIA-LEMS and
ASIA-LESS scores at 1 week after surgery than those non- 4. ‌Differences in postoperative physical function scores
independent ambulators. At 1 week after surgery, 63% of by tumor location
the nonindependent ambulator group could not walk or
could walk only with parallel bars (WISCI II score: 0–4). The comparison was conducted focusing on tumor loca-
Conversely, all patients in the independent ambulator tion, cervical or thoracic (Table 5, Supplement 2, Fig. 2).
group started walking with a walker or a cane (WISCI II Cases with thoracic tumors were found to have signifi-
score of 8 or higher). cantly lower-limb function than those with cervical tumors
1 week after surgery. However, no statistically significant
3. ‌Differences in postoperative physical function scores differences were found in walking ability and sensory func-
by tumor histopathology tion between the cervical and thoracic locations (Fig. 2A–
C). At 2 weeks postoperatively, cases with thoracic tumor
Differences in postoperative walking ability, lower ex- showed significantly lower walking ability and lower-limb
tremity motor function, and sensory function by tumor function, except sensory function (Fig. 2D–F).
histopathology are shown in Table 4 (Supplement 1) and
Fig. 1D–I. Those with solid tumors exhibited significantly 5. ‌Changes in walking ability from 2 weeks to 1 year af-
lower walking ability and sensory function than those ter surgery
with vascular tumors, but no statistically significant dif-
ference was observed in lower-limb function at 1 and 2 Finally, the transition of walking ability has been evalu-
 360 Tetsuya Suzuki et al. Asian Spine J 2023;17(2):355-364

p =0.220 **p =0.001 p= 0.174

20 50
50 44 100
94
40 90
15 80
13 30
10 60
8 20
40
5
10 20
A B C
0 0 0
Cervical Thoracic Cervical Thoracic Cervical Thoracic

*p =0.033 **p =0.001 p= 0.177

20 20 50 50
19
48 100
40 89 94
15 80
30
10 60
20
40
5
10 20

D 0 E 0 F 0
Cervical Thoracic Cervical Thoracic Cervical Thoracic
Fig. 2. Comparison of cervical and thoracic tumor groups at 1 week (A-C) and 2 weeks (D-F) postoperatively. WISCI II, Walking Index for Spinal Cord Injury II; ASIA,
American Spinal Injury Association; LEMS, lower extremity motor score; LESS, lower extremity sensory score. *p <0.05. **p <0.01.

78
20

15
WISCI II

10

A 0 B 0
2 Weeks 1 Year 2 Weeks 1 Year

Fig. 3. Walking ability at 2 weeks and 1 year postoperatively. (A) Changes in walking independence. (B) Walking Index for Spinal Cord Injury II (WISCI II) from 2 weeks
to 1 year.

ated among 78 individuals who were evaluated by FIM-L assistance or walking aid (WISCI II: 6–19), and nine pa-
and WISCI II, and who were followed 1 year after surgery tients had difficulty walking or walked with parallel bars
(Fig. 3). Fig. 3A shows the results at 2 weeks and 1 year (WISCI II: 0–2). All 27 patients who needed walking aid
follow-up. Nonindependent ambulators decreased from or assistance at 2 weeks after surgery recovered as inde-
43% to 10% at 2 weeks and 1 year postoperatively. Fig. 3B pendent ambulators (walking without a cane or without
shows the change in WISCI II scores from 2 weeks to 1 assistance with a cane or brace) 1 year after surgery. Of
year postoperatively. At 2 weeks after surgery, 42 patients the nine patients with a WISCI II score of 0–2 at 2 weeks
walked without a cane (WISCI II: 20), 27 patients required after surgery, one recovered to walk without a cane (WISCI
 Asian Spine Journal Walking Ability after Spinal Cord Tumor Resection 361

Table 6. WISCI II cutoff value to determine whether a person can walk inde- year postoperatively (Table 6). Therefore, an earlier start
pendently or not
of postoperative rehabilitation for ISCTs is considered
WISCI II Independent Non-independent Total necessary to strengthen lower-limb muscles and practice
≤2 2 8 10 repetitive movements considering sensory disturbance to
>2 69 0 69 improve walking ability.
Total 71 8 79 Regarding the difference in surgical outcomes by tumor
WISCI II, Walking Index for Spinal Cord Injury II. histopathology, those with solid tumors (ependymoma,
astrocytoma, or lipoma) were found to have lower walk-
ing ability and sensory function at 1 and 2 weeks after the
II: 20), one used a cane and no assistance (WISCI II: 19), surgery than those with vascular tumors (hemangioblas-
five used walking aids or assistance (WISCI II: 6–14), one toma or cavernoma). A smaller population of people with
remained with difficulty walking (WISCI II: 0), and one solid tumors could recover to walk independently at 2
had difficulty walking (WISCI II: 2–0) after reoperation weeks postoperatively. Differences in tumor histopathol-
due to recurrence at 1 year after surgery. The cutoff value ogy could determine the surgical approach, especially for
of the WISICI II score at 2 weeks postoperatively was myelotomy procedures. Vascular-type ISCTs, consisting
derived using the ROC analysis to determine the level of of hemangioblastoma and cavernoma, typically exhibited
walking independence at 1 year postoperatively. The op- lateral deviation on axial magnetic resonance imaging
timal cutoff value of the WISICI II score at 2 weeks post- images and/or trans-pial exophytic appearance on the mi-
operatively was 2 points to predict walking independence croscope and forced the surgeons to perform myelotomy
at 1 year postoperatively according to the Youden index from the dorsal root entry zone or direct trans-pial my-
(Table 6, Supplement 3). The area under the curve was 0.99 elotomy [18,19]. However, ependymomas, accounting
(95% confidence interval, 0.99–1.00), and the sensitivity for the majority (63%) of the solid tumor group, typically
and specificity with optimal cutoff value were 100.0% and occupy a central location within the spinal cord [20]. In
97.2%, respectively. other words, vascular tumors are more likely to be pres-
ent on the spinal surface, which might contribute to the
Discussion achievement of less invasive myelotomy maneuvers dur-
ing tumor dissection and removal; those with vascular tu-
In this study, the postoperative functional status in the mors showed milder postoperative functional impairment
early phase (1 and 2 weeks postoperatively) was evalu- than those with solid tumors. The solid tumor group did
ated using the FIM-L score (walking independence), the not differ from the vascular tumor group in lower-limb
WISCI II score (walking ability), ASIA-LEMS (lower-limb motor function but had poor sensory function and infe-
function), and ASIA-LESS score (sensory function), and rior walking ability. This may be due to differences in the
independent walkers at 2 weeks after surgery were found myelotomy approach.
to have better lower-limb and sensory functions recovery ISCT surgery is based on the posterior median sulcus
at 1 week postoperatively and could walk with a walker approach, which is indicated for most ISCTs, especially
or cane. Although there is a risk of motor deterioration ependymomas [21-23]. Postoperative sensory disturbanc-
and gait disturbance after ISCT resection, preservation es are common [12]. This sensory disturbance can range
of the lower-limb and sensory functions at 1 week post- from mild to severe, with difficulty standing and walking
operatively predicts gradual and steady motor function due to deep sensory disturbance. When deep sensory dis-
recovery at 2 weeks postoperatively. In other words, while turbance occurs, coordination is severely impaired, and
sensory function was poorly recovered, lower-limb motor walking is often difficult even when lower-limb muscle
function exhibited significantly better recovery, suggest- strength is maintained. The solid tumor group was more
ing that improvement in walking ability involved not only likely to develop deep sensory disturbance due to surgical
lower-limb motor function but also motor coordination. invasion by the posterior median sulcus approach, and
Furthermore, we found that the cutoff value of the WISICI improvement in walking ability was poor at 2 weeks post-
II score at 2 weeks postoperatively was 2 points to predict operatively. Comparing the tumor location, those with
recovery of walking ability as independent ambulator at 1 tumors in the thorax showed poorer lower-limb function
 362 Tetsuya Suzuki et al. Asian Spine J 2023;17(2):355-364

at 1 week postoperatively and lower-limb function and help predict functional recovery.
walking ability at 2 weeks postoperatively than those with
tumors located cervically. This result was consistent with Conclusions
previous reports of surgical results of intramedullary spi-
nal ependymomas [24,25]. One presumed reason for the By 2 weeks postoperatively, more than 50% of postop-
fragility of the thoracic cord is the smaller size of the cord erative patients with ISCT surgery regained their level
than that of the cervical cord [24,26,27], and the other is of walking independence. If lower-limb motor and sen-
the poorer blood supply of the thoracic cord [28]. These sory functions are preserved at 1 week postoperatively,
anatomical factors might have little influence on the tol- an improved walking ability can be expected at 2 weeks
erability of the thoracic cord to intramedullary surgical postoperatively. The cutoff value of the WISICI II score
procedures. at 2 weeks postoperatively was 2 points to predict recov-
The optimal cutoff value of the WISICI II score at 2 ery of walking ability as independent ambulator at 1 year
weeks postoperatively was 2 points to predict walking in- postoperatively. Therefore, an early start of postoperative
dependence at 1 year postoperatively using ROC analysis rehabilitation for ISCTs is deemed necessary.
(Table 6). WISCI II 2 points are defined as “ambulates in
parallel bars, with braces and physical assistance of two Conflict of Interest
persons, 10 meters,” while 3 points indicate “ambulates
in parallel bars, with braces and physical assistance of No potential conflict of interest relevant to this article was
one person, 10 meters.” While previous reports appreci- reported.
ated the importance of preoperative walking ability to
achieve a better ambulatory outcome after ISCT resection Acknowledgments
[5,7,8,10,12,24,25,29], our results suggested that earlier
and more aggressive intervention by physical therapy The authors thank for Dr. Akio Iwanami for his critical
could facilitate long-term recovery of ambulation after advices. The authors also thank for Ms Makiko Miyazaki,
ISCT resection. Ms Yukari Yamanishi, and Ms Kie Wakita for their as-
This study has several limitations. First, evaluating for sistance. The final draft of this manuscript was edited by
the sensory function was not enough, especially for posi- Francois Renault-Mihara (ClearBioEditing).
tion sense and deep sensation. In this study, the ASIA-
LEMS score was adopted to quantitatively assess for ORCID
sensory disturbance. However, it was not suitable for
evaluating position sense and deep sensation. Since our Tetsuya Suzuki: https://orcid.org/0000-0003-3978-831X
results suggested a close relationship between sensory Osahiko Tsuji: https://orcid.org/0000-0002-4584-1757
disturbance and postoperative motor impairment, a more Masahiko Ichikawa: https://orcid.org/0000-0001-7416-4938
detailed evaluation of sensory function is needed. Second, Ryota Ishii: https://orcid.org/0000-0003-1725-4579
postoperative myelopathic pain should also be considered. Narihito Nagoshi: https://orcid.org/0000-0001-8267-5789
Postoperative pain and numbness have been reported Michiyuki Kawakami: https://orcid.org/0000-0001-6459-3325
to arise often after ISCT resection, and their persistence Kota Watanabe: https://orcid.org/ 0000-0002-4830-4690
could impair patients’ quality of life in the postoperative Morio Matsumoto: https://orcid.org/0000-0002-1934-6998
period [30]. Third, the assessment of motor function was Tetsuya Tsuji: https://orcid.org/0000-0002-4728-9409
exclusively limited to lower-limb functions. This study Toshiyuki Fujiwara: https://orcid.org/0000-0003-1664-1745
focused on walking ability and independence; however, Masaya Nakamura: https://orcid.org/0000-0001-7916-5497
not only the lower-limb function but also trunk function
plays an important role in walking ability. Therefore, the Author Contributions
lack of analysis of trunk functions limited the quality of
this study. Although further research is needed, elucidat- TS, OT, and TF designed the study, and wrote the initial
ing the characteristics of physical function in patients draft of the manuscript. NN, KW, MM, TT, and MN was
after ISCT surgery in the early postoperative phase would responsible for designing the study protocol, recruiting
 Asian Spine Journal Walking Ability after Spinal Cord Tumor Resection 363

participants. RI played an important role in the statisti- cal treatment of intramedullary spinal cord tu-
cal verification, and contributed to the preparation of the mors: prognosis and complications. Spinal Cord
manuscript. MI and MK contributed to analysis and in- 2008;46:282-6.
terpretation of data and assisted in the preparation of the 9. Rashad S, Elwany A, Farhoud A. Surgery for spi-
manuscript. OT was responsible for all working related to nal intramedullary tumors: technique, outcome
this submission as corresponding author. Also, all authors and factors affecting resectability. Neurosurg Rev
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