Treatment of patients with spinal cavernous malformations: a systematic review.

Introduction: Spinal cavernous malformations (SCM) are intramedullary vascular malformations that can be treated surgically or conservatively. Research question: What is the optimal treatment strategy for patients with SCM? Material and methods: We searched Medline, Embase, Web of Science, and Cochrane Library (until 3 April 2025) for studies evaluating treatment outcomes of ≥5 patients with SCM of all ages. Two independent reviewers assessed study eligibility and risk-of-bias using ROBINS-I. We descriptively analyzed change in neurological outcome, independent ambulation, and hemorrhage rates. Results: Of 1293 articles screened, we included 50 studies reporting on 2328 patients with SCM (mean age 42 years [SD ± 14], 47% women). Studies were predominantly retrospective (48 [96%]) and single-center (46 [92%]). Overall risk-of-bias was serious in 80% and moderate in 20% of studies. The pooled annual hemorrhage rate during 649 person-years of follow-up was 4.8% (95% CI 3.2%-6.8%). After surgical treatment (n = 1909 [82%], mean follow-up 43 months [SD ± 38]), the neurological outcome improved in 45%, was stable in 41%, and worsened in 9%, and 72% ambulated independently versus 60% preoperatively. After conservative management (n = 419 [18%], mean follow-up 47 months [SD ± 34]), the neurological outcome improved in 16%, was stable in 69%, and worsened in 10%, and 76% ambulated independently versus 79% at baseline. Discussion and conclusion: The majority of patients with SCM were treated surgically and had worse baseline outcomes than those managed conservatively. Approximately three-quarters ambulated independently after either strategy. Low methodological quality and high risk-of-bias complicated direct comparisons, precluding definitive conclusions. Prospective, multicenter studies are warranted.