Treatment of patients with spinal cavernous malformations: a systematic review

Spinal cavernous malformations (SCM) are intramedullary vascular malformations that can be treated surgically or conservatively. What is the optimal treatment strategy for patients with SCM? 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. Of 1,293 articles screened, we included 50 studies reporting on 2,328 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=1,909 [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. 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. • The annual hemorrhage risk from spinal cavernous malformations is approximately 5% • The surgery group was larger and more severely affected than the conservative group • Neurological outcome improved more often with surgery than conservative management • Around three-quarters of patients ambulated independently after either strategy • Prospective, multicenter studies are needed to better inform treatment decisions