Neurological outcomes following nerve root sacrifice during resection of dumbbell tumors of the spine: a systematic review and pooled analysis

Neurological outcomes following nerve root sacrifice during resection of dumbbell tumors of the spine: a systematic review and pooled analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Neurological outcomes following nerve root sacrifice during resection of dumbbell tumors of the spine: a systematic review and pooled analysis Alberto Benato, Donato Creatura, Gabriele Capo, Cédric Yves Barrey This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7427118/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Apr, 2026 Read the published version in European Spine Journal → Version 1 posted 12 You are reading this latest preprint version Abstract Background : In the surgical treatment of spinal dumbbell tumors, preservation of the nerve root of origin is often challenging, and complete tumor removal may require intentional sacrifice of motor-relevant nerve roots. Despite this, postoperative motor deficits are frequently minimal or transient, as reported by several series. This systematic review and meta-analysis evaluates neurological outcomes following nerve root sacrifice at motor-relevant levels. Methods : A systematic search of PubMed and Scopus was performed per PRISMA guidelines. Studies included adult patients (≥18 years) with dumbbell tumors at motor-relevant spinal levels (C5–T1, L3–S1) treated with nerve root sacrifice. Pooled analyses and meta-analyses of proportions were conducted, including subgroup analyses for lumbar and cervical tumors. Results: Thirteen studies comprising 121 patients were included. After pooling of raw data across studies, crude rates of immediate and persistent motor deficits were 46% and 18%, respectively. Meta-analytic estimates showed immediate deficits in 46% (95% CI: 31%–62%) and persistent deficits in 21% (95% CI: 14%–31%). Severe persistent motor deficits (Medical Research Council grade ≤3) were rare, occurring in 1% (95% CI: 0%–7%); crude rate was 4%. Sensory deficits were more variable across studies. Conclusions : Most patients tolerate nerve root sacrifice without significant long-term motor impairment, likely due to chronic nerve compression inside the intervertebral foramen and neural compensation. Although transient motor deficits are frequent, severe permanent deficits are uncommon. Our analysis provides the first synthesis of the literature on this topic to help supporting surgical decision making. Caution in interpretating these results is still warranted due to small sample sizes and potential publication bias. Dumbbell tumor schwannoma neurofibroma spinal tumors nerve root sacrifice neurological outcome meta-analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Introduction Dumbbell tumors of the spine are most commonly schwannomas or neurofibromas arising from the spinal nerve roots. Compared to tumors confined solely to the intraspinal or extraspinal compartments, dumbbell tumors exhibit unique anatomical and surgical challenges [ 1 ]. Notably, obtaining a meaningful tumor resection with concomitant preservation of the affected nerve root is difficult or impossible [ 1 ], and intracapsular resection carries a significant risk of leaving residual tumor and does not reliably protect uninvolved nerve fibers [ 2 ] [ 3 ]. Several authors have published their experience with total sacrifice of the involved nerve root [ 4 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 1 ] [ 3 ] [ 9 ] [ 10 ], suggesting that this strategy is associated with relatively low rates of persistent neurological deficits. Chronic compression of the nerve fibers by tumor and compensation by functional plasticity at the plexus level have been hypothesized as mechanisms mitigating the impact of root sacrifice [ 5 ] [ 11 ] [ 12 ] [ 13 ] [ 14 ] [ 15 ] [ 16 ] [ 17 ] [ 2 ]. The aim of this study is to systematically collect, for the first time, the available evidence on neurological outcomes following nerve root sacrifice in the treatment of spinal dumbbell tumors. We perform both a descriptive analysis by pooling raw data and a meta-analysis of proportions to estimate the reported rates of immediate and long-term postoperative neurological deficits along with other outcomes. 2. Materials and methods 2.1 Study design and review question The protocol of this study was registered in PROSPERO (ID: CRD420251067665) on June 22, 2025. In designing the study, we followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines [ 18 ]. The review questions were formulated using the population, intervention, comparison, and outcome (PICO) model as follows: Population Adult patients (≥ 18 years) with Eden type II or III/Sridhar [ 19 ] type III or IV dumbbell tumors at motor-relevant spinal levels (C5–T1, L3–S1). Intervention Surgical resection of the tumor involving total nerve root sacrifice. Comparison(s) Comparisons between subgroups (cervical vs. lumbar; intra-extradural vs extradural) where applicable. No external control group. Outcome(s) : Neurological outcomes after nerve root sacrifice: early and persistent motor deficits (primary outcome), early and persistent sensory deficits, early and persistent postoperative pain, and persistent relevant motor deficits (Medical Research Council scale ≤ 3, reported as disabling/affecting quality of life, or mentioned as other than “mild”). Tumors were considered as “dumbbell” if they had an intracanal origin with transforaminal extension (Eden type II - intra-extradural - or type III - extradural, or Sridhar type III or IV). A significant extraspinal component was not mandatory (e.g., Sridhar type III). Tumors with giant extraspinal extension and/or large cervical/thoracic/abdominal/pelvic tumors with transforaminal canal invasion were excluded. Neurological deficits were defined as any deterioration from the preoperative status; patients with unchanged pre-existing motor deficits were not considered to have postoperative neurological deficits. 2.2 Methodology of literature search Two online databases (PubMed and Scopus) were screened independently by the first two authors (A.B. and D.C.). The following search strings were adopted: ("schwannoma" OR "neurofibroma" OR “neurinoma” OR "dumbbell" OR "nerve sheath tumor") AND spine NOT "case report” for PubMed, filtering for English language results and adult patients, and (dumbbell OR schwannoma OR neurofibroma OR neurinoma OR "nerve sheath tumor?") AND spine AND NOT "case report” for Scopus, filtering for English language results. The last search was conducted in June 2025. The screening involved elimination of duplicate results by using the Rayyan online platform (with manual check of each suspect duplicate found by the software) and then manual title screening followed by abstract screening. Papers corresponding to inclusion criteria underwent review of their full text and reference lists (for forward search). After comparison of the search results, controversies were solved by the senior author (C.B.). The PRISMA flowchart of our literature search is presented in Fig. 1 . 2.3 Inclusion and exclusion criteria Papers were included if they met the following criteria: Prospective or retrospective studies presenting ≥ 3 patients affected by dumbbell tumors of the spinal nerves (see definition in section 2.1 ), treated with tumor resection with sacrifice of the involved nerve root Tumors had to involve spinal nerves associated with a significant motor function (C5-T1 or L3-S1. Of note, despite its contribution to hip flexion, the L2 nerve root was excluded by most series in the literature, as its sacrifice can be compensated for by adjacent roots, even in the absence of chronic tumor compression. We thus decided to exclude it from our analysis to minimize confounding). Papers had to describe at least the motor outcomes, both in the immediate postoperative period and at follow-up Papers were excluded if they had the following characteristics: Case reports or case series including < 3 patients with dumbbell tumors; Case series on mixed spinal nerve tumors not reporting specific neurologic outcomes of the dumbbell subgroup; Studies where nerve root sacrifice was not clearly mentioned and could only be supposed; Studies dealing with purely intradural tumors, giant tumors, or cervical/abdominal/thoracic/pelvic tumors with transforaminal invasion of the canal; Studies dealing with malignant nerve sheath tumors; Studies written in languages other than English; Studies on pediatric (< 18 years old) patients; Studies on non-human animals. 2.4 Risk of bias assessment Risk of bias was independently assessed for each study by the first two authors (A.B. and D.C.) using the Risk of Bias In Non-randomized Studies – of Interventions (ROBINS-I V2) tool [ 20 ]. The results of the assessment are reported in Table 1 . Table 1. Risk of bias assessment according to the ROBINS-I V2 tool. Author and year D1 confounding D2 classification of interventions D3 selection of participants into the study D4 deviations from intended interventions D5 missing data D6 outcome measurements D7 selection of reported results Overall Schulteiss 1993 Moderate Low Low Low Moderate Moderate Moderate Moderate McCormick 1996* Low Low Low Low Low Moderate Moderate Moderate Miura 1998 Low Low Low Low Low Low Moderate Moderate Celli 2005 Low Low Low Low Low Low Moderate Moderate Jiang 2009 Moderate Low Low Low Moderate Moderate Moderate Moderate Satoh 2011 Moderate Low Low Low Moderate Moderate Moderate Moderate Nakamura 2012 Low Low Low Low Moderate Moderate Moderate Moderate Yamane 2013 Low Low Low Low Low Moderate Moderate Moderate Butenschoen 2020 Low Low Low Low Low Moderate Moderate Moderate Vandenbulcke 2023 Low Low Low Low Low Moderate Moderate Moderate Yang 2024 Low Low Low Low Moderate Moderate Moderate Moderate 2.5 Collected variables For each of the included studies, two authors (A.B. and D.C.) independently collected the following variables using a pre-designed grid: Mean age of patients Number of total, cervical (C5-T1) and lumbar (L3-S1) tumors; Mean tumor size; Number of patients with neurological deficits (motor and sensory) and neuropathic pain at the immediate postoperative period and at follow-up, for each of the following categories: all patients, patients with cervical tumors, patients with lumbar tumors; Number of patients where complete resection was obtained; Number of patients with persistent significant motor deficits at FU - these were defined as deficits MRC ≤ 3 (when quantified), deficits affecting the quality of life, or described as other than “mild”; Intraoperative neurophysiological monitoring responses in patients that did and did not develop postoperative motor deficits; Mean follow-up duration; Number of total tumors per nerve root (C5-T1, L3-S1); Number of immediate and persistent postoperative motor deficits per nerve root (C5-T1, L3-S1). 2.6 Statistical analysis Total raw patient numbers were aggregated across studies and descriptive pooling was performed for all variables. A meta-analysis of proportions was also conducted using the inverse variance method for pooling effect sizes across studies, when at least 5 studies reported the same outcome. Between-study heterogeneity was estimated using the restricted maximum-likelihood (REML) estimator for τ², with Q-profile–based confidence intervals computed for both τ and τ². The I² statistic was derived from Cochran’s Q to quantify the proportion of variability attributable to heterogeneity rather than sampling error. Proportions were transformed using the logit transformation to stabilize variances and improve the normality of sampling distributions. For parameters that showed a tendency to extreme proportions, the Freeman-Tukey double arcsine transformation was used instead, due to its better performance in this context. Clopper-Pearson exact confidence intervals were calculated for individual study proportions to ensure accurate estimation, particularly in small samples. For studies with zero events in one or more cells, a continuity correction of 0.5 was applied to enable inclusion in the analysis and prevent computational errors. To assess potential biases, funnel plots were generated for parameters reported in more than 10 studies. A subgroup analysis of cervical and lumbar tumors was also performed. To assess whether the rate of motor deficits varied by nerve root, we performed a generalized Fisher’s exact test. Additionally, binomial tests compared the observed rates of deficits for each root against reference values derived from our meta-analysis. Descriptive differences between observed and expected rates were visualized using a bar plot. All statistical analyses were performed by using the R software. 3. Results Our search initially yielded 1,561 papers. After removing duplicates, 1,135 records were screened by title for eligibility. Of these, 97 were deemed suitable for abstract screening, and 61 were selected for full-text review. Four additional eligible reports were identified through the bibliography of the reviewed papers, bringing the total number of full-text articles assessed to 64. Ultimately, 12 studies met the inclusion criteria for our analysis. For the purposes of this study, we grouped two publications by McCormick from 1996 [ 1 ][ 3 ], which separately reported his experience with cervical and thoracolumbar tumors. These were treated as a single study, referred to as “McCormick 1996 a + b.” Consequently, the final number of included studies was considered to be 11. A total of 121 patients were included (Table 2 ). Immediate and follow-up (FU) motor outcomes were reported in all 11 studies (121 patients). The degree of motor deficits at follow-up was available in 10 studies, encompassing 96 patients. Sensory outcomes were reported in 5 studies (52 patients). Pain outcomes were clearly described in only three studies with great heterogeneity and were therefore excluded from the analysis. Data on intraoperative neurophysiological monitoring responses were reported in one paper only [ 15 ] and were thus excluded from the analysis. Table 2 Summary of the data reported in the included papers. Raw numbers have been pooled calculating crude proportions. Author, year N Mean age (y) N. cervical N. lumbar Immediate motor deficits Immediate sensory deficits Motor deficits FU Sensory deficits FU Significant* motor deficits FU Mean FU (MOs) Schulteiss 1993 7 54 4 3 2 NR 1 NR 0 2 McCormick 1996* 6 43 3 3 3 0 3 0 1 24 Miura 1998 12 50 12 0 8 8 3 6 0 49 Celli 2005 7 NR 1 6 1 7 0 7 0 NR Jiang 2009 6 NR 6 0 2 2 1 0 0 9 Satoh 2011 4 NR 0 4 3 NR 1 NR 1 > 12 Nakamura 2012 25 NR 25 0 17 NR 6 NR NR NR Yamane 2013 5 NR 5 0 4 NR 2 NR 1 NR Butenschoen 2020 21 49 5 16 4 3 1 0 0 NR Vandenbulcke 2023 13 47 5 8 5 NR 2 NR 1 NR Yang 2024 15 NR 15 0 7 NR 2 NR 0 NR Sum or weighted average 121 49 81 40 56 20 (n = 52) 22 13 (n = 52) 4 (n = 96) 24 Crude proportion (CI) 46% (38%-55%) 38% (26%-52%) 18% (12%-26%) 25% (15%-39%) 4% (2%-10%) 3.1 Global analysis Immediate postoperative motor deficits : crude proportion: 46% (95%CI 38%-55%). Proportion estimated with random effects model: 46% (95% CI: 31%-62%). I^2 was 46.5%, indicating moderate heterogeneity. Persistent motor deficits at last FU : crude proportion: 18% (95%CI 12%-26%). Proportion estimated with random effects model: 21% (95% CI: 14%-31%). I^2 was 0.0%, indicating low heterogeneity. Significant motor deficit (MRC ≤ 3) at last FU : crude proportion: 4% (95%CI 2%-10%). Proportion estimated with random effects model: 1% (95% CI: 0%-7%). I^2 was 0.0%, indicating low heterogeneity. The forest and funnel plots for motor outcomes are shown in Fig. 2 . Immediate postoperative sensory deficits : crude proportion: 38% (95%CI 26%-52%). Proportion estimated with random effects model: 40% (95% CI: 6%-88%). I^2 was 73.2%, indicating substantial heterogeneity. Persistent postoperative sensory deficits at last FU : crude proportion: 25% (95%CI 15%-39%). Proportion estimated with random effects model: 24% (95% CI: 2%-75%). I^2 was 72.7%, indicating substantial heterogeneity. Forest plots for sensory outcomes are shown in Fig. 3 . Due to the low number of studies reporting these outcomes (< 10), funnel plots are not applicable. 3.2 Subgroup analysis To identify possible differences in outcome between cervical and lumbar tumors, we have performed a subgroup analysis. For this purpose, studies presenting both cervical and lumbar tumors have been split. Of note, this can introduce a bias as it modifies the weight of those studies by reducing their sample size. However, given the similarity in surgical techniques and the overall good quality of the papers, we believe that the impact of this procedure should be not significant. The results of this subgroup analysis, including raw proportions, are also reported in Table 3 . The forest plots for the subgroup analyses can be found in the supplementary material. Table 3 Summary of the crude proportions and meta-analytical estimates of the incidence of postoperative motor deficits for all tumors, lumbar tumors and cervical tumors. Crude Proportions Immediate motor deficit Persistent motor deficit Significant deficit at FU Total 46% (38%-55%), 18% (12%-26%) 4% (2%-10%) Cervical 52% (41%-63%) 21% (13%-31%) 4% (1%-13%) Lumbar 32% (19%-49%) 12% (5%-28%) 5% (1%-18%) Meta-analysis Immediate motor deficit Persistent motor deficit Significant deficit at FU Total 46% (31%-62%) I² = 46.5% 21% (14%-31%), I² = 0.0% 1% (0%-7%), I² = 0.0% Cervical 51% (36%-67%), I² = 17.9% 23% (16%-33%), I² = 0% 0% (0%-4%), I² = 0% Lumbar 34% (16%-59%), I² = 25.3% 20% (8%-41%), I² = 0% 1% (1%-12%), I² = 0% Chi-square tests were conducted to compare proportions between groups. Although there appeared to be a notable difference in the rate of early motor deficits between the cervical and lumbar groups, this difference did not reach statistical significance. We also conducted a separate analysis focused on the rate of postoperative motor deficits associated with each individual nerve root. Data on outcomes by nerve root were available in eight studies, comprising a total of 80 patients (Table 4 ). Within this subgroup, 38 immediate postoperative motor deficits (46%) and 14 permanent motor deficits (18%) were reported rates that are consistent with those observed in the overall cohort. Table 4. Data on postoperative motor deficits per nerve root, with crude proportions Root Total Transient deficit (%) Persistent deficit (%) C5 19 13 (68%) 5 (26%) C6 11 7 (64%) 3 (27%) C7 10 4 (40%) 1 (10%) C8 8 7 (87%) 4 (50%) T1 3 0 (0%) 0 (0%) L3 9 0 (0%) 0 (0%) L4 5 1 (20%) 1 (20%) L5 7 4 (57%) 0 (0%) S1 8 2 (25%) 0 (0%) Total (%) 80 (100%) 38 (47%) 14 (17%) Fisher’s Test Significant (p0.05) The generalized Fisher’s exact test revealed a statistically significant difference in the distribution of immediate motor deficits across nerve roots (p < 0.001), indicating that deficits were not evenly distributed. In contrast, the test did not show statistical significance for permanent deficits, suggesting that the distribution of long-term outcomes did not differ significantly from what would be expected under a uniform distribution. Deviations between observed and expected deficit rates for each nerve root are illustrated in Fig. 4 . Binomial tests comparing observed rates of motor deficits for individual nerve roots to the reference proportions calculated in our meta-analysis (0.46 for immediate and 0.21 for persistent deficits) were conducted, adjusting p-value with Bonferroni correction for multiple comparisons. Specifically, for immediate postoperative deficits C8 showed the highest observed rate (87.5%) and reached statistical significance (p = 0.00265). L3 presented a lower-than-expected rate of immediate postoperative deficits (0%) which also reached statistical significance (p = 0.0054). For persistent deficits, no nerve root reached statistical significance. However, these data must be interpreted with great caution due to the very small sample sizes and wide confidence intervals. 4. Discussion The treatment of dumbbell tumors arising from spinal nerves poses distinct challenges compared to purely intracanalicular or extracanalicular tumors. In the former, the affected rootlet - often a sensory or functionally insignificant one [ 21 ] - can typically be identified, isolated from adjacent roots, and sacrificed with minimal neurological consequences [ 10 ]. In the latter, nerve-sparing intracapsular resection is generally feasible and has been associated with favorable neurological and oncological outcomes [ 22 ] [ 23 ]. Dumbbell tumors, however, differ significantly in both anatomy and behavior. Subarachnoid nerve fascicles lack well-developed connective tissue layers (particularly perineurium and epineurium) that compartmentalize tumor growth and allow for intracapsular, nerve-sparing resection in postganglionic tumors [ 23 ] [ 1 ]. As a result, when a tumor extends into the foraminal and ganglionic portions of the nerve, “bystander” fascicles appear to dissolve into the tumor, and intracapsular resection does not reliably preserve them [ 2 ]. Moreover, evidence indicates that the remaining non-tumoral fascicles within the affected nerve root exhibit histopathological features of chronic degeneration [ 16 ]. This finding may help explain reports showing that complete resection of the involved nerve root is often associated with surprisingly low rates of persistent postoperative motor deficits [ 6 ] [ 10 ]. A plausible pathophysiological rationale is that prolonged compression against the bony limits of the intervertebral foramen has already impaired the functional integrity of these fascicles (Fig. 5 ). Consequently, compensatory neurological adaptation may have occurred at the plexus level prior to surgery (or may emerge postoperatively) thereby contributing to the generally low incidence of new or lasting neurological deficits. This is in contrast with peripheral nerve tumors, where nerve sacrifice is typically associated with permanent, severe deficits [ 22 ]. For these reasons, instead of trying to preserve the continuity of the nerve by performing a subtotal resection, which does not grant spared function [ 2 ] [ 1 ] [ 3 ] and is associated with significantly higher risk of recurrence [ 24 ] [ 25 ], some authors routinely perform total nerve root sacrifice in the treatment of dumbbell tumors, aiming for a radical resection [ 5 ]. Although several case series have been published, no systematic study of this practice has been performed to date. The first relatively large study on this topic was published by Kim and colleagues [ 10 ] [ 10 ]. In their series of 31 tumors arising from nerve roots at the C5–T1 and L3–S1 levels, the authors reported that both intradural rootlet and complete nerve root sacrifice resulted in similarly low rates of postoperative deficits (approximately 20%). In particular, among the 15 “large tumors” requiring full nerve root sacrifice, only 24% of patients experienced postoperative motor or sensory deficits. Despite its historical relevance, this study was excluded from our analysis due to two limitations: (1) it reported mixed motor and sensory outcomes, and (2) it lacked long-term motor follow-up. [ 10 ], McCormick published separately two detailed reports on dumbbell tumors of the cervical [ 1 ] and thoracolumbar spine [ 3 ], including 24 patients. Among these, complete sacrifice of a motor root was performed in six cases (three cervical and three lumbar), resulting in three (50%) immediate motor deficits, which persisted at FU (although only one was significant). As stated previously, due to their methodological and clinical homogeneity, the two studies were considered as a single group in our analysis. Further evidence comes from Miura’s 1998 series, which included 15 patients, 12 with dumbbell tumors and 3 with purely intradural lesions [ 8 ]. Among the dumbbell tumor subgroup, 12 motor-relevant roots were sacrificed, resulting in eight (67%) immediate and three (25%) persistent motor deficits. However, none were important. In a 2012 study, Nakamura reviewed 75 cases of cervical dumbbell tumors [ 7 ]. Of these, 25 patients underwent total sacrifice of a motor-relevant nerve root. Seventeen (68%) experienced immediate motor deterioration, with persistent deficits in six cases (24%) at follow-up. Unfortunately, the severity of these residual deficits was not specified. A more recent series by Butenschoen, published [ 10 ], examined 21 patients, reporting four (19%) immediate motor deficits, only one (5%) of which persisted (and was of mild severity) [ 6 ]. Yang and colleagues, in a study proposing a new classification system for cervical dumbbell tumors based on a cohort of 295 cases, reported on 15 instances of total motor root sacrifice [ 4 ]. Of these, seven patients (47%) exhibited immediate postoperative deficits, with only two (17%) persisting, neither of which were considered clinically significant. Finally, our institutional series of 26 dumbbell tumors (including the sacrifice of 13 motor-relevant nerve roots) [ 5 ] demonstrated an incidence of immediate motor deficits of 38% (5 of 13 patients) and persistent deficits of 15% (2 patients). However, only one deficit (7.6%) was considered clinically important at follow-up. Globally, our analysis indicates that in the surgical treatment of dumbbell tumors of motor-relevant spinal nerves, complete sacrifice of the affected nerve root results in new postoperative motor deficits in approximately 46% of patients (95% CI: 31–62%) immediately after surgery, and in 21% (95% CI: 14–31%) as persistent deficits. Among those with lasting deficits, significant motor impairment (MRC ≤ 3 or clinically disabling) is rare, occurring in roughly 1% of all patients (95% CI: 0–7%). The higher heterogeneity (I^2 = 46.5%) in immediate motor deficits could reflect variation in disease stage at the time of surgery, with differing degrees of preoperative neural compensation. In contrast, the more consistent rates of persistent motor deficits suggest that long-term recovery may level out these initial differences. Sensory outcomes showed considerable variability across studies. The estimated proportion of immediate postoperative sensory deficits was 40% (95% CI: 6–88%), while persistent deficits were estimated at 24% (95% CI: 2–75%). Crude proportions were 38% and 25%, respectively. However, high heterogeneity was observed for both outcomes, significantly limiting the precision of these estimates. A reason for the lower quality of data on this domain may be the tendency to focus on motor outcomes, overlooking sensation. Outcomes following nerve root sacrifice were analyzed separately for cervical and lumbar tumors. For cervical tumors, the estimated incidence of immediate postoperative motor deficits was 51% (95% CI: 36–67%), with 23% (95% CI: 16–33%) of patients experiencing persistent deficits. Significant long-term motor deficits (MRC ≤ 3) were rare, with an estimated rate of 0% (95% CI: 0–4%). For lumbar tumors, immediate motor deficits occurred in 34% of cases (95% CI: 16–59%), with 20% (95% CI: 8–41%) showing persistent symptoms. Significant motor deficits were again uncommon, estimated at 1% (95% CI: 0–12%). Similarly, sensory outcomes were highly heterogeneous (see the “results” section). Notably, the observed differences between cervical and lumbar groups were not statistically significant. We explored whether specific nerve roots were more prone to postoperative motor deficits when sacrificed, using data from eight studies totaling 80 patients. Fisher’s exact test showed a significant difference in the distribution of immediate deficits (p < 0.001), suggesting variability among roots. However, no significant difference was found for persistent deficits, indicating more uniform long-term outcomes. When individual roots were studied, binomial tests showed significant deviations from expected rates only for C8 and L3, with C8 demonstrating higher-than-expected and L3 lower-than-expected rates of immediate deficits. A similar, though non-significant, trend was observed for persistent deficits (Fig. 4 ). Although interesting, these data must be interpreted with great caution due to the very small sample sizes and wide confidence intervals. Other authors suspected higher rates of permanent motor deficits after sacrifice of the C5 root [ 6 ] [ 15 ]. Larger samples would be required to better explore these putative asymmetries. Of note, the L2 nerve root was excluded from most studies in the literature, likely because, although it contributes to motor function (hip flexion), its loss can often be compensated for by adjacent muscles. Including it could therefore introduce confounding. For this reason, we also chose not to incorporate L2 in our analysis. We initially aimed to analyze data on intraoperative neurophysiological monitoring, a parameter of considerable clinical interest [ 26 ]. However, meaningful information was available in only one study [ 15 ], preventing its inclusion in our analysis. Similarly, pain outcomes related to sacrificed motor-relevant roots were reported in just three studies (considering the two studies by McCormick as one) with great heterogeneity (two studies [ 15 ] [ 1 ] [ 3 ] reporting no cases of long-term neuropathic pain and one study reporting six cases [ 6 ]), making any meaningful analysis unfeasible. Our study has several limitations, largely deriving from biases in the available literature. The total number of included patients was relatively small, reflecting the rarity of the condition. While this limits statistical power, the systematic aggregation of existing data remains valuable in the absence of larger prospective studies. Of note, many studies on nerve root sacrifice were excluded from our analysis because they did not report outcomes specific to motor-relevant roots or failed to distinguish between intradural rootlet sacrifice and complete root resection. This contributed to reducing the sample size, but increased the homogeneity of the data and strengthened our conclusion. Important clinical variables, such as tumor size, were inconsistently reported (only three studies) making meaningful analysis impossible. However, the focus on dumbbell tumors only (as defined in the methods section) helped in minimizing heterogeneity, excluding both small, purely intracanalicular tumors, as well as giant/complex tumors. Similarly, data regarding the entity of resection was available for 4 studies only; however, given the total sacrifice of the nerve root performed in all cases, we believe that the entity of tumor resection had little impact on postoperative radicular deficits. Follow-up duration was documented in 6 studies only, potentially affecting estimates of long-term deficits. However, longer or more consistent follow-up would likely reveal lower rates of persistent deficits, rather than higher. Sensory deficits could be analyzed as they were reported in a sufficient number of studies; however, the great heterogeneity observed warns of interpreting the results with caution. Unfortunately, pain outcomes could not be studied as they were clearly reported in two studies only. Finally, publication bias is possible, with a tendency to publish case series reporting more favorable outcomes. To help assess this, we included funnel plots where the number of studies permitted, even if they are not typically employed in meta-analyses of proportions [ 27 ]. The plots appeared symmetrical, reducing the likelihood of significant publication bias. 5. Conclusions Our study reviews the existing literature on neurological outcomes following treatment of spinal dumbbell tumors involving nerve root sacrifice. Despite important limitations in the available literature (mainly deriving from the rarity of the condition, the difficulty in performing comparative and randomized studies, and the publication bias typical of retrospective surgical series) our analysis indicates that transient motor deficits are common, while permanent, severe deficits are rare. Evidence regarding sensory and pain outcomes remains highly heterogeneous and difficult to interpret. Although additional data are needed to reach more definitive conclusions, this study provides the first synthesis of the literature on this topic over the past 30 years. Declarations Author Contribution A.B. designed the study. A.B., D.C. and C.Y.B. collected the data. A.B. performed the statistical analysis. A.B. and D.C. wrote the main manuscript text. D.C., G.C., and C.Y.B. prepared the figures and the tables. G.C. and C.Y.B. reviewed the manuscript. C.Y.B. supervised the project. All authors approved the final version of the manuscript. 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Assessment of pure single nerve root resection in the treatment of spinal schwannoma: focus on solitary spinal schwannomas located below the thoracolumbar junction. J Orthop Sci. 2011 Mar;16(2):148-55. doi: 10.1007/s00776-011-0032-8. Jiang L, Lv Y, Liu XG, Ma QJ, Wei F, Dang GT, Liu ZJ. Results of surgical treatment of cervical dumbbell tumors: surgical approach and development of an anatomic classification system. Spine (Phila Pa 1976). 2009 May 20;34(12):1307-14. doi: 10.1097/BRS.0b013e3181a27a32. Celli P, Trillò G, Ferrante L. Extrathecal intraradicular nerve sheath tumor. J Neurosurg Spine. 2005 Jul;3(1):1-11. doi: 10.3171/spi.2005.3.1.0001. Hasegawa M, Fujisawa H, Hayashi Y, Tachibana O, Kida S, Yamashita J. Surgical pathology of spinal schwannoma: has the nerve of its origin been preserved or already degenerated during tumor growth? Clin Neuropathol. 2005 Jan-Feb;24(1):19-25. PMID: 15696780. Celli P. Treatment of relevant nerve roots involved in nerve sheath tumors: removal or preservation? Neurosurgery. 2002 Sep;51(3):684-92; discussion 692. PMID: 12188946. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29;372:n71. doi: 10.1136/bmj.n71. Sridhar K, Ramamurthi R, Vasudevan MC, Ramamurthi B. Giant invasive spinal schwannomas: definition and surgical management. J Neurosurg. 2001 Apr;94(2 Suppl):210-5. doi: 10.3171/spi.2001.94.2.0210. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, Henry D, Altman DG, Ansari MT, Boutron I, Carpenter JR, Chan AW, Churchill R, Deeks JJ, Hróbjartsson A, Kirkham J, Jüni P, Loke YK, Pigott TD, Ramsay CR, Regidor D, Rothstein HR, Sandhu L, Santaguida PL, Schünemann HJ, Shea B, Shrier I, Tugwell P, Turner L, Valentine JC, Waddington H, Waters E, Wells GA, Whiting PF, Higgins JP. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016 Oct 12;355:i4919. doi: 10.1136/bmj.i4919. Safaee MM, Lyon R, Barbaro NM, Chou D, Mummaneni PV, Weinstein PR, Chin CT, Tihan T, Ames CP. Neurological outcomes and surgical complications in 221 spinal nerve sheath tumors. J Neurosurg Spine. 2017 Jan;26(1):103-111. doi: 10.3171/2016.5.SPINE15974. Benato A, D'Alessandris QG, Murazio M, Pacelli F, Mattogno PP, Fernández E, Lauretti L. Integrated Neurosurgical Management of Retroperitoneal Benign Nerve Sheath Tumors. Cancers (Basel). 2023 Jun 10;15(12):3138. doi: 10.3390/cancers15123138. Stone JJ, Spinner RJ. Go for the Gold: A "Plane" and Simple Technique for Resecting Benign Peripheral Nerve Sheath Tumors. Oper Neurosurg. 2020 Jan 1;18(1):60-68. doi: 10.1093/ons/opz034. Fehlings MG, Nater A, Zamorano JJ, Tetreault LA, Varga PP, Gokaslan ZL, Boriani S, Fisher CG, Rhines L, Bettegowda C, Kawahara N, Chou D. Risk Factors for Recurrence of Surgically Treated Conventional Spinal Schwannomas: Analysis of 169 Patients From a Multicenter International Database. Spine (Phila Pa 1976). 2016 Mar;41(5):390-8. doi: 10.1097/BRS.0000000000001232. Sohn S, Chung CK, Park SH, Kim ES, Kim KJ, Kim CH. The fate of spinal schwannomas following subtotal resection: a retrospective multicenter study by the Korea spinal oncology research group. J Neurooncol. 2013 Sep;114(3):345-51. doi: 10.1007/s11060-013-1190-7. Kaneko K, Kato Y, Kojima T, Imajyo Y, Taguchi T. Intraoperative electrophysiologic studies on the functions of nerve roots involved in cervical dumbbell-shaped schwannoma and their clinical utility. J Spinal Disord Tech. 2006 Dec;19(8):571-6. doi: 10.1097/01.bsd.0000211227.04802.b3. Barker TH, Migliavaca CB, Stein C, Colpani V, Falavigna M, Aromataris E, Munn Z. Conducting proportional meta-analysis in different types of systematic reviews: a guide for synthesisers of evidence. BMC Med Res Methodol. 2021 Sep 20;21(1):189. doi: 10.1186/s12874-021-01381-z. Additional Declarations No competing interests reported. Supplementary Files forestplotsforgroups.pdf Cite Share Download PDF Status: Published Journal Publication published 03 Apr, 2026 Read the published version in European Spine Journal → Version 1 posted Editorial decision: Revision requested 06 Oct, 2025 Reviews received at journal 06 Oct, 2025 Reviews received at journal 02 Oct, 2025 Reviews received at journal 29 Sep, 2025 Reviewers agreed at journal 15 Sep, 2025 Reviewers agreed at journal 14 Sep, 2025 Reviewers agreed at journal 13 Sep, 2025 Reviewers agreed at journal 13 Sep, 2025 Reviewers invited by journal 13 Sep, 2025 Editor assigned by journal 25 Aug, 2025 Submission checks completed at journal 25 Aug, 2025 First submitted to journal 21 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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02:47:03","extension":"xml","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":125324,"visible":true,"origin":"","legend":"","description":"","filename":"19136548423c4f2ebdc359974abdfc931structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7427118/v1/05da7c4ff9d60476acdfd29e.xml"},{"id":91936310,"identity":"afe9818b-b1d9-4b02-b9ad-e563c3802a2e","added_by":"auto","created_at":"2025-09-23 02:47:03","extension":"html","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":135454,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7427118/v1/ec95b37e52056aaff4155775.html"},{"id":91936307,"identity":"c19c0aab-5e46-4b6a-870b-7245921d1dbb","added_by":"auto","created_at":"2025-09-23 02:47:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":115839,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePRISMA flowchart summarizing the literature screening process\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7427118/v1/6a2ddc2fc28bcb6f20ed7c47.png"},{"id":91936336,"identity":"b59aa58e-ecdc-439e-802d-b5242ce62d0e","added_by":"auto","created_at":"2025-09-23 02:47:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":496509,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMeta analysis plots for motor outcomes. Forest and funnel plots for immediate postoperative motor deficits (A, B), persistent motor deficits at last FU (C, D) and significant motor deficits at last FU (E, F), respectively.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7427118/v1/1dbde028458ed153fa6eaf3a.png"},{"id":91937872,"identity":"93223924-68cb-4511-8081-be58969c6849","added_by":"auto","created_at":"2025-09-23 03:03:03","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":769584,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eForest plots for sensory outcomes. (A) Immediate postoperative sensory deficits; (B) persistent sensory deficits at FU. Funnel plots were not applicable.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7427118/v1/975409888cf4cab72205f71e.png"},{"id":91937385,"identity":"895be899-547a-4d1b-901a-09c1ec417350","added_by":"auto","created_at":"2025-09-23 02:55:03","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":276660,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eGraphical illustration of the deviations of the rate of motor deficits observed for single nerve roots from the overall rates estimated in our meta-analysis (46% for immediate postoperative deficits and 21% for persistent deficits, respectively).\u003c/em\u003e \u003cem\u003eOnly C8 and L3 showed statistically significant deviations from the overall incidence and only for immediate postoperative deficits. These the trends have to be interpreted with caution due to the small sample sizes.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7427118/v1/2a5cf7f51c4579bab4ffeac1.png"},{"id":91936303,"identity":"f106c6b1-5257-413c-9491-0d8769f8ff3b","added_by":"auto","created_at":"2025-09-23 02:47:03","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":342221,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eIllustration of the intraforaminal growth of a dumbbell tumor (T) causing chronic compression of the nerve root against the bony margins of the intervertebral foramen. A proposed classification: 1) the tumor does not fill the foramen entirely; 2) the tumor totally occupies the foramen; 3) the tumor is responsible for bony remodeling of the foramen with scalloping.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7427118/v1/26e58f4c7623d52ad42bc608.jpeg"},{"id":106343625,"identity":"ee0aedd7-5c5e-49a0-90aa-ca9ead960f4c","added_by":"auto","created_at":"2026-04-07 16:07:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3064648,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7427118/v1/49b74e0c-7a4b-492f-acf7-a7e860c30411.pdf"},{"id":91937391,"identity":"4b926e6b-abaa-487a-9801-67273595135f","added_by":"auto","created_at":"2025-09-23 02:55:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":2926857,"visible":true,"origin":"","legend":"","description":"","filename":"forestplotsforgroups.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7427118/v1/90937d7cc34ff0336eeb8dab.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Neurological outcomes following nerve root sacrifice during resection of dumbbell tumors of the spine: a systematic review and pooled analysis","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eDumbbell tumors of the spine are most commonly schwannomas or neurofibromas arising from the spinal nerve roots. Compared to tumors confined solely to the intraspinal or extraspinal compartments, dumbbell tumors exhibit unique anatomical and surgical challenges [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Notably, obtaining a meaningful tumor resection with concomitant preservation of the affected nerve root is difficult or impossible [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], and intracapsular resection carries a significant risk of leaving residual tumor and does not reliably protect uninvolved nerve fibers [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSeveral authors have published their experience with total sacrifice of the involved nerve root [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], suggesting that this strategy is associated with relatively low rates of persistent neurological deficits. Chronic compression of the nerve fibers by tumor and compensation by functional plasticity at the plexus level have been hypothesized as mechanisms mitigating the impact of root sacrifice [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe aim of this study is to systematically collect, for the first time, the available evidence on neurological outcomes following nerve root sacrifice in the treatment of spinal dumbbell tumors. We perform both a descriptive analysis by pooling raw data and a meta-analysis of proportions to estimate the reported rates of immediate and long-term postoperative neurological deficits along with other outcomes.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Study design and review question\u003c/h2\u003e\u003cp\u003eThe protocol of this study was registered in PROSPERO (ID: CRD420251067665) on June 22, 2025. In designing the study, we followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The review questions were formulated using the population, intervention, comparison, and outcome (PICO) model as follows:\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePopulation\u003c/strong\u003e\u003cp\u003eAdult patients (\u0026ge;\u0026thinsp;18 years) with Eden type II or III/Sridhar [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] type III or IV dumbbell tumors at motor-relevant spinal levels (C5\u0026ndash;T1, L3\u0026ndash;S1).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003cp\u003eSurgical resection of the tumor involving total nerve root sacrifice.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eComparison(s)\u003c/strong\u003e\u003cp\u003eComparisons between subgroups (cervical vs. lumbar; intra-extradural vs extradural) where applicable. No external control group.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eOutcome(s)\u003c/b\u003e: Neurological outcomes after nerve root sacrifice: early and persistent motor deficits (primary outcome), early and persistent sensory deficits, early and persistent postoperative pain, and persistent relevant motor deficits (Medical Research Council scale\u0026thinsp;\u0026le;\u0026thinsp;3, reported as disabling/affecting quality of life, or mentioned as other than \u0026ldquo;mild\u0026rdquo;).\u003c/p\u003e\u003cp\u003eTumors were considered as \u0026ldquo;dumbbell\u0026rdquo; if they had an intracanal origin with transforaminal extension (Eden type II - intra-extradural - or type III - extradural, or Sridhar type III or IV). A significant extraspinal component was not mandatory (e.g., Sridhar type III). Tumors with giant extraspinal extension and/or large cervical/thoracic/abdominal/pelvic tumors with transforaminal canal invasion were excluded. Neurological deficits were defined as any deterioration from the preoperative status; patients with unchanged pre-existing motor deficits were not considered to have postoperative neurological deficits.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Methodology of literature search\u003c/h2\u003e\u003cp\u003eTwo online databases (PubMed and Scopus) were screened independently by the first two authors (A.B. and D.C.). The following search strings were adopted: \u003cem\u003e(\"schwannoma\" OR \"neurofibroma\" OR \u0026ldquo;neurinoma\u0026rdquo; OR \"dumbbell\" OR \"nerve sheath tumor\") AND spine NOT \"case report\u0026rdquo;\u003c/em\u003e for PubMed, filtering for English language results and adult patients, and \u003cem\u003e(dumbbell OR schwannoma OR neurofibroma OR neurinoma OR \"nerve sheath tumor?\") AND spine AND NOT \"case report\u0026rdquo;\u003c/em\u003e for Scopus, filtering for English language results. The last search was conducted in June 2025. The screening involved elimination of duplicate results by using the Rayyan online platform (with manual check of each suspect duplicate found by the software) and then manual title screening followed by abstract screening. Papers corresponding to inclusion criteria underwent review of their full text and reference lists (for forward search).\u003c/p\u003e\u003cp\u003eAfter comparison of the search results, controversies were solved by the senior author (C.B.).\u003c/p\u003e\u003cp\u003eThe PRISMA flowchart of our literature search is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Inclusion and exclusion criteria\u003c/h2\u003e\u003cp\u003ePapers were included if they met the following criteria:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eProspective or retrospective studies presenting\u0026thinsp;\u0026ge;\u0026thinsp;3 patients affected by dumbbell tumors of the spinal nerves (see definition in section \u003cspan refid=\"Sec3\" class=\"InternalRef\"\u003e2.1\u003c/span\u003e), treated with tumor resection with sacrifice of the involved nerve root\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTumors had to involve spinal nerves associated with a \u003cb\u003esignificant motor function\u003c/b\u003e (C5-T1 or L3-S1. Of note, despite its contribution to hip flexion, the L2 nerve root was excluded by most series in the literature, as its sacrifice can be compensated for by adjacent roots, even in the absence of chronic tumor compression. We thus decided to exclude it from our analysis to minimize confounding).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePapers had to describe at least the motor outcomes, \u003cb\u003eboth\u003c/b\u003e in the immediate postoperative period and at follow-up\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003ePapers were excluded if they had the following characteristics:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eCase reports or case series including\u0026thinsp;\u0026lt;\u0026thinsp;3 patients with dumbbell tumors;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCase series on mixed spinal nerve tumors not reporting specific neurologic outcomes of the dumbbell subgroup;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStudies where nerve root sacrifice was not clearly mentioned and could only be supposed;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStudies dealing with purely intradural tumors, giant tumors, or cervical/abdominal/thoracic/pelvic tumors with transforaminal invasion of the canal;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStudies dealing with malignant nerve sheath tumors;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStudies written in languages other than English;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStudies on pediatric (\u0026lt;\u0026thinsp;18 years old) patients;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStudies on non-human animals.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Risk of bias assessment\u003c/h2\u003e\u003cp\u003eRisk of bias was independently assessed for each study by the first two authors (A.B. and D.C.) using the Risk of Bias In Non-randomized Studies \u0026ndash; of Interventions (ROBINS-I V2) tool [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The results of the assessment are reported in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eTable 1. Risk of bias assessment according to the ROBINS-I V2 tool.\u003c/p\u003e\n\u003ctable style=\"border-collapse: collapse;border: none;width: 603px;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50.25pt;border: 1pt solid black;padding: 2pt;height: 44.6pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eAuthor and year\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;padding: 2pt;height: 44.6pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eD1\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003econfounding\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;padding: 2pt;height: 44.6pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eD2\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eclassification of interventions\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53.25pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;padding: 2pt;height: 44.6pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eD3\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eselection of participants into the study\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.25pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;padding: 2pt;height: 44.6pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eD4\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;deviations from intended interventions\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39.75pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;padding: 2pt;height: 44.6pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eD5\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003emissing data\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.75pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;padding: 2pt;height: 44.6pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eD6\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;outcome measurements\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;padding: 2pt;height: 44.6pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eD7\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eselection of reported results\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;padding: 2pt;height: 44.6pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eOverall\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family: \"Times New Roman\",serif;'\u003eSchulteiss 1993\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family: \"Times New Roman\",serif;'\u003eMcCormick 1996*\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family: \"Times New Roman\",serif;'\u003eMiura 1998\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family: \"Times New Roman\",serif;'\u003eCelli 2005\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family: \"Times New Roman\",serif;'\u003eJiang 2009\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family: \"Times New Roman\",serif;'\u003eSatoh 2011\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family: \"Times New Roman\",serif;'\u003eNakamura 2012\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family: \"Times New Roman\",serif;'\u003eYamane 2013\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:11px;line-height:115%;font-family: \"Times New Roman\",serif;'\u003eButenschoen 2020\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp 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style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp 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bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(182, 215, 168);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eLow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(255, 217, 102);padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:11px;line-height:115%;font-family:\"Times New Roman\",serif;color:black;'\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Collected variables\u003c/h2\u003e\u003cp\u003eFor each of the included studies, two authors (A.B. and D.C.) independently collected the following variables using a pre-designed grid:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eMean age of patients\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNumber of total, cervical (C5-T1) and lumbar (L3-S1) tumors;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMean tumor size;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNumber of patients with neurological deficits (motor and sensory) and neuropathic pain at the immediate postoperative period and at follow-up, for each of the following categories: all patients, patients with cervical tumors, patients with lumbar tumors;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNumber of patients where complete resection was obtained;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNumber of patients with persistent significant motor deficits at FU - these were defined as deficits MRC\u0026thinsp;\u0026le;\u0026thinsp;3 (when quantified), deficits affecting the quality of life, or described as other than \u0026ldquo;mild\u0026rdquo;;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIntraoperative neurophysiological monitoring responses in patients that did and did not develop postoperative motor deficits;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMean follow-up duration;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNumber of total tumors per nerve root (C5-T1, L3-S1);\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNumber of immediate and persistent postoperative motor deficits per nerve root (C5-T1, L3-S1).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Statistical analysis\u003c/h2\u003e\u003cp\u003eTotal raw patient numbers were aggregated across studies and descriptive pooling was performed for all variables. A meta-analysis of proportions was also conducted using the inverse variance method for pooling effect sizes across studies, when at least 5 studies reported the same outcome. Between-study heterogeneity was estimated using the restricted maximum-likelihood (REML) estimator for τ\u0026sup2;, with Q-profile\u0026ndash;based confidence intervals computed for both τ and τ\u0026sup2;. The I\u0026sup2; statistic was derived from Cochran\u0026rsquo;s Q to quantify the proportion of variability attributable to heterogeneity rather than sampling error. Proportions were transformed using the logit transformation to stabilize variances and improve the normality of sampling distributions. For parameters that showed a tendency to extreme proportions, the Freeman-Tukey double arcsine transformation was used instead, due to its better performance in this context. Clopper-Pearson exact confidence intervals were calculated for individual study proportions to ensure accurate estimation, particularly in small samples. For studies with zero events in one or more cells, a continuity correction of 0.5 was applied to enable inclusion in the analysis and prevent computational errors.\u003c/p\u003e\u003cp\u003eTo assess potential biases, funnel plots were generated for parameters reported in more than 10 studies.\u003c/p\u003e\u003cp\u003eA subgroup analysis of cervical and lumbar tumors was also performed.\u003c/p\u003e\u003cp\u003eTo assess whether the rate of motor deficits varied by nerve root, we performed a generalized Fisher\u0026rsquo;s exact test. Additionally, binomial tests compared the observed rates of deficits for each root against reference values derived from our meta-analysis. Descriptive differences between observed and expected rates were visualized using a bar plot.\u003c/p\u003e\u003cp\u003eAll statistical analyses were performed by using the R software.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eOur search initially yielded 1,561 papers. After removing duplicates, 1,135 records were screened by title for eligibility. Of these, 97 were deemed suitable for abstract screening, and 61 were selected for full-text review. Four additional eligible reports were identified through the bibliography of the reviewed papers, bringing the total number of full-text articles assessed to 64. Ultimately, 12 studies met the inclusion criteria for our analysis.\u003c/p\u003e\u003cp\u003eFor the purposes of this study, we grouped two publications by McCormick from 1996 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], which separately reported his experience with cervical and thoracolumbar tumors. These were treated as a single study, referred to as \u0026ldquo;McCormick 1996 a\u0026thinsp;+\u0026thinsp;b.\u0026rdquo; Consequently, the final number of included studies was considered to be 11.\u003c/p\u003e\u003cp\u003eA total of 121 patients were included (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Immediate and follow-up (FU) motor outcomes were reported in all 11 studies (121 patients). The degree of motor deficits at follow-up was available in 10 studies, encompassing 96 patients. Sensory outcomes were reported in 5 studies (52 patients). Pain outcomes were clearly described in only three studies with great heterogeneity and were therefore excluded from the analysis. Data on intraoperative neurophysiological monitoring responses were reported in one paper only [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and were thus excluded from the analysis.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of the data reported in the included papers. Raw numbers have been pooled calculating crude proportions.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"11\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthor, year\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean age (y)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN. cervical\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN. lumbar\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eImmediate motor deficits\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eImmediate sensory deficits\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMotor deficits FU\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eSensory deficits FU\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eSignificant* motor deficits FU\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eMean FU (MOs)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchulteiss 1993\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMcCormick 1996*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiura 1998\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCelli 2005\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJiang 2009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSatoh 2011\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNakamura 2012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYamane 2013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eButenschoen 2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVandenbulcke 2023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYang 2024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSum or weighted average\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e121\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e49\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e81\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e40\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e56\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e20 (n\u0026thinsp;=\u0026thinsp;52)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e22\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003e13 (n\u0026thinsp;=\u0026thinsp;52)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e4 (n\u0026thinsp;=\u0026thinsp;96)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u003cb\u003e24\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCrude proportion (CI)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e46% (38%-55%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e38% (26%-52%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e18% (12%-26%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003e25% (15%-39%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e4% (2%-10%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Global analysis\u003c/h2\u003e\u003cp\u003e\u003cb\u003eImmediate postoperative motor deficits\u003c/b\u003e: crude proportion: 46% (95%CI 38%-55%). Proportion estimated with random effects model: 46% (95% CI: 31%-62%). I^2 was 46.5%, indicating moderate heterogeneity.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePersistent motor deficits at last FU\u003c/b\u003e: crude proportion: 18% (95%CI 12%-26%). Proportion estimated with random effects model: 21% (95% CI: 14%-31%). I^2 was 0.0%, indicating low heterogeneity.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSignificant motor deficit (MRC\u0026thinsp;\u0026le;\u0026thinsp;3) at last FU\u003c/b\u003e: crude proportion: 4% (95%CI 2%-10%). Proportion estimated with random effects model: 1% (95% CI: 0%-7%). I^2 was 0.0%, indicating low heterogeneity.\u003c/p\u003e\u003cp\u003eThe forest and funnel plots for motor outcomes are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eImmediate postoperative sensory deficits\u003c/b\u003e: crude proportion: 38% (95%CI 26%-52%). Proportion estimated with random effects model: 40% (95% CI: 6%-88%). I^2 was 73.2%, indicating substantial heterogeneity.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePersistent postoperative sensory deficits at last FU\u003c/b\u003e: crude proportion: 25% (95%CI 15%-39%). Proportion estimated with random effects model: 24% (95% CI: 2%-75%). I^2 was 72.7%, indicating substantial heterogeneity.\u003c/p\u003e\u003cp\u003eForest plots for sensory outcomes are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Due to the low number of studies reporting these outcomes (\u0026lt;\u0026thinsp;10), funnel plots are not applicable.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Subgroup analysis\u003c/h2\u003e\u003cp\u003eTo identify possible differences in outcome between cervical and lumbar tumors, we have performed a subgroup analysis. For this purpose, studies presenting both cervical and lumbar tumors have been split. Of note, this can introduce a bias as it modifies the weight of those studies by reducing their sample size. However, given the similarity in surgical techniques and the overall good quality of the papers, we believe that the impact of this procedure should be not significant. The results of this subgroup analysis, including raw proportions, are also reported in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The forest plots for the subgroup analyses can be found in the supplementary material.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of the crude proportions and meta-analytical estimates of the incidence of postoperative motor deficits for all tumors, lumbar tumors and cervical tumors.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCrude Proportions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eImmediate motor deficit\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePersistent motor deficit\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSignificant deficit at FU\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e46%\u003c/b\u003e (38%-55%),\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e18%\u003c/b\u003e (12%-26%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e4%\u003c/b\u003e (2%-10%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eCervical\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e52%\u003c/b\u003e \u003cem\u003e(41%-63%)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e21%\u003c/b\u003e \u003cem\u003e(13%-31%)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e4%\u003c/b\u003e \u003cem\u003e(1%-13%)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eLumbar\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e32%\u003c/b\u003e \u003cem\u003e(19%-49%)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e12%\u003c/b\u003e \u003cem\u003e(5%-28%)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e5%\u003c/b\u003e \u003cem\u003e(1%-18%)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMeta-analysis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eImmediate motor deficit\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003ePersistent motor deficit\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eSignificant deficit at FU\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e46%\u003c/b\u003e (31%-62%) I\u0026sup2; = 46.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e21%\u003c/b\u003e (14%-31%), I\u0026sup2; = 0.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e1%\u003c/b\u003e (0%-7%), I\u0026sup2; = 0.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eCervical\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e51%\u003c/b\u003e \u003cem\u003e(36%-67%), I\u0026sup2; = 17.9%\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e23%\u003c/b\u003e \u003cem\u003e(16%-33%), I\u0026sup2; = 0%\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0%\u003c/b\u003e \u003cem\u003e(0%-4%), I\u0026sup2; = 0%\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eLumbar\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e34%\u003c/b\u003e \u003cem\u003e(16%-59%), I\u0026sup2; = 25.3%\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e20%\u003c/b\u003e \u003cem\u003e(8%-41%), I\u0026sup2; = 0%\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e1%\u003c/b\u003e \u003cem\u003e(1%-12%), I\u0026sup2; = 0%\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eChi-square tests were conducted to compare proportions between groups. Although there appeared to be a notable difference in the rate of early motor deficits between the cervical and lumbar groups, this difference did not reach statistical significance.\u003c/p\u003e\u003cp\u003eWe also conducted a separate analysis focused on the rate of postoperative motor deficits associated with each individual nerve root. Data on outcomes by nerve root were available in eight studies, comprising a total of 80 patients (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Within this subgroup, 38 immediate postoperative motor deficits (46%) and 14 permanent motor deficits (18%) were reported rates that are consistent with those observed in the overall cohort.\u003c/p\u003e\n\u003cp\u003eTable 4. Data on postoperative motor deficits per nerve root, with crude proportions\u003c/p\u003e\n\u003ctable style=\"border-collapse: collapse;border: none;width: 601px;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.9pt;border: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eRoot\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eTotal\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eTransient deficit (%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;padding: 2pt 0cm;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003ePersistent deficit (%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.9pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eC5\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e19\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:red;'\u003e13 (68%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:red;'\u003e5 (26%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.9pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eC6\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e11\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:red;'\u003e7 (64%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:red;'\u003e3 (27%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.9pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eC7\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e10\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:#6AA84F;'\u003e4 (40%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:#6AA84F;'\u003e1 (10%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.9pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eC8\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:red;'\u003e7 (87%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:red;'\u003e4 (50%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.9pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eT1\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:#6AA84F;'\u003e0 (0%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:#6AA84F;'\u003e0 (0%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.9pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eL3\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e9\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:#6AA84F;'\u003e0 (0%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:#6AA84F;'\u003e0 (0%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.9pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eL4\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:#6AA84F;'\u003e1 (20%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:red;'\u003e1 (20%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.9pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eL5\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:red;'\u003e4 (57%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:#6AA84F;'\u003e0 (0%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.9pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eS1\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:#6AA84F;'\u003e2 (25%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;color:#6AA84F;'\u003e0 (0%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.9pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eTotal (%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e80 (100%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e38 (47%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e14 (17%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 225.75pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eFisher\u0026rsquo;s Test\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eSignificant (p\u0026lt;0.001)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112.85pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 2pt;vertical-align: bottom;\"\u003e\n \u003cp style='margin:0cm;line-height:115%;font-size:15px;font-family:\"Arial\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:13px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eNon-significant (p\u0026gt;0.05)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe generalized Fisher\u0026rsquo;s exact test revealed a statistically significant difference in the distribution of immediate motor deficits across nerve roots (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that deficits were not evenly distributed. In contrast, the test did not show statistical significance for permanent deficits, suggesting that the distribution of long-term outcomes did not differ significantly from what would be expected under a uniform distribution. Deviations between observed and expected deficit rates for each nerve root are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Binomial tests comparing observed rates of motor deficits for individual nerve roots to the reference proportions calculated in our meta-analysis (0.46 for immediate and 0.21 for persistent deficits) were conducted, adjusting p-value with Bonferroni correction for multiple comparisons. Specifically, for immediate postoperative deficits C8 showed the highest observed rate (87.5%) and reached statistical significance (p\u0026thinsp;=\u0026thinsp;0.00265). L3 presented a lower-than-expected rate of immediate postoperative deficits (0%) which also reached statistical significance (p\u0026thinsp;=\u0026thinsp;0.0054). For persistent deficits, no nerve root reached statistical significance. However, these data must be interpreted with great caution due to the very small sample sizes and wide confidence intervals.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe treatment of dumbbell tumors arising from spinal nerves poses distinct challenges compared to purely intracanalicular or extracanalicular tumors. In the former, the affected rootlet - often a sensory or functionally insignificant one [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] - can typically be identified, isolated from adjacent roots, and sacrificed with minimal neurological consequences [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In the latter, nerve-sparing intracapsular resection is generally feasible and has been associated with favorable neurological and oncological outcomes [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Dumbbell tumors, however, differ significantly in both anatomy and behavior. Subarachnoid nerve fascicles lack well-developed connective tissue layers (particularly perineurium and epineurium) that compartmentalize tumor growth and allow for intracapsular, nerve-sparing resection in postganglionic tumors [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. As a result, when a tumor extends into the foraminal and ganglionic portions of the nerve, \u0026ldquo;bystander\u0026rdquo; fascicles appear to dissolve into the tumor, and intracapsular resection does not reliably preserve them [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMoreover, evidence indicates that the remaining non-tumoral fascicles within the affected nerve root exhibit histopathological features of chronic degeneration [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This finding may help explain reports showing that complete resection of the involved nerve root is often associated with surprisingly low rates of persistent postoperative motor deficits [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A plausible pathophysiological rationale is that prolonged compression against the bony limits of the intervertebral foramen has already impaired the functional integrity of these fascicles (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Consequently, compensatory neurological adaptation may have occurred at the plexus level prior to surgery (or may emerge postoperatively) thereby contributing to the generally low incidence of new or lasting neurological deficits. This is in contrast with peripheral nerve tumors, where nerve sacrifice is typically associated with permanent, severe deficits [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFor these reasons, instead of trying to preserve the continuity of the nerve by performing a subtotal resection, which does not grant spared function [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and is associated with significantly higher risk of recurrence [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], some authors routinely perform total nerve root sacrifice in the treatment of dumbbell tumors, aiming for a radical resection [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Although several case series have been published, no systematic study of this practice has been performed to date.\u003c/p\u003e\u003cp\u003eThe first relatively large study on this topic was published by Kim and colleagues [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In their series of 31 tumors arising from nerve roots at the C5\u0026ndash;T1 and L3\u0026ndash;S1 levels, the authors reported that both intradural rootlet and complete nerve root sacrifice resulted in similarly low rates of postoperative deficits (approximately 20%). In particular, among the 15 \u0026ldquo;large tumors\u0026rdquo; requiring full nerve root sacrifice, only 24% of patients experienced postoperative motor or sensory deficits. Despite its historical relevance, this study was excluded from our analysis due to two limitations: (1) it reported mixed motor and sensory outcomes, and (2) it lacked long-term motor follow-up.\u003c/p\u003e\u003cp\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], McCormick published separately two detailed reports on dumbbell tumors of the cervical [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and thoracolumbar spine [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], including 24 patients. Among these, complete sacrifice of a motor root was performed in six cases (three cervical and three lumbar), resulting in three (50%) immediate motor deficits, which persisted at FU (although only one was significant). As stated previously, due to their methodological and clinical homogeneity, the two studies were considered as a single group in our analysis.\u003c/p\u003e\u003cp\u003eFurther evidence comes from Miura\u0026rsquo;s 1998 series, which included 15 patients, 12 with dumbbell tumors and 3 with purely intradural lesions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Among the dumbbell tumor subgroup, 12 motor-relevant roots were sacrificed, resulting in eight (67%) immediate and three (25%) persistent motor deficits. However, none were important.\u003c/p\u003e\u003cp\u003eIn a 2012 study, Nakamura reviewed 75 cases of cervical dumbbell tumors [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Of these, 25 patients underwent total sacrifice of a motor-relevant nerve root. Seventeen (68%) experienced immediate motor deterioration, with persistent deficits in six cases (24%) at follow-up. Unfortunately, the severity of these residual deficits was not specified.\u003c/p\u003e\u003cp\u003eA more recent series by Butenschoen, published [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], examined 21 patients, reporting four (19%) immediate motor deficits, only one (5%) of which persisted (and was of mild severity) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eYang and colleagues, in a study proposing a new classification system for cervical dumbbell tumors based on a cohort of 295 cases, reported on 15 instances of total motor root sacrifice [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Of these, seven patients (47%) exhibited immediate postoperative deficits, with only two (17%) persisting, neither of which were considered clinically significant.\u003c/p\u003e\u003cp\u003eFinally, our institutional series of 26 dumbbell tumors (including the sacrifice of 13 motor-relevant nerve roots) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] demonstrated an incidence of immediate motor deficits of 38% (5 of 13 patients) and persistent deficits of 15% (2 patients). However, only one deficit (7.6%) was considered clinically important at follow-up.\u003c/p\u003e\u003cp\u003eGlobally, our analysis indicates that in the surgical treatment of dumbbell tumors of motor-relevant spinal nerves, complete sacrifice of the affected nerve root results in new postoperative motor deficits in approximately 46% of patients (95% CI: 31\u0026ndash;62%) immediately after surgery, and in 21% (95% CI: 14\u0026ndash;31%) as persistent deficits. Among those with lasting deficits, significant motor impairment (MRC\u0026thinsp;\u0026le;\u0026thinsp;3 or clinically disabling) is rare, occurring in roughly 1% of all patients (95% CI: 0\u0026ndash;7%). The higher heterogeneity (I^2\u0026thinsp;=\u0026thinsp;46.5%) in immediate motor deficits could reflect variation in disease stage at the time of surgery, with differing degrees of preoperative neural compensation. In contrast, the more consistent rates of persistent motor deficits suggest that long-term recovery may level out these initial differences.\u003c/p\u003e\u003cp\u003eSensory outcomes showed considerable variability across studies. The estimated proportion of immediate postoperative sensory deficits was 40% (95% CI: 6\u0026ndash;88%), while persistent deficits were estimated at 24% (95% CI: 2\u0026ndash;75%). Crude proportions were 38% and 25%, respectively. However, high heterogeneity was observed for both outcomes, significantly limiting the precision of these estimates. A reason for the lower quality of data on this domain may be the tendency to focus on motor outcomes, overlooking sensation.\u003c/p\u003e\u003cp\u003eOutcomes following nerve root sacrifice were analyzed separately for cervical and lumbar tumors. For cervical tumors, the estimated incidence of immediate postoperative motor deficits was 51% (95% CI: 36\u0026ndash;67%), with 23% (95% CI: 16\u0026ndash;33%) of patients experiencing persistent deficits. Significant long-term motor deficits (MRC\u0026thinsp;\u0026le;\u0026thinsp;3) were rare, with an estimated rate of 0% (95% CI: 0\u0026ndash;4%). For lumbar tumors, immediate motor deficits occurred in 34% of cases (95% CI: 16\u0026ndash;59%), with 20% (95% CI: 8\u0026ndash;41%) showing persistent symptoms. Significant motor deficits were again uncommon, estimated at 1% (95% CI: 0\u0026ndash;12%). Similarly, sensory outcomes were highly heterogeneous (see the \u0026ldquo;results\u0026rdquo; section).\u003c/p\u003e\u003cp\u003eNotably, the observed differences between cervical and lumbar groups were not statistically significant.\u003c/p\u003e\u003cp\u003eWe explored whether specific nerve roots were more prone to postoperative motor deficits when sacrificed, using data from eight studies totaling 80 patients. Fisher\u0026rsquo;s exact test showed a significant difference in the distribution of immediate deficits (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), suggesting variability among roots. However, no significant difference was found for persistent deficits, indicating more uniform long-term outcomes. When individual roots were studied, binomial tests showed significant deviations from expected rates only for C8 and L3, with C8 demonstrating higher-than-expected and L3 lower-than-expected rates of immediate deficits. A similar, though non-significant, trend was observed for persistent deficits (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Although interesting, these data must be interpreted with great caution due to the very small sample sizes and wide confidence intervals. Other authors suspected higher rates of permanent motor deficits after sacrifice of the C5 root [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Larger samples would be required to better explore these putative asymmetries.\u003c/p\u003e\u003cp\u003eOf note, the L2 nerve root was excluded from most studies in the literature, likely because, although it contributes to motor function (hip flexion), its loss can often be compensated for by adjacent muscles. Including it could therefore introduce confounding. For this reason, we also chose not to incorporate L2 in our analysis.\u003c/p\u003e\u003cp\u003eWe initially aimed to analyze data on intraoperative neurophysiological monitoring, a parameter of considerable clinical interest [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, meaningful information was available in only one study [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], preventing its inclusion in our analysis.\u003c/p\u003e\u003cp\u003eSimilarly, pain outcomes related to sacrificed motor-relevant roots were reported in just three studies (considering the two studies by McCormick as one) with great heterogeneity (two studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] reporting no cases of long-term neuropathic pain and one study reporting six cases [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]), making any meaningful analysis unfeasible.\u003c/p\u003e\u003cp\u003eOur study has several limitations, largely deriving from biases in the available literature. The total number of included patients was relatively small, reflecting the rarity of the condition. While this limits statistical power, the systematic aggregation of existing data remains valuable in the absence of larger prospective studies. Of note, many studies on nerve root sacrifice were excluded from our analysis because they did not report outcomes specific to motor-relevant roots or failed to distinguish between intradural rootlet sacrifice and complete root resection. This contributed to reducing the sample size, but increased the homogeneity of the data and strengthened our conclusion.\u003c/p\u003e\u003cp\u003eImportant clinical variables, such as tumor size, were inconsistently reported (only three studies) making meaningful analysis impossible. However, the focus on dumbbell tumors only (as defined in the methods section) helped in minimizing heterogeneity, excluding both small, purely intracanalicular tumors, as well as giant/complex tumors. Similarly, data regarding the entity of resection was available for 4 studies only; however, given the total sacrifice of the nerve root performed in all cases, we believe that the entity of tumor resection had little impact on postoperative radicular deficits.\u003c/p\u003e\u003cp\u003eFollow-up duration was documented in 6 studies only, potentially affecting estimates of long-term deficits. However, longer or more consistent follow-up would likely reveal lower rates of persistent deficits, rather than higher.\u003c/p\u003e\u003cp\u003eSensory deficits could be analyzed as they were reported in a sufficient number of studies; however, the great heterogeneity observed warns of interpreting the results with caution. Unfortunately, pain outcomes could not be studied as they were clearly reported in two studies only.\u003c/p\u003e\u003cp\u003eFinally, publication bias is possible, with a tendency to publish case series reporting more favorable outcomes. To help assess this, we included funnel plots where the number of studies permitted, even if they are not typically employed in meta-analyses of proportions [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The plots appeared symmetrical, reducing the likelihood of significant publication bias.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eOur study reviews the existing literature on neurological outcomes following treatment of spinal dumbbell tumors involving nerve root sacrifice. Despite important limitations in the available literature (mainly deriving from the rarity of the condition, the difficulty in performing comparative and randomized studies, and the publication bias typical of retrospective surgical series) our analysis indicates that transient motor deficits are common, while permanent, severe deficits are rare. Evidence regarding sensory and pain outcomes remains highly heterogeneous and difficult to interpret. Although additional data are needed to reach more definitive conclusions, this study provides the first synthesis of the literature on this topic over the past 30 years.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.B. designed the study. A.B., D.C. and C.Y.B. collected the data. A.B. performed the statistical analysis. A.B. and D.C. wrote the main manuscript text. D.C., G.C., and C.Y.B. prepared the figures and the tables. G.C. and C.Y.B. reviewed the manuscript. C.Y.B. supervised the project. All authors approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMcCormick PC. Surgical management of dumbbell tumors of the cervical spine. Neurosurgery. 1996 Feb;38(2):294-300. doi: 10.1097/00006123-199602000-00012.\u003c/li\u003e\n\u003cli\u003eHasegawa M, Fujisawa H, Hayashi Y, Tachibana O, Kida S, Yamashita J. Surgical pathology of spinal schwannomas: a light and electron microscopic analysis of tumor capsules. Neurosurgery. 2001 Dec;49(6):1388-92; discussion 1392-3. doi: 10.1097/00006123-200112000-00016.\u003c/li\u003e\n\u003cli\u003eMcCormick PC. Surgical management of dumbbell and paraspinal tumors of the thoracic and lumbar spine. Neurosurgery. 1996 Jan;38(1):67-74; discussion 74-5. doi: 10.1097/00006123-199601000-00017.\u003c/li\u003e\n\u003cli\u003eYang M, Zhong N, Lou Y, Jiang D, Liu Y, Dai Z, Wan W, Jiao J, Yang X, Xiao J. A Novel and Reproducible Classification of Cervical Dumbbell Tumors to Inform Surgical Approach and Reconstruction Techniques. Spine (Phila Pa 1976). 2024 May 15;49(10):715-725. doi: 10.1097/BRS.0000000000004927.\u003c/li\u003e\n\u003cli\u003eVandenbulcke A, D\u0026apos;Onofrio GF, Capo G, Baassiri W, Barrey CY. Sacrifice of Involved Nerve Root during Surgical Resection of Foraminal and/or Dumbbell Spinal Neurinomas. Brain Sci. 2023 Jan 7;13(1):109. doi: 10.3390/brainsci13010109.\u003c/li\u003e\n\u003cli\u003eButenschoen VM, K\u0026ouml;gl N, Meyer B, Thom\u0026eacute; C, Wostrack M. A Case Series of Surgically Treated Spinal Dumbbell Tumors of Critical Parent Nerve Roots: To Cut or Not to Cut? Oper Neurosurg. 2021 Feb 16;20(3):260-267. doi: 10.1093/ons/opaa365. \u003c/li\u003e\n\u003cli\u003eNakamura M, Iwanami A, Tsuji O, Hosogane N, Watanabe K, Tsuji T, Ishii K, Toyama Y, Chiba K, Matsumoto M. Long-term surgical outcomes of cervical dumbbell neurinomas. J Orthop Sci. 2013 Jan;18(1):8-13. doi: 10.1007/s00776-012-0300-2. \u003c/li\u003e\n\u003cli\u003eMiura T, Nakamura K, Tanaka H, Kawaguchi H, Takeshita K, Kurokawa T. Resection of cervical spinal neurinoma including affected nerve root: recovery of neurological deficit in 15 cases. Acta Orthop Scand. 1998 Jun;69(3):280-2. doi: 10.3109/17453679809000930. PMID: 9703403.\u003c/li\u003e\n\u003cli\u003eSchultheiss R, Gullotta G. 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J Neurosurg. 2001 Apr;94(2 Suppl):210-5. doi: 10.3171/spi.2001.94.2.0210.\u003c/li\u003e\n\u003cli\u003eSterne JA, Hern\u0026aacute;n MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, Henry D, Altman DG, Ansari MT, Boutron I, Carpenter JR, Chan AW, Churchill R, Deeks JJ, Hr\u0026oacute;bjartsson A, Kirkham J, J\u0026uuml;ni P, Loke YK, Pigott TD, Ramsay CR, Regidor D, Rothstein HR, Sandhu L, Santaguida PL, Sch\u0026uuml;nemann HJ, Shea B, Shrier I, Tugwell P, Turner L, Valentine JC, Waddington H, Waters E, Wells GA, Whiting PF, Higgins JP. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016 Oct 12;355:i4919. doi: 10.1136/bmj.i4919.\u003c/li\u003e\n\u003cli\u003eSafaee MM, Lyon R, Barbaro NM, Chou D, Mummaneni PV, Weinstein PR, Chin CT, Tihan T, Ames CP. Neurological outcomes and surgical complications in 221 spinal nerve sheath tumors. J Neurosurg Spine. 2017 Jan;26(1):103-111. doi: 10.3171/2016.5.SPINE15974.\u003c/li\u003e\n\u003cli\u003eBenato A, D\u0026apos;Alessandris QG, Murazio M, Pacelli F, Mattogno PP, Fern\u0026aacute;ndez E, Lauretti L. Integrated Neurosurgical Management of Retroperitoneal Benign Nerve Sheath Tumors. Cancers (Basel). 2023 Jun 10;15(12):3138. doi: 10.3390/cancers15123138. \u003c/li\u003e\n\u003cli\u003eStone JJ, Spinner RJ. Go for the Gold: A \u0026quot;Plane\u0026quot; and Simple Technique for Resecting Benign Peripheral Nerve Sheath Tumors. Oper Neurosurg. 2020 Jan 1;18(1):60-68. doi: 10.1093/ons/opz034.\u003c/li\u003e\n\u003cli\u003eFehlings MG, Nater A, Zamorano JJ, Tetreault LA, Varga PP, Gokaslan ZL, Boriani S, Fisher CG, Rhines L, Bettegowda C, Kawahara N, Chou D. Risk Factors for Recurrence of Surgically Treated Conventional Spinal Schwannomas: Analysis of 169 Patients From a Multicenter International Database. Spine (Phila Pa 1976). 2016 Mar;41(5):390-8. doi: 10.1097/BRS.0000000000001232.\u003c/li\u003e\n\u003cli\u003eSohn S, Chung CK, Park SH, Kim ES, Kim KJ, Kim CH. The fate of spinal schwannomas following subtotal resection: a retrospective multicenter study by the Korea spinal oncology research group. J Neurooncol. 2013 Sep;114(3):345-51. doi: 10.1007/s11060-013-1190-7.\u003c/li\u003e\n\u003cli\u003eKaneko K, Kato Y, Kojima T, Imajyo Y, Taguchi T. Intraoperative electrophysiologic studies on the functions of nerve roots involved in cervical dumbbell-shaped schwannoma and their clinical utility. J Spinal Disord Tech. 2006 Dec;19(8):571-6. doi: 10.1097/01.bsd.0000211227.04802.b3.\u003c/li\u003e\n\u003cli\u003eBarker TH, Migliavaca CB, Stein C, Colpani V, Falavigna M, Aromataris E, Munn Z. Conducting proportional meta-analysis in different types of systematic reviews: a guide for synthesisers of evidence. BMC Med Res Methodol. 2021 Sep 20;21(1):189. doi: 10.1186/s12874-021-01381-z. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Dumbbell tumor, schwannoma, neurofibroma, spinal tumors, nerve root sacrifice, neurological outcome, meta-analysis","lastPublishedDoi":"10.21203/rs.3.rs-7427118/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7427118/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: In the surgical treatment of spinal dumbbell tumors, preservation of the nerve root of origin is often challenging, and complete tumor removal may require intentional sacrifice of motor-relevant nerve roots. Despite this, postoperative motor deficits are frequently minimal or transient, as reported by several series. This systematic review and meta-analysis evaluates neurological outcomes following nerve root sacrifice at motor-relevant levels.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A systematic search of PubMed and Scopus was performed per PRISMA guidelines. Studies included adult patients (≥18 years) with dumbbell tumors at motor-relevant spinal levels (C5–T1, L3–S1) treated with nerve root sacrifice. Pooled analyses and meta-analyses of proportions were conducted, including subgroup analyses for lumbar and cervical tumors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Thirteen studies comprising 121 patients were included. After pooling of raw data across studies, crude rates of immediate and persistent motor deficits were 46% and 18%, respectively. Meta-analytic estimates showed immediate deficits in 46% (95% CI: 31%–62%) and persistent deficits in 21% (95% CI: 14%–31%). Severe persistent motor deficits (Medical Research Council grade ≤3) were rare, occurring in 1% (95% CI: 0%–7%); crude rate was 4%. Sensory deficits were more variable across studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Most patients tolerate nerve root sacrifice without significant long-term motor impairment, likely due to chronic nerve compression inside the intervertebral foramen and neural compensation. Although transient motor deficits are frequent, severe permanent deficits are uncommon. Our analysis provides the first synthesis of the literature on this topic to help supporting surgical decision making. Caution in interpretating these results is still warranted due to small sample sizes and potential publication bias.\u003c/p\u003e","manuscriptTitle":"Neurological outcomes following nerve root sacrifice during resection of dumbbell tumors of the spine: a systematic review and pooled analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 02:46:53","doi":"10.21203/rs.3.rs-7427118/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-06T07:41:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-06T07:14:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-02T16:40:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-29T19:16:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58562184064231072003918251256174549750","date":"2025-09-15T16:07:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22500914195879938999381477886441233856","date":"2025-09-14T18:19:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140357923867414733212111770003768262642","date":"2025-09-13T23:04:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"216967790385794131944407713000097293556","date":"2025-09-13T11:39:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-13T05:13:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-25T06:09:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-25T06:08:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Spine Journal","date":"2025-08-21T14:17:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7ea06781-f493-4549-8f28-1c2a8682f29b","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T16:03:40+00:00","versionOfRecord":{"articleIdentity":"rs-7427118","link":"https://doi.org/10.1007/s00586-026-09903-3","journal":{"identity":"european-spine-journal","isVorOnly":false,"title":"European Spine Journal"},"publishedOn":"2026-04-03 16:00:03","publishedOnDateReadable":"April 3rd, 2026"},"versionCreatedAt":"2025-09-23 02:46:53","video":"","vorDoi":"10.1007/s00586-026-09903-3","vorDoiUrl":"https://doi.org/10.1007/s00586-026-09903-3","workflowStages":[]},"version":"v1","identity":"rs-7427118","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7427118","identity":"rs-7427118","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}