A systematic review of the utility of 5-aminolevulinic acid-induced fluorescence in spine tumor surgery

Background: 5-aminolevulinic acid (5-ALA)-induced fluorescence is well established in intracranial glioma surgery, aiding tumor visualization and extent of resection. This systematic review evaluates the utility of 5-ALA in spinal tumor surgery, focusing on fluorescence characteristics, resection outcomes, and perioperative safety. Methods: A systematic literature search was performed in Embase, Web of Science, PubMed, and MEDLINE databases; 13 studies met the inclusion criteria. Eligible studies involved human subjects undergoing spinal tumor surgery with intraoperative use of 5-ALA for tumor fluorescence. Primary outcomes assessed included fluorescence response and extent of resection; secondary outcomes included postoperative neurological status and adverse effects. Results: Thirteen studies involved 245 patients whose tumor diagnoses included ependymomas, meningiomas, astrocytomas, neurinomas, and metastatic lesions. Fluorescence rates varied by tumor type; uptake showed high positivity in ependymomas and meningiomas, but inconsistent findings for astrocytomas and metastases. Gross total resection was achieved more frequently in well-circumscribed benign tumors. Although patients experienced favorable postoperative outcomes, transient or persistent neurological deficits occurred in a subset of patients depending on tumor location and surgical complexity. Standard dosing (20 mg/kg preoperatively) was consistent across studies, and adverse effects were limited to expected photosensitivity. Conclusion: 5-ALA enhances intraoperative visualization and may facilitate more complete resection of selected spinal tumors, particularly ependymomas and meningiomas.