Spinal cord tumor surgery [Neurosurgery Wiki]

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====== Spinal cord tumor surgery ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1zqXPI1EmDrx_6VCUSPV3ISON7wt5q_553WcQDgDZ83f9-8YBJ/?limit=15&utm_campaign=pubmed-2&fc=20250108180852}}

see [[Spinal intramedullary tumor surgery]]

Most [[intradural spinal tumor]]s can be treated with contemporary microsurgical techniques with long-term control or cure of the lesion and preservation of neurological function
((Spirig J, Fournier JY, Hildebrandt G, Gautschi OP. [Spinal tumors - part 2:
intradural tumors. Epidemiology, clinical aspects and therapy]. Praxis (Bern
1994). 2011 Jul 6;100(14):849-56. doi: 10.1024/1661-8157/a000592. Review. German.
PubMed PMID: 21732297.
)).


Standard posterior approaches provide adequate exposure to safely remove the vast majority of these lesions without the need for a potentially destabilizing resection of the facet or pedicle. Posterior exposures with varying degrees of lateral bone resection, dentate ligament division, and gentle cord rotation may also provide adequate exposure for safe removal of nonmidline ventrolateral superficial pial presenting spinal cord lesions. Nevertheless, in certain cases of ventral intradural lesions, anterior approaches are necessary and should be considered under appropriate circumstances
((Angevine PD, Kellner C, Haque RM, McCormick PC. Surgical management of ventral
intradural spinal lesions. J Neurosurg Spine. 2011 Jul;15(1):28-37. doi:
10.3171/2011.3.SPINE1095. Epub 2011 Apr 15. PubMed PMID: 21495815.)).

In a [[retrospective study]] of 29 [[patient]]s with 30 [[extramedullar]]y, [[intradural]] [[spinal]] [[tumor]]s [[approach]]ed through [[unilateral laminectomy]] -[[hemilaminectomy]]. 

[[Epidemiology]], location and [[histology]] of the [[lesion]]s and radiological and clinical evolution of the patients were recorded. The [[Nurick scale]] was used in the preoperative and postoperative functional assessment conducted during the last follow-up consultation. The mean age of patients was 60 years and there was a predominance of the female gender. The mean time elapsed from the onset of symptoms to diagnosis was 11.6 months. Sensitive and motor deficits were the most common symptoms. Meningioma was the most frequent lesion, followed by neurinoma and ependymoma. The most commonly affected level was the dorsal, followed by the lumbar and cervical.

Total resection was performed in all cases except for one cervical [[neuroma]] with extraforaminal extension. Three patients presented postoperative complications -[[cerebrospinal fluid fistula]], asymptomatic [[pseudomeningocele]] and postoperative functional worsening- which were resolved with [[conservative treatment]]. The mean time of clinical and radiological follow-up was 33.4 months, with no tumoural [[recurrence]]s being observed except for two cases of [[meningioma]]s. After the follow-up period, patients without functional disorders remained stable and all patients with functional disorders presented a clinical improvement of at least one point in the Nurick scale.

The microsurgical unilateral approach is a safe and effective technique for the resection of most extramedullary, intradural spinal tumours
((González-Martínez EL, García-Cosamalón PJ, Fernández-Fernández JJ, Ibáñez-Plágaro FJ, Alvarez B. [Minimally invasive approach of extramedullary intradural spinal tumours. Review of 30 cases]. Neurocirugia (Astur). 2012
Sep;23(5):175-81. doi: 10.1016/j.neucir.2012.02.005. Epub 2012 Aug 4. Spanish. PubMed PMID: 22871355.)).

----

Traditionally, the surgical resection of a [[spinal cord tumor]] has been performed through total [[laminectomy]]
((Cervoni L, Celli P, Cantore G, Fortuna A. Intradural tumors of the cauda
equina: a single institution review of clinical characteristics. Clin Neurol
Neurosurg. 1995 Feb;97(1):8-12. PubMed PMID: 7788980.
)).

Seppala et al.
((Seppälä MT, Haltia MJ, Sankila RJ, Jääskeläinen JE, Heiskanen O. Long-term
outcome after removal of spinal schwannoma: a clinicopathological study of 187
cases. J Neurosurg. 1995 Oct;83(4):621-6. PubMed PMID: 7674010.
))
analyzed 187 patients who had total [[laminectomy]] for [[spinal cord tumor]]s and reported satisfactory prognoses. However, total laminectomy may cause [[spinal instability]] and [[kyphosis]] due to the damage to the musculoligamentous structures and posterior bony elements. And these complications may produce neurologic symptoms by compressing the spinal cord or nerve roots
((Yasuoka S, Peterson HA, MacCarty CS. Incidence of spinal column deformity
after multilevel laminectomy in children and adults. J Neurosurg. 1982
Oct;57(4):441-5. PubMed PMID: 7108592.
)).

In order to prevent such complications, a total laminectomy with arthrodesis or a unilateral limited laminectomy, which was reported to be useful by Yasargil et al.
((Yaşargil MG, Tranmer BI, Adamson TE, Roth P. Unilateral partial
hemi-laminectomy for the removal of extra- and intramedullary tumours and AVMs.
Adv Tech Stand Neurosurg. 1991;18:113-32. Review. PubMed PMID: 1930371.
))
in 1991, often has to be performed. 

Bilateral damage to the [[ligamentum flavum]] and disruption of the [[Interspinous Ligament]] were considered to play an important role
((Chiou SM, Eggert HR, Laborde G, Seeger W. Microsurgical unilateral approaches 
for spinal tumour surgery: eight years' experience in 256 primary operated
patients. Acta Neurochir (Wien). 1989;100(3-4):127-33. PubMed PMID: 2589118.
)).

Stripping, dissection, and denervation of the posterior paraspinal muscle complex were also suggested to be responsible for post-laminectomy deformities
((Alexander E., Jr . Neurosurgery. New York: McGraw-Hill; 1985. Post-laminectomy kyphosis in Wilkins RH, Rengachary SS(eds) pp. 2293–2297.))
((Sario-glu AC, Hanci M, Bozkuş H, Kaynar MY, Kafadar A. Unilateral
hemilaminectomy for the removal of the spinal space-occupying lesions. Minim
Invasive Neurosurg. 1997 Jun;40(2):74-7. PubMed PMID: 9228342.
))
----
Intradural-extramedullary spinal cord tumors that are not extended to the vertebral foramen can be resected safely and completely by a unilateral limited laminectomy
((Sim JE, Noh SJ, Song YJ, Kim HD. Removal of intradural-extramedullary spinal
cord tumors with unilateral limited laminectomy. J Korean Neurosurg Soc. 2008
May;43(5):232-6. doi: 10.3340/jkns.2008.43.5.232. Epub 2008 May 20. PubMed PMID: 
19096602; PubMed Central PMCID: PMC2588222.
)).

----


Nowadays, the microsurgical technique, including the use of an [[ultrasonic aspirator]] (Cavitron Ultrasonic Surgical Aspirator [CUSA]), is employed as standard. 
Boström et al.recommend evoked potential-guided microsurgical total resection of ependymomas and other benign lesions; partial resection or biopsy followed by adjuvant therapy should be confined to patients with high-grade astrocytomas, whereas resection or biopsy with adjuvant therapy is the best option for metastatic lesions
((Boström A, Kanther NC, Grote A, Boström J. Management and outcome in adult
intramedullary spinal cord tumours: a 20-year single institution experience. BMC 
Res Notes. 2014 Dec 15;7:908. doi: 10.1186/1756-0500-7-908. PubMed PMID:
25495874; PubMed Central PMCID: PMC4302119.)).
===== Laminoplasty =====

----
[[Laminectomy]] (LAMT) and [[laminoplasty]] (LAMP) have been wildly applied on patients with [[spinal cord tumor]]s (SCTs). However, the clinical efficacy of LAMP versus LAMT remains controversial. The purpose of a study of Sun et al., from [[Yangzhou]], China. is to assess the safety and efficacy of LAMP compared with LAMT in the treatment of SCTs.

They searched several English and Chinese [[database]]s ([[PubMed]], [[EMBASE]], The [[Cochrane Library]], CBM, CNKI and WanFang) to identify relevant [[randomized controlled trial]]s (RCTs) or [[observational]] studies (OSs). The [[quality]] of included studies was assessed by the [[Cochrane Collaboration's tool]] and the [[Newcastle Ottawa Scale]] (NOS). The [[pooled analysis]] was conducted by [[RevMan]] 5.3 software. The [[outcome]] measures included the primary and secondary outcomes. Subgroups analysis was performed to explore the impact of study type, age, type of tumor, tumor size, surgical levels, follow-up time, surgical methods (whether with fusion) on the outcome measures.

Sixteen studies of 1096 patients with SCTs were included in this meta-analysis. The results showed that statistically significant difference between LAMP and LAMT groups was found in terms of effective recovery rate (ERR) (p = 0.003), blood loss (p < 0.00001), hospital stays (p = 0.006), spinal deformity (p = 0.01), cerebrospinal fluid (CSF) leak (p < 0.00001). However, there was no significant difference in total resection rate of tumor (p = 0.21) and operation time (p = 0.14). In subgroup analysis, the results indicated that age, type of tumor, follow-up time, surgical levels and methods were the influence factors for spinal deformity incidence.

LAMP might be a safer and more effective surgical method in the treatment of SCTs. In addition, the advantage of fusion in preventing the occurrence of spinal deformity should not to be ignored. However, due to the lack of high quality RCT studies and adequate data, the safety and validity of LAMP was undermined
((Sun S, Li Y, Wang X, Lu G, She L, Yan Z, Zhang H. Safety and efficacy of
laminoplasty versus laminectomy in the treatment of spinal cord tumors: a
systematic review and meta-analysis. World Neurosurg. 2018 Dec 19. pii:
S1878-8750(18)32855-9. doi: 10.1016/j.wneu.2018.12.033. [Epub ahead of print]
Review. PubMed PMID: 30579011.
)).

===== Intraoperative monitoring =====

[[Intraoperative monitoring for spinal cord tumor surgery]].

===== Intraoperative ultrasound for intradural spinal tumor =====

[[Intraoperative ultrasound for intradural spinal tumor]].

===== Complications =====
[[cerebrospinal fluid fistula]], asymptomatic [[pseudomeningocele]] and postoperative functional worsening

total laminectomy may cause [[spinal instability]] and [[kyphosis]] due to the damage to the musculoligamentous structures and posterior bony elements. And these complications may produce neurologic symptoms by compressing the spinal cord or nerve roots
((Yasuoka S, Peterson HA, MacCarty CS. Incidence of spinal column deformity
after multilevel laminectomy in children and adults. J Neurosurg. 1982
Oct;57(4):441-5. PubMed PMID: 7108592.
)).

In order to prevent such complications, a total laminectomy with arthrodesis or a unilateral limited laminectomy, which was reported to be useful by Yasargil et al.
((Yaşargil MG, Tranmer BI, Adamson TE, Roth P. Unilateral partial
hemi-laminectomy for the removal of extra- and intramedullary tumours and AVMs.
Adv Tech Stand Neurosurg. 1991;18:113-32. Review. PubMed PMID: 1930371.
))
in 1991.
----
Careful follow-up for postoperative spinal deformity and instability. Younger age, C2 laminectomy, and more laminectomy level were significantly associated with occurrence of deformity and instability after [[cervical]] [[spinal cord tumor]] resection. Upfront spinal fixation at the time of resection should be considered in selected patients
((Noh SH, Takahashi T, Inoue T, Park SM, Hanakita J, Minami M, Kanematsu R, Shimauchi-Ohtaki H, Ha Y. Postoperative spinal deformity and instability after cervical spinal cord tumor resection in adults: A systematic review and meta-analysis. J Clin Neurosci. 2022 Apr 23;100:148-154. doi: 10.1016/j.jocn.2022.04.005. Epub ahead of print. PMID: 35472680.)).
===== References =====