Spinal tumor surgery

J.Sales-Llopis

Neurosurgery Department, General University Hospital Alicante, Spain

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Spinal tumor surgery is often performed to remove or reduce the size of tumors affecting the spinal cord or spine, such as meningiomas, schwannomas, or other neural or bone-related tumors. The specific approach depends on the tumor's type, location, and symptoms.

1. Tumor Removal: The primary goal is to remove as much of the tumor as possible without damaging surrounding nerves or spinal structures.

2. Decompression: Relieving pressure on the spinal cord and nerves to alleviate pain, restore function, or prevent further neurological damage.

3. Stabilization: If the tumor has weakened the spine, spinal fusion or instrumentation (screws, rods) may be necessary to maintain stability.

The procedure for spinal tumor surgery involves several critical steps to ensure the effective removal of the tumor while minimizing damage to the surrounding spinal cord and nerves. Here is a detailed overview of the typical steps involved:

### 1. Preoperative Preparation:

1. Imaging Studies: Detailed imaging studies such as MRI and CT scans are performed to identify the tumor's location, type, and extent.
2. Preoperative Assessment: Includes a thorough evaluation of the patient’s overall health, including blood tests, and possibly a neurosurgical consultation.
3. Consent: The patient is informed about the procedure, including its risks and benefits, and gives consent for the surgery.

### 2. Anesthesia:

1. General Anesthesia: The patient is placed under general anesthesia to ensure they are unconscious and pain-free throughout the procedure.

### 3. Positioning:

1. Patient Positioning: The patient is carefully positioned on the operating table, often lying face down (prone) or on their side, depending on the location of the tumor.

### 4. Surgical Approach:

1. Incision: An incision is made over the area of the spine where the tumor is located. The size and location of the incision depend on the tumor’s location and the planned surgical approach.
2. Exposure: The muscles and tissues around the spine are carefully moved aside to expose the vertebrae and, if necessary, a section of the bone (lamina) is removed to access the tumor (laminectomy).

### 5. Tumor Removal:

1. Microsurgical Techniques: For tumors located near or within the spinal cord, microsurgical techniques with high magnification and precision tools are used to minimize damage to surrounding tissues.
2. Tumor Resection: The tumor is carefully removed. If the tumor is intradural (inside the dura mater but outside the spinal cord), it is carefully separated from the surrounding spinal cord and nerves.
3. Tumor Debulking: In cases where complete removal is not feasible, debulking (partial removal) may be performed to reduce the tumor’s size and alleviate pressure.

### 6. Decompression and Stabilization:

1. Decompression: Removing the tumor relieves pressure on the spinal cord and nerves, which can alleviate pain and improve neurological function.
2. Spinal Stabilization: If the tumor has caused instability in the spine, additional procedures such as spinal fusion or insertion of screws and rods may be performed to stabilize the spine.

### 7. Closure:

1. Closure: The incision is closed with sutures or staples. The muscles and tissues are repositioned, and the skin is closed.

### 8. Postoperative Care:

1. Recovery Room: The patient is monitored in the recovery room as they wake from anesthesia.
2. Pain Management: Pain management is provided, often including medications and sometimes physical therapy.
3. Monitoring: Vital signs and neurological status are closely monitored to detect any potential complications.

### 9. Follow-up:

1. Postoperative Imaging: MRI or CT scans are often performed to check the extent of tumor removal and to ensure there are no complications.
2. Rehabilitation: Depending on the surgery’s impact, physical therapy and rehabilitation may be required to help the patient regain strength and function.
3. Follow-up Visits: Regular follow-up visits are scheduled to monitor recovery, manage any complications, and check for potential tumor recurrence.

Each spinal tumor surgery is tailored to the individual patient’s needs and the specific characteristics of the tumor. The overall success and recovery depend on various factors, including the tumor type, location, and the patient’s overall health.

- Neurological Deficits: There is a risk of damaging spinal nerves, which could result in paralysis or loss of sensation. - Infection or Bleeding. - Spinal Instability: Post-surgery instability might require additional procedures. - Tumor Recurrence: Some tumors can recur, requiring further treatment.

### Recovery: - Hospital Stay: Usually several days, depending on the extent of the surgery. - Rehabilitation: Physical therapy is often required to regain strength, mobility, and function, especially if the patient had preoperative neurological deficits. - Follow-up: Regular MRIs are often performed to monitor for tumor recurrence.

### Outlook: - Benign Tumors: Prognosis is often excellent with complete removal, especially for benign tumors like meningiomas or schwannomas. - Malignant Tumors: If the tumor is metastatic or malignant, surgery is often combined with other treatments like radiation or chemotherapy.

In summary, spinal tumor surgery is highly individualized, and outcomes depend on factors such as tumor type, location, and the patient's overall health.

Cervical corpectomy.

Costotransversectomy.

En bloc resection for vertebral tumor.

Lumbar corpectomy.

Lumbar spondylectomy

Total sacrectomy

Spinal tumor surgery is often the treatment of choice for tumors that can be removed with an acceptable risk of spinal cord or nerve injury damage.

Newer techniques and instruments allow neurosurgeons to reach tumors that were once considered inaccessible. The high-powered microscopes used in microsurgery make it easier to distinguish tumor from healthy tissue.

Doctors also can monitor the function of the spinal cord and other important nerves during surgery, thus minimizing the chance of injuring them. In some instances, very high-frequency sound waves might be used during surgery to break up tumors and remove the fragments.

But even with the latest technological advances in surgery, not all tumors can be totally removed. When the tumor can't be removed completely, surgery may be followed by radiation therapy or chemotherapy or both.

Recovery from spinal surgery may take weeks or longer, depending on the procedure. You may experience a temporary loss of sensation or other complications, including bleeding and damage to nerve tissue.

Multiple studies have attempted to evaluate the utility of 5-ALA-aided resection of spinal neoplasms.

Wainwright et al., from the Westchester Medical Center, Tohoku University, Sendai, reviewed the existing literature on the use of 5-ALA and PpIX fluorescence as an aid to resection of primary and secondary spinal neoplasms by searching the PUBMED and EMBASE database for records up to March 2018. Data was abstracted from all studies describing spinal neurosurgical uses in the English language.

In the reviewed studies, the most useful fluorescence was observed in meningiomas, ependymomas, drop metastases from cerebral gliomas, and spinal hemangiopericytoma, which is consistent with applications in cerebral neoplasms.

The available literature is significantly limited by a lack of standardized methods for measurement and quantification of 5-ALA fluorescence. The results of the reviewed studies should guide future development of rational trial protocols for the use of 5-ALA guided resection in spinal neoplasms ¹⁾.