Spinal cord tumor surgery

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see Spinal intramedullary tumor surgery

Most intradural spinal tumors can be treated with contemporary microsurgical techniques with long-term control or cure of the lesion and preservation of neurological function ¹⁾.

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 ²⁾.

In a retrospective study of 29 patients with 30 extramedullary, intradural spinal tumors approached through unilateral laminectomy -hemilaminectomy.

Epidemiology, location and histology of the lesions 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 recurrences being observed except for two cases of meningiomas. 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 ³⁾.

Traditionally, the surgical resection of a spinal cord tumor has been performed through total laminectomy ⁴⁾.

Seppala et al. ⁵⁾ analyzed 187 patients who had total laminectomy for spinal cord tumors 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 ⁶⁾.

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. ⁷⁾ 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 ⁸⁾.

Stripping, dissection, and denervation of the posterior paraspinal muscle complex were also suggested to be responsible for post-laminectomy deformities ^{9) 10)}

Intradural-extramedullary spinal cord tumors that are not extended to the vertebral foramen can be resected safely and completely by a unilateral limited laminectomy ¹¹⁾.

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 ¹²⁾.

Laminectomy (LAMT) and laminoplasty (LAMP) have been wildly applied on patients with spinal cord tumors (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 databases (PubMed, EMBASE, The Cochrane Library, CBM, CNKI and WanFang) to identify relevant randomized controlled trials (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 ¹³⁾.

Intraoperative monitoring for spinal cord tumor surgery.

Intraoperative ultrasound for intradural spinal tumor.

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 ¹⁴⁾.

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. ¹⁵⁾ 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 ¹⁶⁾.