Neurosurgery Outlines. Paul E. Kaloostian
1.22 (a–d) An elderly man with a dural-based intradural extramedullary tumor (meningioma) received laminoplasty (C6 and C7) and tumor resection treatment. Cord decompression and total tumor resection were achieved. No complications were present at time of discharge. (Source: Spinal meningiomas. In: Sheehan J, Gerszten P, eds. Controversies in Stereotactic Radiosurgery: Best Evidence Recommendations. 1st ed. Thieme; 2014).
Fig. 1.23 (a, b) Computed tomography (CT) scan through C3 revealed cervical extradural tumor (chordoma) in a child. Magnetic resonance imaging (MRI) demonstrates cervical cord compression. (Source: Extradural tumors. In: Dickman C, Fehlings M, Gokaslan Z, eds. Spinal Cord and Spinal Column Tumors. 1st ed. Thieme; 2006).
• If asymptomatic or mildly symptomatic with neck pain/radiculopathy with small focus of tumor:
– Radiation treatment (radiation oncology consultation)
◦ Some metastatic tumors are radioresistant
– Chemotherapy (medical oncology consultation)
◦ Some metastatic tumors are radioresistant
– Kyphoplasty (to treat pain)
– Surgical instrumentation and fusion (if there is concern for deformity, instability, or cord compression)
• If symptomatic with cord compression and myelopathy with large tumor burden:
– Urgent surgical decompression and fusion over multiple segments with tumor resection if deemed suitable candidate for surgery; may be followed by radiation treatment after resection if considered necessary by the radiation oncologist
◦ The oncologist will need to determine overall prognosis, Karnofsky performance score, and extent of visceral disease
◦ If poor surgical candidate with poor life expectancy, medical management is recommended
◦ Surgery may be done anteriorly, posteriorly, or combined two-stage approach for added stabilization
– Preoperative embolization may be indicated for select vascular tumors to the spine such as renal cell cancer, thyroid cancer, breast cancer, etc. in order to decrease vascularity intraoperatively
Indications for Surgical Intervention
• Intractable neck and radicular pain refractory to all conservative routes
• Cord compression with or without myelopathy
• To obtain diagnosis if no other site for biopsy is available
• Risk of pathological fractures without stabilization
Surgical Procedure for Posterior Cervical Spine
1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Celebrex/Naprosyn/other anticoagulants and anti-inflammatory drugs for at least 2 weeks
2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist
3. Patient placed prone with Mayfield pins on Jackson Table with all pressure points padded
4. Neuromonitoring is needed
5. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed
6. Make an incision down the midline of back, over the vertebrae where laminectomy is to be performed
7. Perform subperiosteal dissection of muscles bilaterally to expose the spinous process and paraspinal muscles
8. Dissect tissue planes along spinous process and laminae using rongeurs
9. Move paraspinal muscles laterally to expose the laminae
10. Once the bone is exposed, it is best to localize and verify the correct vertebra via X-ray or fluoroscopic imaging and confirming with at least two people in the room
11. Perform the laminectomy over segments needed based on preoperative imaging of levels that are compressed due to tumor:
a. Using Leksell rongeurs and hand-held high-speed drill, remove the bony spinous process and bilateral lamina as indicated for specific procedure
b. Remove the thick ligamentum flavum with Kerrison rongeurs with careful dissection beneath the ligament to ensure no adhesions exist to dura mater below and thus avoiding CSF leak
c. Perform appropriate foraminotomy with Kerrison rongeurs as needed for appropriate decompression of nerve roots
d. Identify location of tumor and resect tumor as needed within the spinal canal:
i. Use operative microscope and open the spinal cord dura midline with 11 blade and tack up the dural leaflets with suture
ii. If tumor is intradural and extramedullary, the tumor can then be resected carefully with microdissection technique without cord injury (neuromonitoring needed in these cases)
iii. If tumor is intradural and intramedullary, with microdissection technique the cord must be entered midline and the tumor must be identified and resected starting centrally first, then around the edges (neuromonitoring needed in these cases)
12. After appropriate tumor resection, there may be need for additional stabilization to prevent kyphosis if the resection caused multiple segment decompression. Therefore, instrumentation with lateral mass screws can be placed over the segments involved with rods bilaterally and fusion/arthrodesis along these segments
13. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion, often with placement of postoperative drains that can be removed after 2 to 3 days
Surgical Procedure for Anterior Cervical Spine
1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Celebrex/Naprosyn/other anticoagulants and anti-inflammatory drugs for at least 2 weeks
2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist
3. Patient placed in supine position, breathing through endotracheal tube with ventilator
4. Neuromonitoring may be required to monitor nerves
5. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed
6. Make a 2 to 4 cm (about 1 inch) transverse neck crease incision at the appropriate level off of the midline
7. Incise fascia over the platysma muscle and split it into a superficial plane in line with the neck incision
8. Identify anterior border of sternocleidomastoid muscle and incise fascia to retract it laterally
9. Identify and retract strap muscles medially (sternohyoid and sternothyroid), forming another middle plane
a. The plane between the sternocleidomastoid muscle and the strap muscles can now be entered
b. A plane between the esophagus and the carotid sheath will be created next for entry
10. Identify the carotid pulse and retract carotid sheath laterally
11. Cut through the pretracheal fascia
12. Localize superior and inferior thyroid arteries, tying them off if necessary
13. Split longus colli muscles and anterior longitudinal ligament
14. Subperiosteally dissect to identify anterior vertebral body, utilizing retractors and an operating microscope
15.