Clip Ligation and Disconnection of a Ruptured Ventral Subaxial Cervical Isolated Spinal Aneurysm Using Tailored Access Osteotomies: An Operative Technique

Abstract

BACKGROUND:Isolated spinal aneurysms (iSAs) are lesions of the spinal vasculature with no associated vascular malformation with difficult management paradigms limited by safe access.OBJECTIVE:To describe a case of an irregular fusiform ruptured distal subaxial cervical spine iSA with a complex angioarchitecture intimately associated with the ventral pial plexus (VPP), treated using open clip ligation and disconnection.METHODS:A 51-year-old woman presented with complete spinal cord injury with a C8 sensory level and ventral subarachnoid hemorrhage at the C6-T1 vertebral levels. After emergent anterior evacuation and fusion, angiography revealed a small iSA around the VPP. A total laminectomy spanning C5 to T3 was completed, and bilateral C7 pedicle resections were performed. A temporary clip was placed from the left for proximal control, and a permanent clip was placed across the dome of the distal vessel for disconnection. The dura was then closed, and a cervicothoracic fusion completed.RESULTS:Postoperative angiography confirmed iSA disconnection and obliteration with anterior spinal artery preservation. The patient had intermittent numbness in the right C8 dermatome. On postoperative day 1, she regained proprioception in the right foot and movement in the lower extremities on command. On postoperative day 3, she regained full sensation and voluntary movement in both lower extremities.CONCLUSION:iSA is a rare and morbid condition with nonstandardized guidelines regarding management. We promote the concept of using tailored osteotomies to establish safe corridors for the open treatment of difficult subaxial cervical ventral lesions not amenable to transarterial treatment. Multidisciplinary collaboration is promising, and further investigation is highly warranted.

Letter: Ventral Subaxial Cervical Access Using Tailored Access Osteotomies, A Cadaveric Study

“…We are now generally an advocate of unilateral dentatolysis with the addition of the trap-door durotomy because we have not encountered a case where bilateral dentatolysis was necessary. Albeit we agree with the findings of Scullen et al 1 that a ≥3 level laminectomy would likely benefit from bilateral dentatolysis because it allows for significantly greater cord rotation and decreases sheer forces on the cord parenchyma as compared with unilateral dentatolysis. Although the cadavers in this study provided a good anatomic model for assessing operative angles, as surgeons we know that our patient population is highly variable, and in our case, the patient was morbidly obese and of short stature thus making a posterior thoracic approach extremely challenging.…”

“…We read with interest the article Ventral Subaxial Cervical Access Using Tailored Access Osteotomies, A Cadaveric Study by Scullen et al 1 in the July issue of Operative Neurosurgery. We agree with the authors on the complexity of the surgical approach to ventral tumors in the cervical and thoracic spine.…”

“…2 We wanted to offer a surgical technique that may assist surgeons on their exposure to ventral tumors. Scullen et al 1 performed a standard midline durotomy, followed by release of the dentate ligaments, unilaterally or bilaterally. Although we agree that the release of the dentate ligaments plays a crucial role in the approach, we think that a unilateral dentatolysis is all that is necessary when combined with a trap-door durotomy, and we agree with Scullen et al 1 that a bilateral dentatolysis comes with some risk.…”

“…Scullen et al 1 performed a standard midline durotomy, followed by release of the dentate ligaments, unilaterally or bilaterally. Although we agree that the release of the dentate ligaments plays a crucial role in the approach, we think that a unilateral dentatolysis is all that is necessary when combined with a trap-door durotomy, and we agree with Scullen et al 1 that a bilateral dentatolysis comes with some risk. 1,3 A trap-door durotomy is a linear midline durotomy followed by a lateral cut in the dura above and below the tumor followed by unilateral sectioning of the dentate ligaments (Figure).…”

“…Although we agree that the release of the dentate ligaments plays a crucial role in the approach, we think that a unilateral dentatolysis is all that is necessary when combined with a trap-door durotomy, and we agree with Scullen et al 1 that a bilateral dentatolysis comes with some risk. 1,3 A trap-door durotomy is a linear midline durotomy followed by a lateral cut in the dura above and below the tumor followed by unilateral sectioning of the dentate ligaments (Figure ). This trapdoor durotomy technique was developed out of necessity for exposure because the patient we were working on had a BMI >50 with a large calcified ventral tumor.…”