Surgical Management of Spinal Intramedullary Tumors: Radical and Safe Strategy for Benign Tumors

Abstract

Surgery for spinal intramedullary tumors remains one of the major challenges for neurosurgeons, due to their relative infrequency, unknown natural history, and surgical difficulty. We are sure that safe and precise resection of spinal intramedullary tumors, particularly encapsulated benign tumors, can result in acceptable or satisfactory postoperative outcomes. General surgical concepts and strategies, technical consideration, and functional outcomes after surgery are discussed with illustrative cases of spinal intramedullary benign tumors such as ependymoma, cavernous malformation, and hemangioblastoma. Selection of a posterior median sulcus, posterolateral sulcus, or direct transpial approach was determined based on the preoperative imaging diagnosis and careful inspection of the spinal cord surface. Tumor-cord interface was meticulously delineated in cases of benign encapsulated tumors. Our retrospective functional analysis of 24 consecutive cases of spinal intramedullary ependymoma followed for at least 6 months postoperatively demonstrated a mean grade on the modified McCormick functional schema of 1.8 before surgery, deteriorating significantly to 2.6 early after surgery (< 1 month after surgery), and finally returning to 1.7 in the late postoperative period (> 6 months after surgery). The risk of functional deterioration after surgery should be taken into serious consideration. Functional deterioration after surgery, including neuropathic pain even long after surgery, significantly affects patient quality of life. Better balance between tumor control and functional preservation can be achieved not only by the surgical technique or expertise, but also by intraoperative neurophysiological monitoring, vascular image guidance, and postoperative supportive care. Quality of life after surgery should inarguably be given top priority.

Posterolateral approach for spinal intradural meningioma with ventral attachment

“…Resected laminae were constructed in lift-up style for the cervical spine or onlay style for the thoracic spine using a titanium mini-plate and screws. [ 20 ] No rigid orthosis was applied after surgery. Supplemental digital content of surgical video Patient 7 was provided.…”

New Application of Actuator-Driven Pulsed Water Jet for Spinal Cord Dissection: An Experimental Study in Pigs

“…Therefore, it was sharply cut in the midline, and care was taken to ensure that the incision did not go too deep. By this method, the intima pia mater 14 was left intact on the dorsal surface of the spinal cord.…”

Differences in Multimodality Intraoperative Neurophysiological Monitoring Changes Between Spinal Intramedullary Ependymoma and Hemangioblastoma

“…Although ependymomas and hemangioblastomas are categorized together in IMSCT, they occur at different anatomic locations and require different surgical techniques. Ependymomas are located centrally (Kim et al, 2014) and can be treated using piecemeal resection and debulking of the tumor with a cavitron ultrasonic aspirator (Brotchi, 2002;Kucia et al, 2011;Takami et al, 2015). In contrast, hemangioblastomas are located posteriorly (Mandigo et al, 2009) and should be removed in an en bloc fashion; debulking of the tumor should be avoided (Brotchi, 2002;Mandigo et al, 2009;Takami et al, 2015).…”

“…Ependymomas are located centrally (Kim et al, 2014) and can be treated using piecemeal resection and debulking of the tumor with a cavitron ultrasonic aspirator (Brotchi, 2002;Kucia et al, 2011;Takami et al, 2015). In contrast, hemangioblastomas are located posteriorly (Mandigo et al, 2009) and should be removed in an en bloc fashion; debulking of the tumor should be avoided (Brotchi, 2002;Mandigo et al, 2009;Takami et al, 2015). However, previous studies on IONM for IMSCT did not separate tumors according to their specific pathology but instead grouped them together as IMSCT (Kothbauer, 2007;Hyun and Rhim, 2009;Cheng et al, 2014;Choi et al, 2014;Kobayashi et al, 2014).…”