Spinal Disorders: Fundamentals of Diagnosis and Treatment Part 102 doc

Surgical treatment of a neurinoma Intraoperative views of a neurinoma at the thoracic region seeCase Study 1.aAfter the dural opening in the midline, dissection of the rostral pole of th

b

Figure 4 Surgical treatment of a neurinoma

Intraoperative views of a neurinoma at the thoracic region (seeCase Study 1).aAfter the dural opening in the midline, dissection of the rostral pole of the tumor is shown.bAfter intracapsular gutting of the tumor, the spinal cord, the roots and the ligamentum dentatum become visible.cView just at the time of opening of the arachnoidea at the rostral pole

of the tumor One recognizes a dorsal root crossing the tumor on its dorsal surface.dView at the end of the tumor removal The neurinoma was carefully dissected and removed from the spinal cord preserving the posterior spinal veins

A part of the dorsal root with tumor attachment was removed together with the tumor

around 7 – 15 % There is no clear correlation between the results and the extent

of resection of the dural attachment The surgical approach is usually via a lami-nectomy for midline dorsal tumors A hemilamilami-nectomy can sometimes be per-formed in small tumors more laterally located For tumors in a lateroventral loca-tion a lateral approach has to be performed [7, 9, 23 – 25, 33, 35].

Intrinsic Spinal Cord Tumor Resection

The surgical approach is mostly via a laminectomy with the patient in the prone position or sitting position The opening should be large enough to expose the

cranial and caudal poles of solid tumor Intraoperative ultrasound echography

can therefore be helpful for this purpose After the laminectomy, the dura and the

arachnoidea are opened in the midline and the opened dural edge is secured by

traction sutures.

Longitudinal posterior median myelotomy through the sulcus medianus

is the standard approach for removal of

intramedullary tumors

Most intramedullary spinal cord tumors are approached through an incision

between the posterior column, i.e., spreading the sulcus medianus, which can be

difficult but is mostly possible by searching out small emerging veins in the

sul-cus (Case Study 3) Occasionally (for hemangioblastomas or astrocytomas) the

access might be through the dorsal root entry zone Once the tumor is

encoun-tered, spread pial edges are sutured using 6-0 Prolene to the opened edge of the

dura on both sides, so that the tumor comes into view more extensively between

the spread posterior columns.

The myelotomy must expose and open the rostral and caudal cysts or the poles

of the solid tumor A frozen section biopsy is obtained for immediate

histopatho-a

b

c

d Case Study 3

This 32-year-old male noticed weakness of the right lower extremity associated with paresthesia at its lateral side, which

appeared only episodically The paresthesia was noticed in the fourth and fifth toes also on the right side since about

6 months previously Weakness and fine motor skills of the left hand had been noted recently Neurological findings on

admission were: no gait disturbance, difficulty standing on one foot, no noticeable weakness in the extremities except

for the right iliopsoas muscle (M4), difficulty walking blind straight, tendon reflex symmetric, no abdominal wall reflex,

no Babinski signs, hypesthesia below T2/3 level especially on the lateral side of the right leg, position sense intact, and

normal sphincter tonus Preoperative MRI displayed an intramedullary tumor from the level of C6 to T2 with only slight

contrast enhancement and with neither syringomyelia nor cyst formation, presenting as a so-called “stift” or “pencil”

gli-oma (a,b) The patient underwent laminectomy from C5 to T2 followed by partial extirpation of intramedullary pilocytic

astrocytoma following a longitudinal myelotomy (c) Demarcation between the tumor and the surrounding tissue was

partly not clear so that only about one-third of the tumor was removed and the myelotomy was left open without pial

closure Postoperative neurostatus was almost unchanged, so that the patient was discharged for physiotherapy on the

9th postoperative day

f

g

h

Case Study 3 (Cont.)

The patient was readmitted on the

13th day after the primary surgery

due to a pseudomeningocele and

neurological deterioration presenting

with tetraparesis and respiratory

dis-tress The T2W images revealed a

swollen spinal cord at the level of

sur-gery and pseudomeningocele (d,e)

At the time of repeat laminectomy

3 weeks after the primary

laminec-tomy, a swollen spinal cord was

noticed especially at the level of

C7 – T1 so that additional

laminec-tomy of T3 was performed followed by further subtotal removal of tumor The

tumor was lateralized to the right side, At the end of tumor removal, the

antero-lateral part of the spinal cord was paper thin at the level of C7 – T1 The

myelo-tomy was left open and a dural patch with fascia lata was performed for

decom-pression, as the spinal cord was still swollen at the level of T2 Postoperatively

the patient was unable to walk due to motor paraparesis and also due to loss of

position sense It took him 2 years to be able to walk with a stick and another

2 years without a stick (f) At the time of follow-up 4 years postoperative

exami-nation, no bowel or bladder dysfunction was complained of MRI displayed no

tumor but a very thin spinal cord (g,h) Most annoying for him after these all

years is the dysesthesia or burning sensation in the left lower extremity and in

the left flank which trouble him occasionally

logical analysis If a malignant glioma is a possible diagnosis, the information may be crucial in deciding whether tumor removal should be continued, and if

so, how aggressive it should be.

Ependymomas can be delineated by a red gray color or by a consistency

slightly more solid than the spinal cord (Case Introduction, Fig 5) After having sent a piece of tumor for frozen section, gutting of the tumor is carried out by suction or with low-power CUSA so that several millimeters of tumor “capsule” are left Blunt dissection of the capsule from the surrounding spinal cord can be done with ease in ependymomas, in which sometimes feeding arteries and drain-ing veins have to be coagulated with low-power currents and cut This procedure should be done with great care at the most anterior part of the tumor, as the site might be very close to the anterior sulcal artery or even to the anterior spinal artery Dissection of ependymomas at the cranial pole or caudal pole can be easy

in cases where cyst or syrinx is present Otherwise the tumor tapers into the spi-nal cord, so that its removal should be performed with great care.

a b c

Figure 5 Surgical treatment of an ependymoma

A case of an ependymoma of the thoracic spinal cord (seeCase Introduction) Intraoperative views:aAfter dural

open-ing followed by a longitudinal myelotomy in the midline, the tumor tissue can be clearly distopen-inguished as pathologic

tis-sue.bDissection of the associated cyst enables identification of the most caudal end of the tumor.cSearching out a clear

cleavage plane is crucial for successful tumor removal.dThe clear cleavage plane at the rostral tumor end is visible.eThe

most critical part of the surgical removal of the tumor is its relation to the anterior spinal artery and the branches.fPart

of the tumor tissue adhered strongly to the anterior spinal artery so that the part with hemostatic sponges is coagulated

and left in order to preserve the artery The spread margin of the pia mater is approximated and closed with continuous

sutures prior to watertight dural closure

After the removal the spread pial ends are closed with 6-0 continuous suture

fol-lowed by dural closure The closure of arachnoidea as much as possible to prevent

CSF leakage or adhesive arachnoidopathy should be kept in mind at the time of

dural closure [22].

In the case of astrocytoma which is diagnosed on frozen section at the early

stage of tumor removal, part of the dissection might not become possible since

the delineation between the tumor and normal tissue is not clear even in the

pres-ence of cysts or syrinx, although a considerable part of the tumor is revealed to

be well delineated up to that stage Tumor extirpation should be stopped at this

site to prevent postoperative new neurological deficits The dangers of tumor extirpation are at the anterior and lateral margins Anterior resection may cause vascular damage to the anterior spinal artery, and lateral resection may directly damage the corticospinal tracts Hemostasis is obtained by warm saline irriga-tion and microfibrillar collagen It is rarely necessary to coagulate major vessels outside the tumor bed [5, 12 – 14, 20, 22, 36].

Intramedullary

ependymo-mas have good delineation,

while astrocytomas usually

do not have an impact on

tumor removal

Spread pial edges do not need to be closed by suture to accomplish decompres-sion Even a dural patch is needed for decompression in the case of spinal cord swelling at the end of partial tumor removal One additional laminectomy (below and above tumor extension) might be necessary or recommendable for effective decompression.

Hemangioblastomas are located usually at the dorsum of the spinal cord, so that

this can be detected just after the dural opening This orange-dark red colored tumor is usually attached to the pia at the margin and is strongly vascularized, so that its gutting is not recommended due to profuse bleeding This tumor is usually associated with cyst or syrinx formation, so that the delineation is clear and dissec-tion is not difficult Tumor capsule coaguladissec-tion and coaguladissec-tion of feeding arteries followed by their cutting are the method of removal The main feeding arteries might be branches of the anterior spinal artery or a radicular artery [39] Pial closure at the end of tumor removal is to be recommended to prevent col-lapse of the spinal cord [22] For a large hemangioblastoma, its preoperative embolization by a trained interventional neuroradiologist might reduce intrao-perative blood loss and even reduce the extent of the laminectomy levels and of myelotomy.

Cavernous angiomas are to be removed in the subacute stage of bleeding In

this subacute stage, detection of cavernous angioma can occasionally be prob-lematic, as one hardly sees any changes on the dorsal surface of the spinal cord such as swelling or discoloration, so that ultrasound echography can be helpful for its detection With midline access, one encounters the hematoma cavity and the typical cavernous angioma with blackberry-like appearance Less than 10 %

of cavernous angiomas are located eccentrically, so that access through the poste-rior root entry zone is necessary When the cavernous angioma is located at the conus, a strong posterior longitudinal vein might cover the sulcus medianus, so that its microsurgical dislocation for preservation is recommended by some authors in order to accomplish the midline access [22].

A decompressive laminectomy and duraplasty are the minimal surgical

proce-dure in the surgery of “inoperable” intramedullary tumors, since patients with

high-grade lesions on biopsy have rapid progression in neurological dysfunction even with aggressive resections.

Acknowledgements. The authors are indebted to Mr P Roth, Ms R Frick and

Ms H Job for their secretarial and technical assistance.

Recapitulation

Epidemiology. Intradural tumors represent about

10 % of primary CNS tumors About two-thirds of

these tumors are found in an extramedullary

loca-tion The incidence of intramedullary tumors is

be-low 1 per 100 000 Most extra- and intramedullary

tumors are slow-growing neoplasms and can be

operated on with a low morbidity.

Etiology and pathogenesis. There is considerable evidence that some neoplasms are the result of

ge-netic disease Gege-netic systemic diseases associated

with intradural tumors are neurofibromatosis and von Hippel-Lindau disease There is an enormous functional adaptive capacity of the spinal cord to slow-growing tumor compression.

Classification Meningiomas and nerve sheath

tumors represent 80 % of extramedullary tumors

and most of them can be surgically removed with a

low recurrence rate The most frequent

intramedul-lary tumors are ependymomas and astrocytomas.

About one-third of patients with

hemangiobla-stoma, one of the infrequent intramedullary

tumors, have von Hippel-Lindau disease.

Clinical presentation. Onset is usually very insidious,

but an abrupt onset can take place Cardinal

symp-toms are progressive local pain, nocturnal pain of a

radicular or medullary nature, non-painful sensory

disturbances, motor weakness, ataxia and

sphinc-ter disturbances In intramedullary tumors, sensory

disturbance tends to be of the dissociated type and

motor disturbance may present with the type of

Brown-S ´equard’s syndrome Sensory disturbance of

the sacral segment can be preserved (sacral sparing)

until a far advanced stage of intramedullary tumors.

Scoliosis or torticollis is often observed.

Diagnostic work-up. MRI is the diagnostic modality

of choice At least two different imaging planes

must be used in order to locate the tumor properly

and to differentiate intra- from extramedullary

tumors The tumor is iso- to hypointense on T1W

and hyperintense on T2W images Almost all spinal

cord tumors demonstrate more or less contrast

en-hancement Existence of a “dural tail” and calcifi-cation in meningiomas may differentiate them from neurinomas Most nerve sheath tumors and ependymomas also demonstrate uniform contrast enhancement but can be inhomogeneous due to intratumoral cyst, hemorrhage or necrosis Intrame-dullary tumors are frequently associated with cysts

or syringomyelia.

Operative treatment. Surgery is indicated in any case

of intradural tumor The goal of surgery for any

benign tumor is gross total resection The goal for a

non-resectable glioma is debulking with preserva-tion of the funcpreserva-tion The approach for microsurgical

tumor removal is usually via a laminectomy Extra-medullary tumors can basically be completely removed Intramedullary tumors are mostly ac-cessed via a dorsal midline myelotomy Tumors such

as ependymomas, hemangioblastomas and cavern-ous angioma with a distinct cleavage plane between tumor and normal spinal cord tissue can be removed totally An immediate intraoperative biopsy may be crucial in deciding whether tumor removal should be continued, and if so, how aggressive it should be In non-resectable gliomas a tumor debulking or a decompressive laminectomy and duraplasty are the minimal surgical procedure Patients with high-grade lesions on biopsy have a rather rapid progression even with aggressive resections.

Key Articles

Bal´eriaux D ( 1999) Spinal cord tumors Eur Radiol 9:1252–1258

This paper summarizes the state of the art in MRI diagnostics of intramedullary tumors

Jallo GI, Kothbauer KF, Epstein FJ ( 2001) Intrinsic spinal cord tumor resection

Neuro-surgery 49:1124–1128

This paper shows the present status of preparation of a surgical approach for

intramedul-lary astrocytomas, ependymomas and vascular lesions, including neuromonitoring and

video demonstration

Brotchi J ( 2002) Intrinsic spinal cord tumor resection Neurosurgery 50:1059–63

This article describes the surgical method of the author developed during a period of

15 years (with Georges Fischer in Lyon) on the basis of experience with more than 260

patients and 300 operations The authors highlight that the standard treatment is

com-plete resection whenever possible For gliomas (ependymomas and astrocytomas), the

author favors a midline approach; for most vascular tumors (such as hemangioblastomas

and cavernomas), however, he prefers to proceed from the point at which the lesion is

observed through the microscope and to dissect the lesion in one piece Meticulous

non-bleeding surgery and experience are regarded as the keys to success

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2 Bal´eriaux D, Brotchi J (1992) Spinal cord tumors: Neuroradiological and surgical consider-ations Riv Neuroradiol 5:29 – 41

3 Bal´eriaux D (1999) Spinal cord tumors Eur Radiol 9:1252 – 1258

4 Birch BD, McCormick PC, Resnick DK (2005) Intradural extramedullary spinal lesions In: Benzel EC (ed) Spine surgery: Techniques, complication avoidance, and management, 2nd edn Livingstone, New York, pp 948 – 960

5 Brotchi J (2002) Intrinsic spinal cord tumor resection Neurosurgery 50:1059 – 1063

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26 McCormick PC, Anson JA (2005) Intramedullary spinal cord lesions In: Benzel EC (ed) Spine surgery: Techniques, complication avoidance, and management, 2nd edn Livings-tone, New York, pp 939 – 947

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Infections of the Spine

Norbert Boos

Core Messages

✔ Spinal infections remain a potentially

life-threatening disease

✔ Diagnosis is very often delayed

✔ MRI is the imaging modality of choice in spinal

infections

✔ In the absence of neurologic deficit, spinal

de-formity and instability or incapacitating pain

not responsive to pain medication, spinal

infec-tions are treated by chemotherapy

✔ Radical debridement and bone grafting accel-erates healing of the infection

✔ Spinal instrumentation does not prevent heal-ing of the spinal infection Instead, the addi-tional stability promotes clinical resolution of the infection and related symptoms

Epidemiology

Although evidence for spinal infections in humans can be found in the Edwin

Smith Surgical Papyrus [6], an ancient Egyptian medical document written about

2000 b.c., Sir Percival Pott is credited with the first description of spinal

tuber-culosis in 1779 [37] In 1897, Lannelongue was the first to describe a pyogenic

infection of the spine [27] At the end of the nineteenth century, Makins and

Abbot reported mortality rates in children and young adults of as high as 70 %

[31].

Spinal infections occur pre-dominantly in the elderly and immunocompromised patient

Spinal infections remain a potentially life-threatening disease

Based on the results of a Swedish and a Danish study, the incidence of

verte-bral osteomyelitis was 0.5 and 2.2/100 000 inhabitants/year, respectively [4, 26].

In particular, if a spinal epidural abscess is present, the morbidity and mortality

remain high [9, 22, 29, 40] Spinal infections today occur predominantly in the

el-derly [44] In young adults, the disease appears to have increased in recent

decades because of immunodeficiency syndromes and intravenous drug abuse

[24] While in Western industrialized societies spinal tuberculosis has become

rare, the incidence seems to be increasing again because of immigrants, extensive

tourism into Third World countries, and HIV infections [1, 5, 20, 36, 38].

Despite the fact that treatment of spinal infections has been improved

dramat-ically by the advent of chemotherapy and sophisticated surgical techniques for

advanced stages, this medical condition remains a potentially life-threatening

disease Today, this fact is sometimes neglected in an era of very powerful

antibi-otics Early diagnosis and aggressive conservative or surgical treatment remain

mandatory for a satisfactory outcome.

a b c d

Case Introduction

A 70-year-old patient presented with increasing low-back pain that was worse with movement Initial therapy consisted

of analgesics and physiotherapy The clinical history of the patient was otherwise normal There was no evidence of a general illness and no clinical signs of infection Despite intensive non-operative treatment, 3 months after onset of symptoms, the patient continued to have back pain, now radiating into the legs and worse during the night Walking became difficult because of general weakness Standard radiographs were taken showing a collapsed disc space at the level of L2/3 with segmental kyphosis (a,b) The key finding was a blurred endplate indicating putative spinal infections Subsequent MRI demonstrated classical signs of spinal infection with decreased signal intensity of the endplates on T1-weighted images (c) and partial signal increase on T2-weighted images (d) Blood samples revealed an elevated blood sedimentation rate and C-reactive protein without any leukocytosis The patient was treated with a broad spectrum of antibiotics for 2 months Despite antibiotic treatment the patient continued to have severe pain with movement and during the night At referral, the patient was in poor general health In a first diagnostic approach, CT-guided biopsy was performed, but remained negative (e) Surgery was indicated because of deteriorating general health, incapacitating back pain, and inability to ambulate because of pain In the first stage, pedicle screws were inserted in the spine from the back at L2 and 3 The kyphotic deformity was corrected using indirect reduction (seeFig 6) In a second stage during the same operation, the spine was approached by a left-sided lumbotomy Radical debridement was carried out with recon-struction of the anterior spinal column using a tricortical bone graft and additional cancellous bone graft No causative organism could be isolated most likely due to the previous, antibiotic treatment Double chemotherapy was adminis-tered postoperatively for 3 months The patient completely recovered from the spinal infection and became completely asymptomatic at 4 months follow-up The follow-up radiographs demonstrate an anatomic monosegmental reconstruc-tion of the anterior column with solid interbody fusion (f,g)