Radiation treatment (radiation oncology consultation)
– Chemotherapy (medical oncology consultation)
– 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 (see ▶Fig. 1.13)
– 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
Fig. 1.13 (a, b) Radiology revealed presence of lower cervical tumor in teenage girl who presented with symptoms of myelopathy. Tumor embolization, anterior corpectomy (C6) with tumor resection and reconstruction, and fusion (C4–C6) were performed. Improved alignment was achieved and the tumor was confirmed to be totally resected. (Source: Introduction and background. In: Cohen A, ed. Pediatric Neurosurgery: Tricks of the Trade. 1st ed. Thieme; 2015).
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
Surgical Procedure for Posterior Cervical Spine
1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/other anticoagulants for at least 2 weeks for elective cases
2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist
3. Patient placed prone with Mayfield pins in neutral alignment on Jackson Table with all pressure points padded
4. Neuromonitoring may be present to monitor nerves (if necessary and indicated)
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 over the vertebrae where laminectomy is to be performed
7. Perform subperiosteal dissection of muscles bilaterally to expose the vertebra
8. 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
9. 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 Kerosen rongeurs as needed for appropriate decompression of nerve roots
d. Identify location of tumor and resect tumor as needed if within the lamina, epidural, or within the spinal canal/cord:
i. If within the lamina or epidural in nature, the tumor can be visualized immediately and removed gently
ii. If within the spinal cord, use operative microscope and open the spinal cord dura midline with 11 blade and tack up the dural leaflets with suture
iii. If tumor is intradural and extramedullary, it can be resected carefully with microdissection technique without cord injury (neuromonitoring needed in these cases) (see ▶Fig. 1.14)
iv. 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)
10. 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. (see ▶Fig. 1.15 and ▶Fig. 1.16)
11. 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.
Fig. 1.14 (a–d) Radiology revealed tumor at the C5 level, accompanying severe cord compression. After dissecting to the tumor, it was successfully resected. (Source: Intradural extramedullary tumors. In: Bernstein M, Berger M, eds. Neuro-oncology: The Essentials. 3rd ed. Thieme; 2014).
Fig. 1.15 (a, b) Preoperative imaging revealed cervical ependymoma. Postoperative imaging demonstrates total removal of tumor. (Source: Intramedullary spinal cord tumors: ependymomas and astrocytomas. In: Nader R, Berta S, Gragnanielllo C, et al, eds. Neurosurgery Tricks of the Trade: Spine and Peripheral Nerves. 1st ed. Thieme; 2014).
Fig. 1.16 (a, b) Radiology revealed a cervical lymphoma and lysis of C3 in an elderly man. Anterior corpectomy and posterior stabilization were performed and confirmed via postoperative CT scan. (Source: Vertebral bone tumors. In: Fessler R, Sekhar L, eds. Atlas of Neurosurgical Techniques: Spine and Peripheral Nerves. 2nd ed. Thieme; 2016).
Pitfalls
