Remove the free ligamentum flavum using Kerrison rongeurs to decompress the nerve roots
4. Open the lamina via “green-stick” fracture technique
5. Utilizing Adson Periosteal Elevator, elevate lamina from the side (do not slide underneath it)
6. Fasten plates and screws at the lateral borders of each lamina and the facet joint, decompressing the spinal cord (if needed, often fusion is not necessary)
7. Wash out the wound with antibiotic saline solution and reachieve hemostasis via Bovie electrocautery and bipolar, applying local anesthetic to the wound to reduce bleeding
8. Place a postoperative drain (can be removed after 2–3 days)
9. Close the fascia and subcutaneous tissue with Vicryl
10. Close the skin with suture, skin-glue, steri-strips, or surgical staples
Embolization Procedure (Onyx)
1. Shake Onyx vial on mixer for 20 minutes. Onyx-18 is common, Onyx-34 is suitable for very high flow AVMs, and Onyx-500 is incorporated in aneurysm embolization treatments
2. Wedge microcatheter tip into arterial branch supplying the AVM, preferably very close to the AVM nidus
3. Perform angiography through the microcatheter to confirm that the arterial branch exclusively supplies the AVM
4. Prime the dimethyl sulfoxide (DMSO)-compatible microcatheter (marathon, echelon, rebar, ultraflow) with 0.3 to 0.8 mL DMSO so that Onyx does not solidify in the microcatheter
5. Slowly inject Onyx solution, allowing no more than 1 cm of reflux. If reflux occurs, continue after a 1 to 2 minutes waiting period
6. Halt injection when Onyx no longer flows into the nidus, but refluxes instead
Pitfalls
• Stroke
• Intraoperative and postoperative bleeding
• Failure to remove the entire AVM
• Future recurrence of AVM
• Recompression of cervical spinal cord
• Postlaminoplasty kyphosis
• Nerve root palsies
• Damage to spinal nerves and/or cord
• Postoperative weakness or numbness or continued pain
• Postoperative wound infection
• Prolonged hospitalization due to invasiveness of surgery and other comorbidities/iatrogenic infection
• Temporary postoperative paresthesia
• Iatrogenic vertebral artery injury during embolization process
Prognosis (AVM Laminectomy)
• Hospitalization rates depend on the type of procedure performed, preoperative examination status, and patient’s age/comorbidities
• PT and OT will be needed postoperatively, immediately and as outpatient to regain strength
• Brace/Collar is used for 8 weeks after discharge to immobilize to increase rate of healing
1.3.3 Cervical Anterior and Posterior Techniques for Tumor Resection (Spinal Canal Pathology)
Symptoms and Signs
• Incidental with symptoms (depending on size and location)
• Moderate/Severe numbness to pain, cold, and heat in upper extremities
• Paresthesia in upper body extremities
• Neck pain and loss of mobility due to neck pain
• Radiating pain down the arms
• Pain in moving shoulders
• Muscle weakness in arms (potentially paralysis)
• Inability to conduct fine motor skills with hands
• Scoliosis
Surgical Pathology
• Cervical spine benign/malignant tumor
Diagnostic Modalities
• CT of cervical spine with and without contrast to assess whether there is bony involvement of tumor
• MRI of cervical spine with and without contrast to assess if there is spinal cord, epidural space, or nerve root involvement of tumor
• PET scan of body to look for other foci of tumor
• CT of chest/abdomen/pelvis to rule out metastatic disease
• X-ray (not as reliable for tumor diagnosis)
• Biopsy to examine tissue sample to determine whether tumor is benign or malignant, and what cancer type resulted in the tumor if malignancy is determined
Differential Diagnosis
• Metastatic tumor
– Breast, prostate, lung, renal cell
• Primary tumor
– Schwannoma, neurofibroma, myeloma, plasmacytoma, meningioma, ependymoma, astrocytoma, hemangioblastoma, lipoma, dermoid, epidermoid, teratoma, neuroblastoma, oligodendroglioma, cholesteatoma, subependymoma, osteosarcoma, chondrosarcoma, Ewing’s sarcoma, chordoma, lymphoma, osteoid osteoma, aneurysmal bone cyst, eosinophilic granuloma, angiolipoma (see ▶Fig. 1.22 and ▶Fig. 1.23)
Treatment Options
• Acute pain control with medications and pain management
Fig. 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.
