Name:
Utility of intraoperative real-time near-infrared fluorescence surgery for spinal schwannoma
Description:
Utility of intraoperative real-time near-infrared fluorescence surgery for spinal schwannoma
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Duration:
T00H07M46S
Embed URL:
https://stream.cadmore.media/player/1e81fc33-3724-40f6-a82b-bb0a57000f6c
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https://cadmoreoriginalmedia.blob.core.windows.net/1e81fc33-3724-40f6-a82b-bb0a57000f6c/21-158.mp4?sv=2019-02-02&sr=c&sig=9gS6sYNOmTwJD5DH8vqEddhK5NzSHMaOXc096XsdV0w%3D&st=2024-05-06T14%3A07%3A57Z&se=2024-05-06T16%3A12%3A57Z&sp=r
Upload Date:
2021-11-27T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This video demonstrates intraoperative real-time, near-infrared fluorescence surgery for spinal schwannoma using indocyanine green. We present two representative cases. The second window indocyanine green (SWIG) technique seems to facilitate brain tumor removal and was used for glioma, meningioma, and the metastatic tumors. SWIG protocol by Madajewski and Lee administered the 5.0 mg/kg ICG 24 hours before surgery.
SPEAKER: In contrast, we modified this technique using the delayed ICG window administering 0.5 mg/kg ICG at the beginning of the surgery. Then the surgeon operate with the guidance of tumor fluorescence after more than 1 hour. KINEVO 900 and the Pentero microscopes were used for near-infrared (NIR) are imaging. Nerve stimulator was used to determine if the adherent structure was a functional motor nerve root.
SPEAKER: That fluorescence parameter are relative, but absolute. Therefore, we obtain a background reading from the adjacent healthy spinal cord to determine the signal- to-background radio (SBR). Case presentation. Case 1. A 55-year-old female with a neurofibromatosis type 2 presented with neck pain.
SPEAKER: A spinal Gd-MRI revealed a well-circumscribed, heterogeneous, intradural extra-axial mass in the upper cervical spine. Neurologically, the patient was intact with no motor or sensory disturbance. She had a multiple intracranial meningiomas and had surgery for a tumor removal twice before. Preoperative imaging studies. MRI with contrast demonstrate a 25-mm intradural extremity realistic tumor at the C1–2 level.
SPEAKER: Surgery. The skin incision was performed from inion to C5. The nuchal ligament was incised and the spinal processes of C1–3 were identified. The C2 posterior arch was divided preserving the muscle surrounding the spinous process. Right C1–2 hemilaminectomy was performed with a 15-mm bone window.
SPEAKER: ICG was administered with a 0.5 mg/kg-dose at the beginning of surgery. After the C1 hemilaminectomy, the dura was exposed. On preoperative MRI, we suspected the meningioma. A strong NIR signaling could be detected through the dura mater more than 1 hour after injection. The tumor was visualized clearly. Its fluorescence moved synchronously with respiration suggesting a diagnosis of schwannoma, not a meningioma.
SPEAKER: We changed the dural incision at the midline because we suspected the schwannoma by NIRS findings. After the midline dural incision, the tumor capsule was exposed. The arrow shows the origin of a tumor at the possible root of C3. The boundary was clearly visible. And the positivity for ICG fluorescence on the NIRS helps identify the tumor margin and differentiate the mass from the surrounding tissue.
SPEAKER: NIRS can help to decide the cutting point from the root. White arrow shows the nerve of tumor origin cutting a point from the tumor. After the tumor resection, NIR shows a fluorescence remaining ICG inside the tumor. No registered tumor on the light field and no NIR signal were observed after the resection.
SPEAKER: Dura mater was closed watertightly. Each half of the C2 split spinous process very approximated using a strong suture. Muscles were sutured layer by layer. Postoperative imaging study. Postoperative MRI showed no enhanced lesions and confirmed the complete resection.
SPEAKER: After the surgery, no neurological deficits were found. The final pathology identified the tumor as schwannoma. Relative tumor fluorescence to spinal parenchyma SBR was 3.04. Case 2. 79-year-old male presented to his right lower-extremity weakness. Neurological findings show right motor weakness in the lower extremity and sensory disturbance below T7.
SPEAKER: Past medical history indicated hypertension. The MRI revealed a well-circumscribed, 38-mm mass with heterogeneous enhancement between C6 and T2. Surgery. ICG was administered with 0.5- mg/kg dose at the beginning of surgery. After the laminectomy from C6 to T2, the dura mater was exposed.
SPEAKER: A weak fluorescence could be observed through the dura more than 1 hour after the injection. The microscope (Pentero) and NIRS accurately localized the intradural extramedullary tumor after incising the dura. Once exposed, the tumor was bluntly dissected in proximity to the capsule to separate the mass from the surrounding tissue. In patients where the nerve root appeared to adhere to the capsule, and nerve stimulator can be used to determine if the adherent structure is a functional motor nerve root.
SPEAKER: NIRS can help to identify the exact tumor location during the dissection. Proximal and distal root connections were dissected for complete tumor removal. There was no postoperative residual tumor and no NIR signal after tumor resection, suggesting total tumor removal. NIR shows the fluorescence remaining ICG inside the tumor.
SPEAKER: Postoperative regarding MRI shows no evidence of residual tumors. After the surgery no neurological deficit were found. The final pathology identifies the tumor as a schwannoma. Relative tumor fluorescence to the spinal parenchyma SBR was 2.79. Conclusions. NIRS of ICG allowed stronger fluorescence from the tumor relative to normal spinal parenchyma.
SPEAKER: Merits of fluorescence- guided spinal surgery were identification of real- time intraoperative tumor localization, confirmation of adequate laminectomy, differentiation from the tumor to surrounding tissues, confirmation of residual tumor. The delayed window ICG (DWIG) technique is not indispensable, but helpful for spinal tumor surgery.