Name:
10.3171/2023.7.FOCVID2378
Description:
10.3171/2023.7.FOCVID2378
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/4fb3bc04-e79d-4475-9ba9-9564afb09dcf/videoscrubberimages/Scrubber_329.jpg
Duration:
T00H08M24S
Embed URL:
https://stream.cadmore.media/player/4fb3bc04-e79d-4475-9ba9-9564afb09dcf
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/4fb3bc04-e79d-4475-9ba9-9564afb09dcf/16. 23-78.mp4?sv=2019-02-02&sr=c&sig=PC%2BSTfvD7gdJEhQn4eNaGdiML2eaSyNfTO2ZIG9dVaE%3D&st=2026-04-05T04%3A04%3A11Z&se=2026-04-05T06%3A09%3A11Z&sp=r
Upload Date:
2023-08-30T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: The patient is a 33-year-old female who presented with 2 months of lower-back pain, right leg weakness, difficulty with ambulation, and intermittent bilateral lower-extremity paresthesias after a recent motor vehicle accident. On exam, the patient was confirmed to have right lower-extremity weakness, 2 out of 5 proximally and 3 out of 5 distally, with intact motor strength in her remaining three limbs. She was also found to have abnormal sensation to light touch and proprioception throughout her right lower extremity and nondermatomal distribution, as well as increased tone with decreased patellar tendon reflex in that same right lower extremity.
SPEAKER: An MRI of the thoracolumbar spine was obtained demonstrating a longitudinally extensive enhancing intradural lesion from the level of T9 to the inferior aspect of L4. The lesion causes significant compression of the lower thoracic spinal cord parenchyma with T2 and STIR hyperintensity extending from T4/5 through T9/10, as well as peripheral displacement of the cauda equina nerve roots within the thecal sac.
SPEAKER: Given the patient's symptoms and presence of a mass lesion on imaging, the patient was recommended a T9–L3 laminectomy and intradural tumor resection with T9– T11 transpedicular approach and T8–L4 posterior instrumentation fixation and fusion. The main goal of the procedure was to relieve the mass effect of the tumor on the spinal cord, especially in light of the patient's presentation with a neurologic decline.
SPEAKER: The potential benefits of the procedure included obtaining a diagnosis, preventing worsening neurologic decline due to further tumor growth, and the potential for curative resection. Risks of the procedure, in addition to common surgical risks, included lower-extremity paralysis; sensory, bowel, or bladder disturbance; adjacent segment disease; wound complication or CSF leak; and tumor recurrence.
SPEAKER: Alternatives included observation, radiation, or chemotherapy treatment. However, none of these options would allow for obtaining a tissue diagnosis nor would the mass effect of the tumor be relieved. Furthermore, treatments such as chemotherapy are not a mainstay treatment for pathologies such as ependymoma. T9–L3 laminectomies and tumor resection without fusion may also be considered.
SPEAKER: However, in this case, given the ventral extension and size of the tumor, a transpedicular approach as well as multilevel facetectomies were needed to achieve gross-total resection and adequate thecal sac decompression. Thus, a fusion was needed to avoid the long-term instability. In terms of positioning, preflip SSEPs and MEP baselines were obtained.
SPEAKER: The patient was then flipped prone on a Jackson table and midline incision was planned. The entirety of the thoracolumbar spine was prepped and draped in the usual fashion. Surgical equipment included the operative microscope, microsurgical instruments, ultrasound, an ultrasonic surgical respirator, neuromonitoring, high-speed drill, spinal instrumentation hardware, and allograft.
SPEAKER: In terms of surgical steps, a midline incision was made. Monopolar electrocautery was used to open the soft tissue and fascia with subperiosteal dissection out to the transverse processes at each level with preservation of the most cranial, T7/8, and caudal, L4/5, facet joints. Laminectomies from T9 to L4 to have access to both the cranial and caudal extent of the tumor were performed.
SPEAKER: Facetectomies were performed at T9/10, T10/11, T11/12, T12/L1, L1/2, L2/3, and L3/4 for further decompression. Transpedicular decompression at T9, T10, and T11 due to ventral positioning of the tumor were then performed. The ultrasound was then used to evaluate whether the amount of dural exposure would be sufficient to reach the top and bottom poles of the tumor. Durotomy was performed in a piecemeal fashion from T9 to L4.
SPEAKER: Microsurgical dissection of the tumor from the nerve roots was followed by a microsurgical resection of the tumor, utilizing a combination of sharp dissection and ultrasonic aspiration for tumor debulking, followed by a dissection off of the neural elements of the tumor tissue. A dural closure was then completed followed by posterior instrumentation and preparation of arthrodesis utilizing autograft and allograft from T8 to L4.
SPEAKER: Multilayer closure after dural graft placement over the durotomy site was performed. Here we see after dural opening blunt dissection of the tumor, taking care to separate the cauda equina nerve rootlets from the tumor tissue. Microsurgical instruments such as Rhoton 6 can be useful for this maneuver. Patties are then carefully placed to delineate already dissected elements.
SPEAKER: Sharp dissection is also often necessary. Here we demonstrate this technique using an 11 blade. Similarly, microsurgical scissors can also be used. Careful, constant installation of saline via a soft angio catheter tip can be used to perform hydrodissection as well. A portion of tumor tissue was then removed to send for a frozen pathology specimen.
SPEAKER: Further blunt dissection was then performed until ventral dura was clearly identified. An ultrasonic surgical aspirator was then utilized to debulk the tumor with bipolar electrocautery used to control bleeding. The durotomy was then carried superiorly, using a combination of a Woodson elevator and an 11 blade followed by hydrodissection on the lateral surfaces to free the cord of dural adhesions.
SPEAKER: Tumor removal was then continued and carried up to the level of the conus. The gutters and dural elements were then inspected for residual tumor. The entirety of the dural exposure can be seen here from the inferior thoracic cord down to the lower lumbar rootlets.
SPEAKER: The dura was then closed in a watertight manner using 5-0 Prolene suture on a VB-1 needle. This was followed by an overlay dural graft with spinal sealant. No CSF egress was noted after a Valsalva maneuver. The patient tolerated the procedure well, with no apparent complications. Pathology demonstrated a WHO grade II myxopapillary ependymoma.
SPEAKER: At 3 months postoperatively, the patient denied any new neurologic deficits, with slow improvement of her right lower-extremity weakness and paresthesias. Postoperative imaging demonstrated gross-total resection of the lesion. Ependymomas are a rare CNS tumor that arise from ependymal cells in the central canal, filum terminale, choroid plexus, or white matter near the ventricular surface.
SPEAKER: Ependymomas are classified by the World Health Organization as grade I, II, or III based on histological findings. Myxopapillary ependymomas are a rare subset of ependymoma classified as WHO grade II. Myxopapillary ependymomas have an incidence in the United States around 1 per million person-years and are typically found in the conus medullaris, cauda equina, or filum terminale. There are two incidence peaks, one in early adulthood between 25 to 29 years of age, and another between 45 to 49 years of age.
SPEAKER: Gross-total resection, and if possible, with an intact tumor capsule, are the historical and modern treatment modalities of choice and are associated with the lowest recurrence rate. Although adjuvant radiation is controversial, there appears to be some increase in progression-free survival with adjuvant radiation therapy.
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