Name:
10.3171/2023.7.FOCVID2368
Description:
10.3171/2023.7.FOCVID2368
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/492f2dc3-77ae-4d9a-96ee-e2c4690c5605/videoscrubberimages/Scrubber_181.jpg
Duration:
T00H07M50S
Embed URL:
https://stream.cadmore.media/v10.3171/2023.7.FOCVID2368
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/492f2dc3-77ae-4d9a-96ee-e2c4690c5605/4. 23-68.mp4?sv=2019-02-02&sr=c&sig=JJGkmfRW%2FFcyO7uTLwamG0tdCuAluHdfjlEUC%2BeomAs%3D&st=2026-04-05T03%3A25%3A55Z&se=2026-04-05T05%3A30%3A55Z&sp=r
Upload Date:
2023-08-16T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This video demonstrates a microsurgical technique for excision of intramedullary tumor at the cervical level. A 66-year-old woman with a medical history presented with neuropathic pain in the left upper limb for more than 6 months. This neuropathic pain was felt in the C5 and C6 dermatomes. The pain was described as a permanent burning background pain and associated with allodynia. Neurological examination did not find any motor anomaly in the upper and lower limbs.
SPEAKER: No pyramidal syndrome was observed. However, she had proprioceptive disorders in the left upper and lower limbs associated to ataxia. Secondly, symptomatology worsened in a few months. Neuropathic pain was no more controlled by pharmacological treatments. And the patient presented sphincter disorders. The patient underwent motor evoked potentials, which were normal in the upper and lower limbs.
SPEAKER: Somatosensory evoked potentials didn't find somesthetic segmental response for lower limbs. In fact, no N22 response, which corresponds to the spinal cord segmental response, was found. While P39 cortical responses were present. Preoperative MRI demonstrated a cystic intramedullary tumor located at the C4–5 levels. Spinal cord edema was observed at the cranial pole of the tumor.
SPEAKER: And syrinx at the caudal pole of the tumor. Axial images showed that the spinal cord tumor was centromedullary, except at its caudal pole, where it was lateralized to the left. After gadolinium enhancement, the cyst walls were strongly enhanced. Here the intramedullary tumor was represented in blue with the spinal cord tissue was represented in yellow. Finally, diffusion tensor imaging was achieved in order to perform spinal cord tractography.
SPEAKER: Fiber tracking highlighted complete dilacerations of the spinal cord white fibers at the location of the tumor. White fibers were pushed back around the tumor and no warped fiber was found within the tumor. According to these data from the tractography, intramedullary ependymoma was proposed as diagnosis. So the scheduled surgical dorsal approach will be faced with the presence of fiber in the two dorsal columns.
SPEAKER: According to the clinical examination, electrophysiological MRI features showing evolutive spinal cord suffering, and before major gait disorder appeared, microsurgical excision of this intramedullary tumor was proposed and accepted by the patient. The patient was in prone position with head fixed with a three-pin head holder. Surgery was performed under general anesthesia without muscle relaxant to allow the interoperative neurophysiological monitoring.
SPEAKER: The cervical midline skin incision was performed from C3 to C6 spinous process. The cervical laminotomy was performed from C3 to C5. The superior part of the lamina of C6 were then resected. At this step, an ultrasound machine was used to confirm that this approach was sufficient to control both poles of the tumor. The dura mater was opened on the midline.
SPEAKER: After its opening, it was carefully suspended. while being cautious of possible fibrotic adhesion to avoid pulls-up on the spinal cord. Arachnoid mater was opened, and then kept intact until the end of the surgery by peripheral suspensions to the dura mater.
SPEAKER: Because of its tortuosity, the mid-dorsal vein is not always a good anatomical landmark for defining the midline. Two anatomical elements can facilitate its recognition. Firstly, in case of swollen tumoral spinal cord, the midpoint between the left and right dorsal rootlets appears to be a reference of the midline. Secondly, blood vessels running on the spinal cord surface and penetrating into the dorsomedial sulcus delineate the sulcus.
SPEAKER: Once the dorsomedial sulcus was identified, the pia mater was incised using a sharp micro knife, and the dorsal columns were carefully separated from each other. In order to avoid repeat traumatism on dorsal colons, pia mater was gently retracted and suspended to the dura using 8-0 sutures under somatosensory evoked potential monitoring.
SPEAKER: Once the intramedullary tumor was exposed through the opening of the dorsal sulcus, caudal pole of the tumor was highlighted. And cleavage plane must be defined. Once the surgeon had properly analyzed the volume tumor, a microbiopsy was performed for immediate histology analysis of the tumor. That could result and influence the surgical strategy. Then debulking can begin.
SPEAKER: It was not necessary to take undue risk for en bloc resection, but it was preferable to achieve a piecemeal resection to avoid repeated trauma on spinal white matter. At this step, ultrasonic aspiration at low intensity could help to reduce the tumoral volume. Tumor was then gently mobilized to highlighted lateral cleavage planes and feeding vascularization was exposed, coagulated at low intensity, and sectioned. These two steps, debulking and alternating cleavage plane, were repeated as required until the cranial pole of the tumor.
SPEAKER: The role of a spinal cord tumor resection is to avoid any traction or compression and any kind of mechanical constraints on the normal spinal cord tissue. The last part of the resection concerns the ventral pole of the tumor. It would be performed very carefully and coagulation of tumor feeding arteries from the anterior spinal artery should be used with great prudence at this step.
SPEAKER: Using all these steps, the goal of surgery is to achieve a gross-total resection of the tumor while maintaining neurological functions. Once gross-total resection was achieved and hemostasis controlled inside the cavity, the spinal cord pia mater was closed using 10-0 sutures. Arachnoid leaflets were folded back on the spinal cord in order to avoid local tethered cord syndrome.
SPEAKER: And then the dura mater was closed and reinforced with biological glue. At the end of the surgery, electrophysiological monitoring demonstrated the persistence of motor and sensory functions. D-wave remained stable during whole surgery, hence somatosensory evoked potential was still present at the end of the surgery.
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