INTRODUCTION TO SPINAL CORD TUMOR CASE STUDIES

The standard and generally accepted surgical approach to remove Spinal Cord Tumors involves an operation called a "Laminectomy". The standard surgical technique requires the removal of the bony "roof" of the Spinal Canal on BOTH SIDES AFTER THE LARGE MUSCLES THAT LIE ON EITHER SIDE OF THE SPINAL COLUMN'S BONE HAVE BEEN STRIPPED FROM THE LAMINA AND HELD UNDER PRESSURE BENEATH A STEEL RETRACTOR. (See Figure 1)

While this operation still remains as the "standard" treatment, it is our experience that the majority of these potentially catastrophic patient problems can be successfully managed with a MINIMALLY INVASIVE BILATERAL LAMINECTOMY using a UNILATERAL (one-sided) APPROACH (See Figure 2). This revolutionary concept in Neurosurgery greatly limits the amount of surgical exposure required and therefore reduces the amount of tissue (including the muscles of the Spine) that are touched and retracted during the operation. This results in less post-operative pain, earlier mobilization, diminished hospital stay, less risk for complications, an earlier return to activities as well as lower overall costs.

Figure 1: Anatomical Diagram of the Thoracic Spine with the Paravertebral Muscles A STANDARD LAMINECTOMY REQUIRES THE REMOVAL OF THESE MUSCLES ON BOTH SIDES OF THE SPINAL COLLUMN.

Figure 2: Anatomical Diagram to Demonstrate the Technique to Perform a Minimally Invasive Microendoscopic BILATERAL LAMINECTOMY using a UNILATERAL APPROACH. The Paravertebral Muscles remain intact as the special Minimally Invasive "Tube Retractor" separates and preserves the muscles fibres. In this illustration, the Lamina on the side of the tube Retractor has been removed (Curved Arrow). The retractor was then angled towards the opposite side allowing the surgeon to drill and remove the Lamina (Oblique Arrow) on the OPPOSITE SIDE. The drilling is accomplished within the Epidural Space which requires considerable technical skill. The muscles on the "Opposite" side are never disturbed. In our experience the surgical exposure for the removal of Spinal Cord Tumors is excellent.

Figure 3: Post-myelographic CT Scan (Axial View) Post-operative L3 Level study in a patient who underwent an L3 & L4 Minimally Invasive Bilateral Laminectomy using a Unilateral Approach for an Intradural Spinal Cord Tumor. The image has been inverted from the traditional view to correspond to the Diagram in Figure 2. The Arrow on the Left of the image represents the area of bone removal of the Patient's Right-sided Lamina. The other Arrow indicates the direction of the drilling of bone from the OPPOSITE LAMINA. In this case the Left Lamina was ONLY PARTIALLY REMOVED by thinning the INTERIOR layers of the Lamina. This surgical exposure is quite sufficient to permit removal of the intradural tumor. Compare this image to that in Figure 2 and view the operative photos in the illustrated cases that follow.

From among our patients* with Spinal Cord Tumors, we have selected several to present in this special section in order to illustrate the application of Minimally Invasive Techniques as well as some of the characteristics, differences and challenges encountered with these clinical problems.

An example of a complete resection of a Filum Terminale Ependymoma is contrasted with another case in order to demonstrate the issue of dense adherence to Nerve Roots, which limits the reasonable possibility of complete resectability.

Patients with Spinal Cord Meningioma and Neurofibroma are included as well. The Meningioma case deserves a special comment since it is the FIRST INTRADURAL CALCIFIED ANTERIOR THORACIC MENINGIOMA TO BE REMOVED USING MINIMALLY INVASIVE TECHNIQUE.

IMPORTANT GUIDELINES THERE ARE TWO (2) GENERAL "GUIDELINES" REGARDING RECOVERY OF NEUROLOGICAL FUNCTION: 1. RECOVERY IS LESS LIKELY TO BE COMPLETE IN THE OLDER PATIENT, PATIENTS IN WHOM THE SYMPTOMS & SIGNS HAVE BEEN PRESENT FOR EXTENDED PERIODS OF TIME AND IN THOSE PATIENTS EXPERIENCING MORE SEVERE NEUROLOGICAL DEFICITS. 2. WHATEVER NEUROLOGICAL DEFICITS REMAIN AT A POINT (1) YEAR AFTER SURGICAL TREATMENT, THEY ARE MOST LIKELY TO BE PERMANENT.

ADDITIONAL TREATMENTS

TREATMENT EXPECTATIONS The results experienced by the patients whose cases are featured in this section are usual for these types of operation. Each patient's recovery differs and depends on many factors. In addition to the biological behavior of the particular tumor, the patient's age, type and extent of neurological disability together with the length of time the neurological deficits were present all play a role in the recovery process. Our treatment goal, in all cases, is to return patients to the fullest extent of functionality as possible given the neurological consequences of their disease process. We would hope to allow the patient to resume all the activities that they did prior to their neurological "injury", whenever possible. NOTICE: * All of these patients have signed a release to permit the sharing of this personal information. We will not and do not disclose any information unless the parties involved agree in writing. Mrs. M-H and Mr. I.H chose to permit their information and statements to be included because of their gratitude to Dr. Martin L. Lazar and his staff. DISCLAIMER: Every effort has been made by the author(s) to provide accurate and up-to-date information. However, the medical knowledge base is dynamic and errors can occur. By using the information contained herein, the viewer willingly assumes all risks in connection with such use. Neither the author nor Neurosurgical Consultants, p.a. shall be held responsible for errors, omissions in information herein nor liable for any special, consequential, or exemplary damages resulting, in whole or in part, from any viewer(s)' use of or reliance upon, this material. CLINICAL DISCLAIMER: Clinical information is provided for educational purposes and not as a medical or professional service. Person(s) who are not medical professionals should have clinical information reviewed and interpreted or applied only by the appropriate health professional(s).

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This page last edited on 2/19