a. Using Leksell rongeurs and hand-held high-speed drill, remove the bony spinous process and bilateral lamina as indicated for specific procedure
b. Remove the thick ligamentum flavum with Kerrison rongeurs with careful dissection beneath the ligament to ensure no adhesions exist to dura mater below and thus avoiding CSF leak
c. Perform appropriate foraminotomy with Kerosen rongeurs as needed for appropriate decompression of nerve roots
d. Identify location of tumor and resect tumor as needed if within the lamina, epidural, or within the spinal canal/cord:
i. If within the lamina or epidural in nature, the tumor can be visualized immediately and removed gently
ii. If within the spinal cord, use operative microscope and open the spinal cord dura midline with 11 blade and tack up the dural leaflets with suture
iii. If tumor is intradural and extramedullary, it can be resected carefully with microdissection technique without cord injury (neuromonitoring needed in these cases) (see ▶Fig. 1.14)
iv. If tumor is intradural and intramedullary, with microdissection technique the cord must be entered midline and the tumor must be identified and resected starting centrally first, then around the edges (neuromonitoring needed in these cases)
10. After appropriate tumor resection, there may be need for additional stabilization to prevent kyphosis if the resection caused multiple segment decompression. Therefore, instrumentation with lateral mass screws can be placed over the segments involved with rods bilaterally and fusion/arthrodesis along these segments. (see ▶Fig. 1.15 and ▶Fig. 1.16)
11. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion, often with placement of postoperative drains that can be removed after 2 to 3 days.
Fig. 1.14 (a–d) Radiology revealed tumor at the C5 level, accompanying severe cord compression. After dissecting to the tumor, it was successfully resected. (Source: Intradural extramedullary tumors. In: Bernstein M, Berger M, eds. Neuro-oncology: The Essentials. 3rd ed. Thieme; 2014).
Fig. 1.15 (a, b) Preoperative imaging revealed cervical ependymoma. Postoperative imaging demonstrates total removal of tumor. (Source: Intramedullary spinal cord tumors: ependymomas and astrocytomas. In: Nader R, Berta S, Gragnanielllo C, et al, eds. Neurosurgery Tricks of the Trade: Spine and Peripheral Nerves. 1st ed. Thieme; 2014).
Fig. 1.16 (a, b) Radiology revealed a cervical lymphoma and lysis of C3 in an elderly man. Anterior corpectomy and posterior stabilization were performed and confirmed via postoperative CT scan. (Source: Vertebral bone tumors. In: Fessler R, Sekhar L, eds. Atlas of Neurosurgical Techniques: Spine and Peripheral Nerves. 2nd ed. Thieme; 2016).
Pitfalls
• Loss of neck mobility (minimal, unless fusion extended to occiput and C1)
• Intraoperative CSF leak
• Blood clot (deep vein thrombosis, or more severe pulmonary embolism)
• Damage to spinal nerves and/or cord
• Postoperative weakness or numbness or continued pain
• Postoperative wound infection
• Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life
• Prolonged hospitalization due to invasiveness of surgery and other comorbidities/iatrogenic infection
Prognosis
• 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
1.3.2 Cervical Vascular Lesion Treatment for Arteriovenous Malformation (AVM) (Vertebral Pathology)
Symptoms and Signs (AVM)
• Dilated arteries and veins with dysplastic vessels
• Subarachnoid hemorrhage
• Neck pain and loss of mobility due to neck pain
• Pain in moving shoulders
• Meningism (neck rigidity, photophobia, and headache)
• Myelopathy
• Seizure
• Ischemic injury to cervical
• Increased sweating around cervical vascular lesion
• Hemorrhaging
• Inability to conduct fine motor skills with hands
Surgical Pathology
• Cervical vascular benign/malignant lesions
Diagnostic Modalities
• Angiography:
– Preoperative spinal angiography
– Intraoperative indocyanine green (ICG) angiography
• CT of cervical spine with and without contrast (can rule out acute hemorrhage)
• MRI of cervical spine with and without contrast
Differential Diagnosis:
• Fibromuscular dysplasia (FMD):
– Craniocervical FMD
• Spinal AVM (see ▶Fig. 1.17 and ▶Fig. 1.18):
– Intradural-intramedullary (hemorrhaging common)
◦ Glomus (Type II) (see ▶Fig. 1.19 and ▶Fig. 1.20)
◦ Juvenile (Type III)
– Intradural-extramedullary
– Conus medullaris
– Metameric
– Extradural
– Cavernoma
– Capillary telangiectasia
• Spinal dural arteriovenous fistula (AVF, Type I) (see ▶Fig. 1.21):
–