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Resection of intraspinal tumor


Medical editor Frode Kolstad MD
Neurosurgeon
Oslo University Hospital

General

Before the operation, the patient should be informed of the risk of function loss in the form of reduced muscle power, loss of sensitivity and loss of natural functions.

What can be achieved by surgical treatment is determined by the degree of malignancy, the localization of the tumor and the preoperative damage that the tumor has already caused to the nerve tissue.

Surgical access is determined by the location of the tumor.

  • Posterior access (laminectomy, laminotomy) for tumors in posterior and lateral locations.
  • Anterior access (transabdominal, transthoracic, anterior neck) for tumors in anterior locations in the spinal canal.

If surgical access or the cancer itself cause destruction that results in a risk of axis deviation or instability, it may be necessary to use internal stabilization.

Ultrasound diagnosis is carried out during the operation to define the boundaries of the tumor.

Neurophysiological monitoring during the operation consists of testing nerve function in the surgical wound. This is done to prevent damage to the nerves during dissection. Through stimulation it is possible to monitor nerve function and thereby avoid dividing functional nerve structures.

Following the extirpation of the tumor, normal anatomy is reconstructed. The membranes around the spinal cord and the nerve roots are sutured to prevent leakage of spinal fluid, the spinal canal is closed and the muscles are fixed in place.

Indications

  • Tumor in the spinal canal

Goal 

  • Curative radical tumor resection
  • Relief of the nerve roots and spinal cord
  • Stabilization of the spinal column

Preparations

  • The patient is informed of the risk for function loss, both with regard to peripheral power and natural functions.
  • The patient's bowels are emptied (enema).
  • The patient is given general anesthesia.
  • The patient lies in the prone position. Pressure on the abdomen is reduced to minimize bleeding.
  • By means of radiation fluoroscopy, the skin incisions are marked.
  • Local anesthetic is injected in the skin.
  • The patient is connected for neurophysiological monitoration.

Implementation

  • An incision is made and the skin edges are pulled to the side so that the spine is revealed.
  • The paraspinal musculature is dissected from the spinal column.
  • The facet joints are dissected bilaterally.
  • A laminotomy is performed in the relevant region.
  • The processes and laminae are resected, but the lowest one is kept attached.
  • The boundaries of the tumor are defined using ultrasound techniques.
  • The dura is opened in the midline, from proximal to distal, and is then pulled to the side with sutures.
  • The function of the nerve structures is monitored during the operation to prevent nerve damage during dissection.
  • The tumor is opened in the center and decompressed using the Cavitron technique.
  • A frozen section is performed.
  • All visible tumor tissue is extirpated.
  • The operation cavity is flushed.
  • The dura is sutured. Glue is applied to the suture line to prevent CSF leak.
  • The laminae are fastened with osteosutures to normalize the anatomy.
  • A vacuum drain is inserted in the lower part of the operation area.
  • The muscles are adapted to the laminae and processes. The fascia is sutured.
  • The subcutis is sutured. The drain tube is sutured to the skin.
  • The wound edges of the skin are closed with sutures.

Follow-up

  • The patient will remain in bed for 3 days after the operation.
  • Steroids are not routinely given but this depends upon the type and localization of the tumor.
  • Antibiotics are given as infection prophylactics during the operation.
  • Postoperative thrombosis prophylactics with LMWH (low molecular weight heparin) are routinely given.
  • The sutures are removed after approximately 14 days.
  • An MRI scan is taken on the first postoperative day.
  • The patient is normally discharged to the local hospital about a week after the operation (depending on the clinical progress).
  • The patient is followed up with a clinical examination and MRI scan at 3 months and 1 year postoperatively at the hospital where the treatment was performed.

Complications in the form of neurological impairment depend on the size, location and degree of malignancy of the tumor. The duration and severity of the symptoms before the operation are also important. Therefore, there is varying need for and duration of postoperative physiotherapy.


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