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|LETTER TO EDITOR
|Year : 2016 | Volume
| Issue : 6 | Page : 1341-1345
Transcorporeal excision of cervical intradural lesions: Two cases and a literature review
Santhosh Rajagandhi, Akshay Hari, Murali Krishna, Rajakumar V Deshpande
Department of Neurosurgery, Fortis Hospitals, Bengaluru, Karnataka, India
|Date of Web Publication||11-Nov-2016|
Rajakumar V Deshpande
Department of Neurosurgery, Fortis Hospitals, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Rajagandhi S, Hari A, Krishna M, Deshpande RV. Transcorporeal excision of cervical intradural lesions: Two cases and a literature review. Neurol India 2016;64:1341-5
Ventrally located cervical intradural pathologies have been described by many authors and surgical removal of such lesions carries a high risk. Posterior or posterolateral approach gives sufficient exposure in most circumstances after a laminectomy. Truly ventrally located lesions without spinal cord rotation or lateral displacement are difficult to remove via the posterior or posterolateral approach. Although the anterior approach with corpectomy has been applied widely for cervical spondylosis, it has rarely been used to remove intradural tumors. Recently, few reports in the literature have described this approach for removal of various cervical intradural pathologies such as nerve sheath tumors, meningiomas, cavernous malformations, dermoids, arachnoid cyst,,, hemangioblastomas, neurenteric cysts, and astrocytomas. Only one case of partial midline C2 corpectomy for excision of an intradural arachnoid cyst has been reported in the Indian literature.
We report our experience with two ventral cervical intradural lesions, which were completely excised by the anterior approach with corpectomy and vertebral body reconstruction.
Our first patient was a 24-year-old male, who presented with gradually progressive weakness and stiffness in both lower limbs with spastic gait and difficulty in initiation of micturition and defecation (Nurick Grade IV). Magnetic resonance imaging (MRI) of the cervical spine showed a large, well-circumscribed intradural-extramedullary lesion at the C6 level with cord compression, cord edema, and myelomalacic changes [Figure 1].
|Figure 1: Magnetic resonance imaging of the cervical spine, three-dimensional constructive interference in steady state sequence, showing the presence of a well-circumscribed intradural-extramedullary cystic lesion measuring 24.6 mm × 13.6 mm at the C6 level. The cord is flattened and posteriorly displaced by the lesion|
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Considering that the lesion was purely ventral in location, displacing the cord posteriorly, a posterior or posterolateral approach would have been detrimental. Hence, an anterior approach with corpectomy was planned.
Intraoperatively, C6 corpectomy was performed and a wide exposure was achieved. Durotomy was done and the entire lesion was exposed. The entire cyst was excised with no retraction on the cord. Dura was closed with 5-0 prolene intermittently and sealed with fibrin glue. Reconstruction of C5-C7 was done with an expandable polyethyletherketone cage and anterior cervical plate [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d.
|Figure 2: Intraoperative pictures showing: (a) corpectomy done with a drill, (b) durotomy, (c) removal of the cyst, (d) hemostatic agent being used|
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Postoperatively, he improved neurologically and was mobilized with a cervical collar [Figure 3]a,[Figure 3]b,[Figure 3]c,[Figure 3]d. The histopathology revealed the lesion to be an enterogenous cyst.
|Figure 3: Postoperative images showing the placement of implants in the radiographs (a and b) and the expansion of the flattened cord is well seen in the magnetic resonance imaging pictures (c and d)|
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Our second patient was a 27-year-old female, who had neck pain and left sided brachialgia for 4 years. Since 2 months, she developed left upper limb numbness and weakness that rapidly progressed to the left lower limb, right upper limb, and right lower limb within a week. She further developed urinary retention and constipation over 2 days.
Her cervical spine MRI showed a focal area of hemorrhage involving the anterior aspect of the cervical cord at the C6-C7 level with intense perilesional edema and expansion of the cord, with marked peripheral contrast enhancement of the nodule, suggestive of a possible cavernoma [Figure 4].
|Figure 4: Magnetic resonance imaging of cervical spine showing focal areas of hemorrhage involving the anterior aspect of the cervical cord at the C6-C7 level with intense perilesional edema and expansion of the cord extending superiorly upto the lower brain stem level and inferiorly up to the D8 level along with linear areas of hemorrhage extending inferiorly up to the D3 level|
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Similar to the previous case, we performed a corpectomy of both C6 and C7 bodies and obtained a wide exposure. After durotomy and medullotomy, the cavernoma was completely excised. Dural closure and reconstruction of C5-D1 were performed as shown in [Figure 5]a,[Figure 5]b,[Figure 5]c,[Figure 5]d,[Figure 5]e,[Figure 5]f,[Figure 5]g,[Figure 5]h.
|Figure 5: Intraoperative pictures of the second patient showing the discectomy; (a) a wide dural exposure is seen following the corpectomy; (b and c) vascular intramedullary lesion is seen after dural opening, and a myelotomy performed; (d-e) the excision of the cavernoma; (f) Use of the fibrin glue after partial dural closure to prevent cerebrospinal fluid leak; (g-h) Demonstration of the ideal placement of an expandable polyethyletherketone cage and anterior cervical plate-cage and the anterior cervical plate, respectively. Note that the bone grafts are being used by interposing them in between the cage and plate for better fusion|
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The postoperative MRI showed complete excision of the lesion and radiographs revealed the implants in situ and in an optimal position. She improved neurologically and was walking with support within 1 week; however, she still had residual urinary retention.
It is well-known that the conventional method for excision of cervical intradural lesions is by a posterior or posterolateral laminectomy although it would not be an ideal approach for purely ventral intradural cervical spinal lesions. Bilateral posterolateral approach is also in use, in case of lesions that extend to both sides of the anterior spinal artery. The concern regarding this traditional technique for purely ventral lesions is the sectioning of the dentate ligament and retraction of the spinal cord for adequate visualization and complete tumor removal, which may injure the spinal cord and cause functional deficits. Angevine et al., have explained that the posterolateral approach can be used in small, superficially located pia-based ventral lesions such as a hemangioblastoma or a perimedullary fistula, although it is unsuitable in the case of lesions with an intramedullary extension. However, more recently, venterolateral or ventral approaches have been described for anteriorly located intradural lesions.,,, A review of the available literature on this subject has been summarized in a tabular format [Table 1].
The anterior approach with corpectomy suitably ensures a sufficient exposure of the ventral surface of the spinal cord on both sides of the anterior spinal artery. Since ventral intradural lesions can cause significant challenges depending on the location, size, extension, and pathology, such an approach can be preferred. Nevertheless, there do exist some drawbacks that can be faced in following the anterior approach, namely, chances of inadequate exposure, epidural venous plexus bleeding, spinal instability requiring bony reconstruction, and postoperative cerebrospinal fluid (CSF) leak. However, with advancement in microsurgical techniques, more secure retraction systems, reliable dural repair methods, and anterior spinal stabilization, the scope of ventral spinal approaches has increased.,
In the present report, specific perioperative measures were taken to overcome the approach-related drawbacks. Adequate access to the lesion was achieved by a wide corpectomy, and epidural venous bleeding was controlled using specific hemostatic agents. CSF leak was avoided by a watertight dural closure using fibrin glue. Bony reconstruction was achieved using an expandable cage and plating system with inclusion of autologous bone fragments. In both of the described cases, there were no postoperative complications such as CSF leak, meningitis, or wound infection and we did not use a lumbar drainage routinely.
Hence, midline cervical ventral intradural lesions, similar to those seen in this report, can be completely and safely removed via an anterior transcorporeal approach.
It is also extremely important to stress that this approach should be considered in a carefully selected clinical setting where the lesion is purely in the midline and anterior to the spinal cord. Further, it may be noted that the procedure may be attempted only by experienced surgeons who are well versed with the anterior corpectomy technique.
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There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]