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Chang C, Che XM, Zhang MG. Resection of cervical extra-intraspinal neuromas through the enlarged intervertebral foramen: Results in 34 case series patients. Front Surg 2022; 9:945857. [PMID: 37152352 PMCID: PMC10157471 DOI: 10.3389/fsurg.2022.945857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/17/2022] [Indexed: 05/09/2023] Open
Abstract
Objective The purpose of this study was to analyze the techniques used to resection cervical extra-intraspinal neuromas (also known as cervical dumbbell neuromas) through the enlarged intervertebral foramen. Methods A total of 34 consecutive patients (19 male, 15 female) with cervical dumbbell neuromas reviewed retrospectively between April 2008 and May 2020. Sixteen tumors were found in the intervertebral foramen of C1-C3, four in C3-C4, and 14 in C4-T1. The approach in all cases was to expose the tumors by intermuscular dissection and to remove them through the enlarged intervertebral foramen without excision of any bony structures. However, to expose tumors at different locations, the incisions shall be made accordingly. In this case series, the incisions were made along the posterior border of the sternocleidomastoid muscle for the C1-C3 tumors and along the anterior border of the muscle for the C3-C4 tumors. Transverse incisions were required for the C4-T1 tumors. Results Following the mentioned incising approach, all 34 tumors were completely exposed. 31 were completely removed in one stage, and 3 tumors underwent subtotal resection because of brachial plexus nerve adhesion. The vertebral artery and spinal cord were undamaged for all cases. The patients who had total tumor resection showed no sign of recurrence on enhanced magnetic resonance imaging during follow-ups. The status of patients who underwent subtotal resection was stable after radiation therapy. None of the patients developed spinal instability. Conclusions Cervical dumbbell neuromas can be exposed and removed through the enlarged intervertebral foramen without causing spinal instability or injury to the spinal cord or vertebral artery. This operative approach can retain the integrity of the structures of spine and should be considered the ideal approach for cervical dumbbell neuromas.
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Affiliation(s)
- Chuan Chang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China
- Department of Neurosurgery, Huashan Hospital, Neurosurgical Institute of Fudan University, Shanghai, China
- Department of Neurosurgery, Huashan Hospital, Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Xiao-Ming Che
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China
- Department of Neurosurgery, Huashan Hospital, Neurosurgical Institute of Fudan University, Shanghai, China
- Department of Neurosurgery, Huashan Hospital, Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- Correspondence: Ming-Guang Zhang Xiao-Ming Che
| | - Ming-Guang Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China
- Department of Neurosurgery, Huashan Hospital, Neurosurgical Institute of Fudan University, Shanghai, China
- Department of Neurosurgery, Huashan Hospital, Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- Correspondence: Ming-Guang Zhang Xiao-Ming Che
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Mushkin AY, Glukhov DA, Zorin VI, Shlomin VV, Snishchuk VP. [Surgical treatment of cervical spine tumors involving vertebral artery in children: analysis of small sample siz]. Khirurgiia (Mosk) 2021:56-65. [PMID: 34786917 DOI: 10.17116/hirurgia202111156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyze the features of cervical spine tumors involving vertebral artery in pediatric patients. MATERIAL AND METHODS A single center 2-year retrospective cohort includes 7 children with cervical spine tumors involving vertebral artery. Demographic data, duration of diagnostic process, clinical and radiological manifestations, features of surgical treatment, morphology, and postoperative outcomes were studied. We analyzed the features of vascular imaging, pre- and intraoperative manipulations on the vertebral artery. RESULTS Mean age of patients was 13.3 years, duration of diagnostic process - 13.1 months. Cervicalgia was the most common complaint. Malignant process was found in 2 cases. Preoperative temporary balloon occlusion test and subsequent endovascular embolization of vertebral artery were performed in 1 case, intraoperative ligation - in 1 patient. Injury and subsequent tamponade were noted in another patient. There were not neurological complications associated with arterial occlusion in postoperative period. CONCLUSION Our group was compared with the data from 14 manuscripts comprising 21 children with similar cervical spine lesions. The decision making algorithm for surgical treatment of patients with cervical spine tumors involving vertebral artery is proposed.
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Affiliation(s)
- A Yu Mushkin
- Saint-Petersburg Research Institute of Phthisiopulmonology, St. Petersburg, Russia.,Pavlov St. Petersburg First State Medical University, St. Petersburg, Russia
| | - D A Glukhov
- Saint-Petersburg Research Institute of Phthisiopulmonology, St. Petersburg, Russia
| | - V I Zorin
- Saint-Petersburg Research Institute of Phthisiopulmonology, St. Petersburg, Russia.,Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - V V Shlomin
- Saint-Petersburg City Multi-field Hospital No. 2, St. Petersburg, Russia
| | - V P Snishchuk
- Leningrad Regional Pediatric Hospital, St. Petersburg, Russia
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Glukhov DA, Zorin VI, Yu. MA. Surgery of cervical spine tumors in the close vicinity to the vertebral artery: literature review. HIRURGIÂ POZVONOČNIKA (SPINE SURGERY) 2020. [DOI: 10.14531/ss2020.3.91-99] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- D. A. Glukhov
- St.Petersburg Research Institute of Phthisiopulmonology
| | - V. I. Zorin
- St.Petersburg Research Institute of Phthisiopulmonology;
North-Western State Medical University n.a. I.I. Mechnikov
| | - Mushkin A. Yu.
- St. Petersburg Research Institute of Phthisiopulmonology
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Westbroek EM, Pennington Z, Ehresman J, Ahmed AK, Gailloud P, Sciubba DM. Vertebral Artery Sacrifice versus Skeletonization in the Setting of Cervical Spine Tumor Resection: Case Series. World Neurosurg 2020; 139:e601-e607. [PMID: 32330623 DOI: 10.1016/j.wneu.2020.04.071] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Tumors of the cervical spine often encase 1 or both vertebral arteries (VA), presenting the treating surgeon with the dilemma of whether to sacrifice or skeletonize the artery. We propose an algorithm for VA management in surgeries for cervical neoplasms METHODS: A retrospective review was carried out of 67 patients undergoing resection of cervical spine tumors with VA involvement. Patients were categorized by tumor origin (primary vs. metastatic) and degree of circumferential VA involvement: 1) abutment only; 2) <180° circumferential involvement; 3) >180° circumferential involvement without complete encasement; or 4) complete encasement. RESULTS Twelve patients (18%) underwent VA sacrifice, whereas 55 (82%) underwent VA skeletonization. Compared with 11/30 patients with primary tumors (37%), only 1/37 patients (3%) with metastatic disease underwent VA sacrifice (P < 0.01). This patient had invasion of the V2 arterial wall, requiring VA sacrifice. Odds of VA sacrifice also increased with increasing circumferential involvement (P < 0.01). No patients with simple abutment or 0°-180° circumferential involvement underwent sacrifice, whereas 6 of 10 (60%) with 180°-359° involvement and 6 of 29 (21%) with complete encasement underwent VA sacrifice. Of the 27 patients with ≥180° involvement, the reasons for preserving the VA were metastatic disease at the time of treatment (n = 18), a compromised contralateral VA (n = 7), vertebrobasilar junction aplasia (n = 1), and presence of a radiculomedullary artery at the affected level (n = 1). CONCLUSIONS Primary tumor disease and >180° of circumferential VA involvement should be considered as indications for intraoperative sacrifice of the VA pending preoperative angiographic evaluation for contraindications.
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Affiliation(s)
- Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeff Ehresman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Philippe Gailloud
- Division of Interventional Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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5
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Pham M, Awad M. Outcomes following surgical management of cervical chordoma: A review of published case reports and case series. Asian J Neurosurg 2017; 12:389-397. [PMID: 28761513 PMCID: PMC5532920 DOI: 10.4103/1793-5482.185066] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Aim: This review aimed to summarize the clinical outcomes in relation to tumor resection margins of cervical chordomas. Methods: Studies that described any surgical intervention for cervical chordoma were identified. Cervical chordomas with cranial or spinal extension, purely retropharyngeal chordomas or where resection type was not reported, were excluded from the study. Results: Seventy-six articles were obtained and these reported a total of 195 patients. Seventy-six percent cervical chordoma patients had intralesional resection with adjuvant radiotherapy. Ninety-two percent chordoma recurrences and all chordoma metastases occurred in patients with intralesional resection. En bloc surgeries were longer (900 min vs. 619 min) and staged surgeries. Intralesional surgeries (2899 ml vs. 2661 ml) had greater intraoperative blood loss. Vertebral artery and nerve root sacrifice were greater in en bloc patients (35%, 39%) compared to intralesional patients (17%, 10%). Postoperative complications were more common in en bloc (54%) than in intralesional patients (11%). Conclusions: En bloc resection cervical chordomas are associated with less recurrence and no metastasis compared to intralesional resection. En bloc is possible through wide exposure of the vertebrae via a multidisciplinary team approach and utilization of particular surgical equipment. The higher rate of complications associated with en bloc surgeries may be acceptable, particularly when there is a chance of cure of disease.
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Affiliation(s)
- My Pham
- Department of Neurosurgery, The Royal Melbourne Hospital, Victoria 3050, Australia
| | - Mohammed Awad
- Department of Neurosurgery, The Royal Melbourne Hospital, Victoria 3050, Australia
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Kumar CV, Satyanarayana S, Rao BR, Palur RS. Extreme lateral approach to ventral and ventrolaterally situated lesions of the lower brainstem and upper cervical cord. Skull Base 2011; 11:265-75. [PMID: 17167629 PMCID: PMC1656882 DOI: 10.1055/s-2001-18633] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Lesions situated ventrally and ventrolaterally to the lower brainstem and upper cervical spinal cord test the skills of neurosurgeons. We present our experience with eight such patients who underwent the extreme lateral craniocervical approach. The pathologies encountered include three distal vertebral aneurysms, one prepontine epidermoid, one anterior foramen magnum meningioma, and three high cervical dumbbell neurofibromas. All lesions were treated effectively. Postoperatively, the patients improved significantly. Complications included transient lower cranial nerve paresis in three patients, meningitis in one patient, and a pseudomeningocele in two patients. All complications improved with therapy. We conclude that the extreme lateral approach offers excellent visualization and access with minimal neural retraction for treating these difficult lesions.
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Wang J, Ou SW, Wang YJ, Wu AH, Wu PF, Wang YB. Microsurgical management of dumbbell C1 and C2 schwannomas via the far lateral approach. J Clin Neurosci 2011; 18:241-6. [DOI: 10.1016/j.jocn.2010.03.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 03/26/2010] [Accepted: 03/28/2010] [Indexed: 11/27/2022]
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Takami T, Yamagata T, Chokyu I, Ikeda H, Tsuyuguchi N, Ohata K. Surgery of spinal nerve sheath tumors originating from C1 or C2 of high cervical spine. Neurol Med Chir (Tokyo) 2010; 50:1044-9. [PMID: 21123996 DOI: 10.2176/nmc.50.1044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Spinal nerve sheath tumors (NSTs) originating from the C1 or C2 level are unique from both anatomical and clinical perspectives. Surgical technique to accomplish radical but safe resection of these tumors is described in 8 cases treated during the past 5 years. Surgical measures included positioning the patient in the lateral oblique position, unilateral posterior approach, exposure of the tumor along the surgical plane of the dural or perineural boundary, and proximal and distal amputation of the tumor with resection of dural penetration. Excessive bone resection and soft tissue manipulation were unnecessary. Microscopic complete removal of the tumor was accomplished in seven of eight cases. Subtotal resection was done in one case where the tumor extended beyond the vertebral artery. Functional assessment demonstrated satisfactory improvement after surgery in all cases. Surgery-related complications were not encountered in any case. Exposure of the tumor along the surgical plane of the dural or perineural boundary may be the key procedure required to accomplish radical but safe resection of spinal NSTs originating from the C1 or C2 level.
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Affiliation(s)
- Toshihiro Takami
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
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9
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Al Barbarawi M, Odat Z, Alheis M, Qudsieh S, Qudsieh T. Surgical resection of neoplastic cervical spine lesions in relation to the vertebral artery V2 segment. Neurol Int 2010; 2:e11. [PMID: 21577335 PMCID: PMC3093210 DOI: 10.4081/ni.2010.e11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Revised: 04/16/2010] [Accepted: 05/05/2010] [Indexed: 11/23/2022] Open
Abstract
Neoplastic cervical spine lesions are seen infrequently by the spinal surgeon. The surgical management of these tumors, particularly with associated neurovascular compromise, is challenging in terms of achieving proper resection and spinal stabilization and ensuring no subsequent recurrence or failure of fixation. In this report we highlight some of the problems encountered in the surgical management of tumors involving the cervical spine with techniques applied for gross total resection of the tumor without compromising the vertebral arteries. Ten patients with neoplastic cervical spine lesions were managed in our study. The common cardinal presentation was neck and arm pain with progressive cervical radiculo-myelopathy. All patients had plain X-rays, computer tomography scans, and magnetic resonance imaging of the cervical spine. Digital subtraction or magnetic resonance angiograms were performed on both vertebral arteries when the pathology was found to be in proximity to the vertebral artery. When a tumor blush with feeders was evident, endovascular embolization to minimize intraoperative bleeding was also considered. A single approach or a combined anterior cervical approach for corpectomy and cage-with-plate fixation and posterior decompression for resection of the rest of the tumor with spinal fixation was then accomplished as indicated. All cases made a good neurological recovery and had no neural or vascular complications. On the long-term follow-up of the survivors there was no local recurrence or surgical failure. Only three patients died: two from the primary malignancy and one from pulmonary embolism. This report documents a safe and reliable way to deal with neoplastic cervical spine lesions in proximity to vertebral arteries with preservation of both arteries.
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Affiliation(s)
| | | | - Mwaffaq Alheis
- Department of Radiology, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Suhair Qudsieh
- Hashemite University, Faculty of Medicine, Zarqa, Jordan
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10
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Extensive posterolateral exposure and total removal of the giant extraforaminal dumbbell tumors of cervical spine: surgical technique in a series of 16 patients. Spine J 2009; 9:822-9. [PMID: 19664969 DOI: 10.1016/j.spinee.2009.06.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 06/16/2009] [Accepted: 06/25/2009] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Removal of cervical dumbbell tumors can be particularly challenging because of unique exposure requirements and proximity of the vertebral artery (VA). There are no reports describing the treatment of giant cervical spine dumbbell tumors (CSDTs). PURPOSE To introduce an extensive posterolateral approach to CSDTs involving total lateral mass resection and laminectomy. STUDY DESIGN Prospective study of all the patients with multilevel CSDTs treated by this new procedure between December 2002 and March 2006. PATIENT SAMPLE Sixteen patients (3 men and 13 women) with CSDTs underwent the procedure we describe. The follow-up periods ranged from 9 to 51 months (average 9 months). Average age at surgery was 45 years (range 23-68 years). OUTCOME MEASURES Axial symptoms and Japanese Orthopedic Association scores were recorded. Pre- and postoperative ranges of neck motion were measured on lateral flexion and extension radiographs. METHODS After making a midline incision, we preferred exposing the extraforaminal component of the tumor before performing a semilaminectomy and lateral mass resection. Any lateral extension of a tumor can be attained by detachment of the adjacent three or more segments of the lateral mass muscle insertion. The most lateral portion can be separated beneath the tumor's superficial muscle flap, and then when the tumor is retracted medially, the whole portion of the lateral component can be totally exposed. We then performed total lateral mass resection and laminectomy to expose the tumor at the foramina and cervical canal. RESULTS We were able to completely resect the tumors in every patient. The average duration of surgery was 150 minutes. Blood loss was minimal (average 400 mL). All patients were monitored for a minimum of 9 months (range 9-51 months; mean 28 months). The follow-up period was uneventful, and no patients developed spinal instability. CONCLUSIONS Extensive posterolateral exposure enables surgeons to reach the lateralmost portion of CSDTs and also facilitates septation of the VA and resection of vertebral body encroachment of the tumor.
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11
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Kim JH, Han S, Kim JH, Kwon TH, Chung HS, Park YK. Surgical consideration of the intraspinal component in extradural dumbbell tumors. ACTA ACUST UNITED AC 2008; 70:98-103. [DOI: 10.1016/j.surneu.2007.05.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2006] [Accepted: 05/14/2007] [Indexed: 01/30/2023]
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Barrenechea IJ, Perin NI, Triana A, Lesser J, Costantino P, Sen C. Surgical management of chordomas of the cervical spine. J Neurosurg Spine 2007; 6:398-406. [PMID: 17542504 DOI: 10.3171/spi.2007.6.5.398] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECT Chordomas of the cervical spine are rare tumors. Although en bloc resection has proven to be the ideal procedure in other areas, there is controversy regarding this approach in the cervical spine. The goal in this study was to determine whether piecemeal tumor resection was efficient in the management of chordomas that arise in this location. METHODS The authors retrospectively reviewed all 74 cases of chordoma treated by their group. Seven patients with isolated cervical chordomas who were treated between October 1992 and January 2006 were identified. There were four male and three female patients, whose ages ranged from 6 to 61 years (mean 34.4 years). Follow-up duration ranged from 7 to 169 months (median 23 months). All cases were managed using a retrocarotid approach with mobilization of the vertebral artery. When the tumor could not be completely resected via the initial anterior approach, a subsequent posterior resection was performed. Tumor resection was intralesional in all cases, and gross-total tumor resection was achieved in six cases. One patient required a second resection 4 months later. In all cases, a posterior stabilization procedure was performed. Five patients underwent anterior fusion (three with fibular allograft and two with iliac crest), whereas two underwent occipitocervical fusion. In two patients with dedifferentiated chordoma metastasis developed, and one of them died 7 months later. The other patient with metastasis died suddenly at home 26 months postsurgery, presumably from aspiration. At the time of this submission, there were no signs of recurrence in five patients. CONCLUSIONS The authors believe that, in most cases, en bloc resection of cervical chordoma is not feasible. This is due to the tendency of chordomas to involve multiple compartments at the time of diagnosis. In the authors' experience, intralesional radical resection remains an effective surgical approach to this disease entity.
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Affiliation(s)
- Ignacio J Barrenechea
- The Center for Cranial Base Surgery, Department of Neurosurgery, St. Luke's-Roosevelt Hospital Center, New York, New York 10019, USA.
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Barrey C, Saint-Pierre G, Frappaz D, Hermier M, Mottolese C. Complete removal of an intraspinal and extraspinal cervical chordoma in one stage using the lateral approach. Technical note. J Neurosurg Spine 2006; 5:471-5. [PMID: 17120901 DOI: 10.3171/spi.2006.5.5.471] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe a precise surgical technique in which a large intraspinal and extraspinal, multivertebral, cervical chordoma was completely removed in one stage using the lateral approach. The patient in this case was a 29-year-old woman who presented with signs of radicular pain in the left C-3 area. Computed tomography and magnetic resonance imaging demonstrated a large intra- and extraspinal multivertebral tumor from C-2 to C-5, a finding that suggested a cervical chordoma. The tumor was completely removed in one stage using the lateral approach while controlling the vertebral artery (VA), and a partial corporectomy of C2-5 was also performed. Results from a postoperative histopathological examination confirmed that the tumor was a typical chordoma. The patient's postoperative course was uneventful. Cervical chordomas are typically excised using a posterior-anterior surgical approach with partial resection of the tumor. The lateral approach was appropriate in this patient for complete resection in one stage, because it enabled the surgeons to control the VA and access both extraspinal and intraspinal components of the chordoma.
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Affiliation(s)
- Cédric Barrey
- Department of Neurosurgery, Hôpital Neurologique et Neurochirurgical Pierre Wertheimer, Lyon, France.
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14
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Paolini S, Lanzino G. Anatomical relationships between the V2 segment of the vertebral artery and the cervical nerve roots. J Neurosurg Spine 2006; 5:440-2. [PMID: 17120894 DOI: 10.3171/spi.2006.5.5.440] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT During surgical procedures focused on the cervical nerve roots, the surgeon works in proximity to the V2 segment of the vertebral artery (VA). Depending on the specific surgical approach, it may be necessary to identify, expose, or mobilize the artery. In most cases, the artery may be left undisturbed. To reduce the risk of iatrogenic injury to the V2 segment during anterior and anterolateral approaches to the cervical spine, the authors analyzed the relationship between the V2 segment and the proximal segment of the C3-6 nerve roots. METHODS Six cadaveric cervical spines (12 sides) were fixed with formalin, injected with red and blue latex, and investigated intraoperatively using different magnifications (x 3-40). The VA rested on the anteromedial surface of the cervical nerve roots at the level of each intertransverse space. The exiting nerve roots intersected the VA at a distance ranging from 4.5 to 8.1 mm (mean 6.3 +/- 1.06 mm) from the dural sac. The distance was slightly shorter at cephalad levels, suggesting that the artery is more posteriorly and medially situated at those levels. Arterial pedicles anchored the VA to the cervical nerve roots at various levels. These arteries gave rise to purely radicular, ligamentous, and medullary branches without a predictable pattern. After reaching the nerve roots on their lower margin, the nonligamentous branches pierced the radicular dural sheath within the neural foramen at a distance of 2 to 4 mm from the VA. CONCLUSIONS Proximal-to-distal dissection of a cervical nerve root may proceed with relative safety for at least 4 mm. The V2 segment of the VA gives rise to at least one radicular arterial pedicle between C-4 and C-6. These trunks give rise to purely radicular, ligamentous, and medullary branches in an unpredictable pattern.
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Affiliation(s)
- Sergio Paolini
- Università degli Studi di Perugia, IRCCS Neuromed, Pozzilli, Italy
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Tubbs RS, Shoja MM, Acakpo-Satchivi L, Wellons JC, Blount JP, Oakes WJ, Iskandar BJ. Exposure of the V1–V3 segments of the vertebral artery via the posterior cervical triangle: a cadaveric feasibility study. J Neurosurg Spine 2006; 5:320-3. [PMID: 17048768 DOI: 10.3171/spi.2006.5.4.320] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Surgical exposure of the extracranial part of the vertebral artery (VA) is occasionally necessary. Historically, the greater portion of the extracranial portion of the VA has been approached by traversing the anterior cervical triangle. The authors speculated that this entire segment of the VA could be reached with equal efficacy via the posterior cervical triangle (PCT).
Methods
Six adult cadavers underwent dissection of the left and right VAs via the PCT. The entire extracranial VA was easily exposed through this approach. Only three of 12 sides required the transection of the clavicular head of the sternocleidomastoid muscle for exposure of the most proximal segment of the VA as it originated from the subclavian artery. No gross injury to the VA or other regional vessels or nerves was noted.
Conclusions
The authors found that the extracranial VA can be exposed easily through the PCT. Following confirmation of this technique in vivo, this approach may be added to the surgeon’s armamentarium for exposing the extracranial segment of the VA.
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Affiliation(s)
- R Shane Tubbs
- Department of Cell Biology, University of Alabama at Birmingham, Alabama, USA.
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Bilsky MH, Boakye M, Collignon F, Kraus D, Boland P. Operative management of metastatic and malignant primary subaxial cervical tumors. J Neurosurg Spine 2005; 2:256-64. [PMID: 15796349 DOI: 10.3171/spi.2005.2.3.0256] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The authors describe the preoperative assessment, intraoperative strategies, and long-term outcomes in 41 consecutive patients who underwent spinal reconstruction after resection of subaxial cervical neoplasms.
Methods. Thirty-three tumors were metastatic and eight were primary. Preoperative studies included direct laryngoscopy and vertebral artery (VA) balloon occlusion tests in selected patients. Based on the tumor location, approaches included 12 anterior, 13 posterior, and 16 combined. All patients underwent aggressive intralesional resection and spinal reconstruction. In 12 patients, the VA was dissected from the periphery of the tumor, two cases of which required ligation. Fibula allograft and an anterior rigid plate fixation were most commonly used for anterior reconstruction. Posterior reconstruction was initially performed using lateral mass plates (LMPs) in 13 patients and screw/rod systems in the remaining patients.
At follow up, pain level improved to mild or was absent in 39 patients (95%) who had presented with moderate or severe pain. The American Spinal Injury Association (ASIA) Scale scores were stable in 25 patients who presented with ASIA Score E and improved in 14 patients (88%) who presented with ASIA Score B, C, or D. Functional radiculopathy significantly improved in 16 (94%) of 17 patients.
Complications occurred in 10 patients (24%) and included three fixation failures requiring revision. Two fixation failures involved cervical LMP screw pullout. The overall mean survival duration was 8.6 months for patients with metastatic tumors and 33.4 months for primary tumors.
Conclusions. Surgery for the treatment of subaxial spine neoplasms is effective for relieving pain, encouraging functional nerve root recovery, and preserving spinal cord function with acceptable complication rates.
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Affiliation(s)
- Mark H Bilsky
- Neurosurgery, Head and Neck, and Orthopedic Services, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
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Kawashima M, Tanriover N, Rhoton AL, Matsushima T. The transverse process, intertransverse space, and vertebral artery in anterior approaches to the lower cervical spine. J Neurosurg 2003; 98:188-94. [PMID: 12650404 DOI: 10.3171/spi.2003.98.2.0188] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The microsurgical anatomy of the C3-6 transverse processes and their relationship to the intertransverse space and vertebral artery (VA) were examined with special attention to the aspect exposed in the anterior surgical approach. METHODS Ten adult cadaveric spines were examined (magnification levels X 3-40) after perfusion of the arteries and veins with colored silicone. The morphological detail of the transverse process and intertransverse space, the distances between selected surgical landmarks and the VA were measured, and the means and standard deviations were calculated. The osseous changes in the anterior root of the transverse process were classified according to their extent. The transverse processes became smaller, and the anterior intertransverse spaces and the width of the VA exposed in the space increased in size proceeding from caudal to rostral levels, thus exposing the VA to increased risk of injury during procedures at cephalad levels. The distance between the medial border of the longus colli muscle and the VA decreased when proceeding caudally from C2-3 to C4-5 interspaces but began to increase at the level of C5-6. The VA coursed closer to the lateral border of the vertebral body than to the medial border of the anterior tubercle of transverse process. Osseous changes consisting of thinning or defects in the anterior root of the transverse process were observed from C-3 to C-5. The thinning was most prominent in the lower half of the anterior root just above where the VA ascends behind the lower edge of the anterior root. The osseous change may reflect the erosive effect of the VA on the anterior root of the transverse process. CONCLUSIONS This study provides new information regarding the transverse process and especially the anterior root. An awareness of the thinness and defects in the anterior root of the transverse process and the relationships to the surrounding area will aid in reducing VA injury during anterior approaches to the cervical spine.
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Affiliation(s)
- Masatou Kawashima
- Department of Neurological Surgery, University of Florida, Gainesville, Florida 32610-0265, USA
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Kiya N, Sawamura Y, Dureza C, Fukushima T. Minimally invasive surgical exposure of the extreme high cervical internal carotid artery: anatomical study. J Clin Neurosci 2000; 7:438-44. [PMID: 10942667 DOI: 10.1054/jocn.1999.0241] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The purpose of this study is to investigate a minimally invasive access to a high cervical lesion involving the internal carotid artery. Using 13 fixed cadaveric preparations, we sought to design a surgical approach that would cause minimal involvement of the surrounding structures and maximal exposure to the extreme high cervical area. This technique preserves the function and integrity of the mandible, sternocleidomastoid, posterior belly of digastric and styloid process muscles. The method uses retraction and mobilisation of those muscles, as well as decompression of the facial from the stylomastoid foramen. The internal carotid artery is exposed up to the entry point into the carotid canal. The cranial nerves IX, X, XI and XII are kept in sight up to the jugular foramen. This approach creates a wide corridor into the deep high cervical and inferior cranial base area and can be utilised for high cervical carotid lesions and tumours related to the artery.
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Affiliation(s)
- N Kiya
- Department of Neurosurgery, Allegheny General Hospital, Allegheny University of the Health Sciences, Pittsburgh, Pennsylvania, USA
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