Use of Intraoperative Ultrasound to Achieve Gross Total Resection of a Large Cervicomedullary Ependymoma: 2-Dimensional Operative Video

Real-Time Intraoperative Ultrasound Using a Minimally Invasive Transducer During Anterior Cervical Spine Surgery

BACKGROUND AND OBJECTIVES

Intraoperative ultrasound (IOUS) during anterior cervical surgery is hindered by large transducer size and small operative corridor. We hypothesized that a linear (minimally invasive) transducer designed for transsphenoidal surgery can visualize the spinal cord, nerve roots, and surrounding structures during anterior cervical approaches, facilitating intraoperative assessment of central and foraminal decompression.

METHODS

IOUS was used to evaluate 26 levels in 17 patients (15 anterior cervical discectomy and fusion, 1 corpectomy, 1 arthroplasty) with a linear probe (7 × 6-mm end-fire transducer, 150-mm length, 12-15 MHz). After pin-based distraction, discectomy, and posterior longitudinal ligament resection, IOUS assessed adequacy of cord decompression and, following proximal foraminotomy or uncinectomy, nerve root decompression. If indicated, additional decompression was completed. Criteria for adequate central and foraminal decompression were visualization of subarachnoid space around the cord and cerebrospinal fluid pulsatility along the root sleeve/absence of nerve root compression distal to the root sleeve, respectively.

RESULTS

IOUS successfully visualized the cord, nerve roots, and surrounding structures in all 26 levels and influenced management in 11 levels (42.3%). IOUS indicated persistent cord and nerve root compression in 2 and 7 levels, respectively. Planned uncinectomy was aborted in 2 levels after IOUS demonstrated adequate nerve root decompression with intervertebral distraction/proximal foraminotomy alone. IOUS identified persistent nerve root compression after initial proximal foraminotomy in 4 levels and uncinectomy in 2 levels. An unplanned uncinectomy was performed in 1 level after IOUS showed persistent nerve root compression after multiple iterations of proximal foraminotomy. At follow-up (mean 3.1 months), the mean improvement in Numeric Rating Scale neck and arm pain, Neck Disability Index, and modified Japanese Orthopedic Association was 4.0%, 3.2%, 3.7%, and 0.7%, respectively.

CONCLUSION

The neural elements and their relationships to surrounding bone/soft tissue can be visualized using a minimally invasive IOUS transducer during anterior cervical surgery without having to remove pin-based distraction. This allows surgeons to intraoperatively verify the extent of central and foraminal decompression.