Surgical results after unilateral laminectomy for the removal of spinal cord tumors

A Novel Marking Technique for Accurate Minimal Invasive Approaches in Spine Tumor Surgeries With Activated Carbon Marking

BACKGROUND AND OBJECTIVES

To describe a novel, practical, reproducible, and effective preoperative marking technique for accurate localization of the spinal level in a series of patients with tumor lesions.

METHODS

We retrospectively analyzed patients undergoing minimally invasive (MIS) surgery for spine tumors from 2016 to 2021, in which this marking technique was used. Twenty-one patients, with tumor lesions involving difficult radioscopic visualization (cervicothoracic junction or upper dorsal spine, C6-T8), were included. Tumor lesion level was previously determined with enhanced MRI in all cases. Twenty-four to forty-eight hours before surgery, computed tomography image-guided carbon marking was performed by administration of aqueous suspension of carbon with a 21-gauge needle placed resembling the MIS approach planned trajectory. During surgery, activated carbon marking was followed until reaching the final target on the bone. Next, sequential dilators and an MIS retractor were placed. Then, bone resection and tumor exeresis were performed according to the case.

RESULTS

Average age was 60.6 years (26-76 years). Fifteen (71%) patients were women. In most cases (76%), tumor pathology involved intradural lesions (meningiomas and schwannomas). In all cases, the marking described allowed to accurately guide the MIS approach to tumor site. Neither intraoperative fluoroscopy nor approach enlargement was required in any procedure. Postoperative complications were reported in only 4 patients, none related with the marking.

CONCLUSION

Computed tomography image-guided activated carbon marking allows to accurately lead MIS approaches in a practical, reproducible, and effective way in cases of tumors localized in regions of the spine of difficult radioscopic visualization.

A Retrospective Cohort Study Evaluating the Comparative Effectiveness of Unilateral Hemilaminectomy and Bilateral Laminectomy in the Resection of Spinal Meningiomas

BACKGROUND AND OBJECTIVES

The primary treatment modality for spinal meningiomas (SM) is surgical resection. In recent years, minimal invasive spine surgery has gained considerable popularity, attributing its growth to advancements in surgical technologies and improved training of surgeons. Nonetheless, the suitability and effectiveness of minimal invasive spine surgery for intradural spinal tumor resection remain a subject of debate. In this cohort study, we aimed to compare the extent of resection of the unilateral hemilaminectomy approach, a less invasive technique, with the more traditional and invasive bilateral laminectomy.

METHODS

We performed a retrospective cohort study including patients with SM who underwent surgery at our department between 1996 and 2020. Cohorts included patients who underwent tumor resection through bilateral laminectomy and patients who underwent a unilateral hemilaminectomy. The primary end point was extent of resection according to the Simpson classification.

RESULTS

Of 131 with SM, 36 had a bilateral laminectomy and 95 were operated through a unilateral hemilaminectomy. In both groups, gross total resection, Simpson grades 1 and 2, was achieved in 94.44% and 94.74%, respectively (P = .999). The neurological outcome was also comparable in both cohorts (P = .356). Both length of hospital stay and estimated blood loss were significantly lower in the unilateral cohort (P < .05).

CONCLUSION

The results of this study indicate that the unilateral hemilaminectomy yields comparable results in both oncological and neurological outcome when compared with the bilateral laminectomy. Thus, unilateral hemilaminectomy may serve as a viable and safe alternative for the surgical removal of SM.

A multilevel posterior tension band-sparing laminectomy for intraspinal lesions: patient series

BACKGROUND

Minimally invasive spine surgery (MISS) represents a major development in spinal tumor surgery. However, considering that many intradural lesions compromise multiple spinal segments, MISS has certain limitations. Thus, some intraspinal lesions still require traditional approaches. Because laminectomy has been shown to predispose patients to kyphosis, laminoplasty and hemilaminectomy are the most widely used approaches to preserve the posterior tension band (PTB). However, these techniques are not devoid of complications. To overcome these issues, the authors modified a previously described technique to preserve the PTB while removing various types of intradural lesions. This procedure was originally designed to treat lumbar stenosis and was modified to avoid muscle ischemia during long procedures.

OBSERVATIONS

Between 2014 and 2021, the authors found 17 cases of spinal lesions with a minimum of 2 years of follow-up after surgical treatment using their approach. No significant postoperative changes in the paraspinal Goutallier grade or spinal angles were observed. The cross-sectional area of the measured paraspinal muscles decreased 6% postoperatively. By performing certain technical modifications in this PTB-sparing (PBS) laminectomy, the authors avoided ipsilateral muscle ischemia.

LESSONS

In this initial series, PBS laminectomy proved to be a safe, versatile, inexpensive, and reliable technique to remove intraspinal lesions.

Hemilaminectomy for the removal of the spinal tumors: An analysis of 901 patients

Objective

We report our experience with the use of hemilaminectomy approach for the removal of benign intraspinal tumors.

Method

A retrospective review of 1,067 patients who underwent hemilaminectomy in our hospital between 2013 and 2019 was analyzed. Baseline medical data were collected. One hundred sixteen patients were excluded due to degenerative diseases, spinal bone tumors, and malignant tumors. The remaining 901 patients (916 tumors) were enrolled. The Dennis Pain Scale (DPS) was used to assess improvement in pain before surgery and during long-term follow-up. Neurological status was assessed using the American Spinal Injury Association (ASIA) impairment scale.

Results

The age of the patients was 48.7 ± 15.3 years, the duration of symptoms was 16.5 ± 32.0 months, and the tumor size was 2.6 ± 1.4 cm. Three hundred two tumors were located in the cervical region, 42 in the cervicothoracic region, 234 in the thoracic region, 57 in the thoracolumbar region, and 281 in the lumbar and lumbosacral region. Twenty-three tumors were ventrally located, 677 were dorsal or dorsolateral, 63 were intramedullary, 87 were epidural, and the rest were dumbbell-shaped. The most common pathologies were schwannomas (601, 66.7%) and meningiomas (172, 19.1%). Total excision was achieved at 97.8%. The operative time was 94.3 ± 32.6 min and the blood loss during surgery was 96.9 ± 116.5 ml. The symptom of pain improved in 87.0% of patients during long-term follow-up, neurological function improved in 68.3% and remained unchanged at 30.5%.

Conclusion

The hemilaminectomy approach was a rapid and safe procedure to remove intradural and extradural tumors. This approach has offered several advantages. It could be used for the resection of most extradural or intradural extramedullary lesions, even some intramedullary tumors.

Spinal dermal sinus coinciding with an infected giant epidermoid cyst in an infant presenting with constipation: a case report

Early diagnosis of spinal tumors is a prerequisite for achieving satisfactory neurological recovery. However, rare diseases tend to have a long diagnostic course.1 In addition, the clinical presentation of spinal tumors in most children is not apparent, moreover, spinal tumors may not show clinical symptoms if they are located in the lumbar spine and sized no more than one vertebra.2,3 Clinical presentations caused by tumors in the lumbar spine may include weakness of both limbs, impaired urination, and constipation.

Laminectomy Versus Laminectomy with Fusion for Intradural Extramedullary Tumors: A Systematic Review and Meta-Analysis

OBJECTIVE

The primary objective of our systematic review and meta-analysis was to systematically compare the reported outcomes between laminectomy and laminectomy with fixation/fusion (LF) for the treatment of intradural extramedullary tumors (IDEMTs). Our secondary objective was to compare the outcomes between different laminectomy exposure techniques.

METHODS

PubMed and Embase were queried for literature on laminectomy and LF for IDEMTs. Reports of transforaminal approaches, interlaminar approaches, corpectomy, pediatrics patients, intramedullary tumors, technical studies, animal or cadaver studies, and literature reviews were excluded. The outcome measures recorded were pain, neurologic function, functional independence, cerebrospinal fluid leak, and wound infection. Where possible, the laminectomy technique (partial laminectomy [PL] vs. total laminectomy [TL]) was specified. Stata, version 17, was used for the fixed effects inverse variance meta-analysis.

RESULTS

Of 1849 reports assessed, 17 were included. The meta-analysis revealed that laminectomy (PL or TL) resulted in higher rates of postoperative sagittal instability compared with LF (odds ratio, 1.81; P < 0.001). No differences in any other postoperative outcome were observed between laminectomy and LF (P = 0.44). The systematic review also revealed no differences in postoperative pain, neurologic function, or functional independence or disability between PL and TL. Some evidence suggested that TL might result in greater rates of sagittal instability compared with PL.

CONCLUSIONS

No differences between LF, PL, or TL in pain, neurologic deficit, functional independence, cerebrospinal fluid leak, or wound infection were reported. Laminectomy had greater odds of sagittal instability compared with LF. Patients with preoperative sagittal instability requiring extensive removal of the posterior spinal column to achieve adequate resection of large tumors might benefit from LF.

Clinical Outcomes of Surgical Correction and Fusion for Postlaminectomy Kyphosis Following Spinal Tumor Resection in Adolescent Patients

BACKGROUND

Progressive spinal deformity following laminectomy and resection surgery of spinal tumor has been well-documented. However, the postlaminectomy deformity in adolescent patients often bring challenge to clinical treatment, which may be subjected to rapid progression of kyphosis during the growth spurt. The aim of this study is to investigate the clinical outcome of long fusion correction surgery for thoracic or thoracolumbar kyphotic deformity secondary to laminectomy and tumor resection in adolescent patients.

METHODS

Records of 12 cases underwent correction surgery of postlaminectomy thoracic (n=6) or thoracolumbar (n=6) kyphotic deformity were reviewed. The Cobb angle of sagittal and coronal curve before surgery, immediately after surgery, and at the final follow-up were measured to evaluate the correction of deformity and loss of correction. Neurological function was evaluated using the Frankel grading system. Back pain was assessed by using the visual analog score (VAS). Disability status was evaluated by the Oswestry Disability Index (ODI). Patients' satisfaction to surgery was assessed by the patient satisfactory index.

RESULTS

The mean kyphosis angle reduced from 76±20 degrees before surgery to 34±18 degrees immediately after surgery and remained at 39±17 degrees at the final follow-up with the average correction rate of 58.6% and 51.0%, respectively. For 7 patients with concomitant scoliosis, the Cobb angle of major curve reduced from 52±21 degrees before surgery to 16±9 degrees immediately after surgery and 20±9 degrees at the final follow-up. The average corrective rate was 69.5% and 62.4%, respectively. The mean ODI score improved from 19.9±7.5 to 10.8±8.0, whereas the mean VAS score improved from 5.3±2.0 to 1.5±1.4. The sagittal and coronal balance of the spine, Frankel grading, ODI, and VAS were improved, and the patient satisfactory index was 100%. One patient had inferior paraplegia recovered to Frankel grade E after treatment.

CONCLUSIONS

Satisfactory clinical outcomes can be achieved after long fusion surgery for thoracic or thoracolumbar kyphotic deformity secondary to laminectomy for spinal tumor. Due to the high risk of secondary kyphotic deformity in adolescent patients, internal fixation should be performed simultaneously with the resection of spinal tumor, especially for the cases in the thoracic or thoracolumbar region.

LEVEL OF EVIDENCE

Level III.

The Optimal Surgical Approach to Intradural Spinal Tumors: Laminectomy or Hemilaminectomy?

Objective Traditionally, laminectomy has been the preferred surgical approach for the resection of intradural spinal tumors. Recent trends towards minimally invasive techniques have generated interest in hemilaminectomy as an effective alternative surgical approach to resect spinal tumors. However, it remains unclear if the potential benefits of hemilaminectomies, used in other routine spinal procedures, apply to intradural spinal tumors. This report presents a six-year single institutional analysis of open resection of intradural tumors using laminectomies as compared to hemilaminectomies. Methods A single institution, multisurgeon, retrospective review of 52 patients undergoing resection of intradural spinal tumors over a six-year period was performed. Estimated blood loss, operative time, post-operative complications, length of stay, and post-operative clinical spinal instability were analyzed and compared between the two surgical techniques. Results The mean follow-up was 34 and 20 months for the laminectomy and hemilaminectomy groups, respectively. There was no statistically significant difference in operative times between the two groups (hemilaminectomy: 250.13±76.44 minutes, laminectomy: 244.49±92.85 minutes; p=0.43). Similarly, there was no difference in overall estimated blood loss (hemilaminectomy: 125±74 cc, laminectomy: 256.05±320.8 cc; p=0.27) or mean hospital length of stay (hemilaminectomy: 4.00±2.12 days, laminectomy: 5.26±3.0 days; p=0.60). No patient in either surgical group had post-operative evidence of clinical spinal instability. Conclusion Hemilaminectomy is a viable approach for the resection of intradural spinal tumors, with similar rates of post-operative complications to laminectomy when using an open surgical approach. The laminectomy allows for bilateral exposure of the entire spinal canal and neural foramina; and continues to be the preferred method for resection of large tumors with complex morphology.

Lemierre Disease: A Case With Multilevel Epidural Abscess and Aggressive Neurological Weakness: Case Report and Literature Review

BACKGROUND

Lemierre disease is a rare postanginal sepsis caused by the anaerobe Fusobacterium necrophorum. It is associated with a pharyngitis that progresses quickly to thrombophlebitis of the internal jugular vein and metastatic abscesses to pulmonary, soft tissue, articular, and organ systems. It is rarely associated with spinal epidural abscesses. Because of the increasing antibiotic resistance, its incidence is on the rise.

METHODS

A single-patient case report of an adolescent male who initially presented to our institution for bacteremia and febrile episodes. Over a 1-week course, he developed severe back pain and progressive lower extremity weakness. Advanced imaging revealed an epidural abscess spanning T2-L3 level with extension into the psoas and the paraspinal musculature. Acute management consisted of broad-spectrum intravenous (IV) antibiotics and hemilaminectomy decompression from T2 to L3. The patient completed a 6-week course of IV antibiotics and was followed for a 1-year time period with close clinical follow-up.

RESULTS

Blood cultures identified the infecting organism as F. necrophorum. The combination of IV antibiotics and acute hemilaminectomy decompression resulted in successful clearance of the infecting organism with normalization of inflammatory markers and cultures. The patient noted immediate and sustained neurological improvement, with return of full motor and sensory function. At the 1-year timepoint, the patient was able to return to sports and no sagittal/coronal imbalance was noted on radiographs.

CONCLUSIONS

An aggressive case of Lemierre disease with extensive epidural abscess formation and neurological weakness was successfully managed with the combination of IV antibiotics and extensive hemilaminectomies for decompression. The patient exhibited no long-term sequela as a result of either the epidural abscess or of its treatment.

LEVEL OF EVIDENCE

Level V.