Maduri Rodolfo, Bobinski Lukas, Duff John Michael
Neurosurgical Service, Department of Clinical Neurosciences, University Hospital of Lausanne, Faculty of Biology and Medicine, Lausanne, Switzerland.
Neurosurgical Service, Department of Clinical Neurosciences, University Hospital of Lausanne, Faculty of Biology and Medicine, Lausanne, Switzerland.
World Neurosurg. 2017 Feb;98:594-602. doi: 10.1016/j.wneu.2016.05.092. Epub 2016 Jun 8.
Standard translaminar approaches for intradural extramedullary (IDEM) tumors require extensive soft tissue dissection and partial facet removal. Ventral lesions may necessitate wider bone resection with subsequent possible spinal instability. Any manipulation of an already compromised spinal cord may lead to neurological injury. We describe an image-guided minimal access technique for IDEM tumor resection.
Retrospective chart review of 13 consecutive patients after institutional ethics committee approval. We superimpose preoperative magnetic resonance imaging data with intraoperative 3-dimensional fluoroscopic images, allowing to simultaneously visualize osseous anatomy and the soft tissue lesion using appropriate windowing. We then plan optimal angle of trajectory to the tumor, which defines the skin incision and the transmuscular trajectory. A tubular retractor is placed to span the tumor. Microsurgical tumor resection is then carried out using this angle of approach.
Thirteen patients (mean age. 57 years; male-to-female ratio, 10:3) were operated on during 28 months. Gross total resection was achieved in all patients. Neurological improvement occurred in 12 of the 13 patients. There was no neurological deficit outside of the expected sensory loss due to intentional nerve root sacrifice. No mechanical pain nor tumor recurrence were noted during the follow-up (mean, 16 months; range, 2-30 months).
Image merge tailored access resection appears to be at least equivalent in terms of tumor resection, blood loss, and complications to other tubular techniques. It may reduce risks of neurological deficit and spine instability. Image merge tailored access resection is a novel application of merging intraoperative fluoroscopic images with preoperative magnetic resonance images for tailored IDEM resection.
用于硬脊膜内髓外（IDEM）肿瘤的标准经椎板入路需要广泛的软组织解剖和部分关节突切除。腹侧病变可能需要更广泛的骨切除，随后可能导致脊柱不稳定。对已经受损的脊髓进行任何操作都可能导致神经损伤。我们描述了一种用于IDEM肿瘤切除的影像引导下的微创技术。
经机构伦理委员会批准后，对13例连续患者进行回顾性病历审查。我们将术前磁共振成像数据与术中三维透视图像叠加，通过适当的窗口设置，能够同时可视化骨性解剖结构和软组织病变。然后我们规划到达肿瘤的最佳轨迹角度，这确定了皮肤切口和经肌肉的轨迹。放置一个管状牵开器跨越肿瘤。然后使用这个入路角度进行显微外科肿瘤切除。
在28个月期间对13例患者（平均年龄57岁；男女比例为10:3）进行了手术。所有患者均实现了肿瘤全切。13例患者中有12例神经功能得到改善。除了因故意牺牲神经根导致的预期感觉丧失外，没有出现神经功能缺损。随访期间（平均16个月；范围2 - 30个月）未发现机械性疼痛或肿瘤复发。
影像融合定制入路切除术在肿瘤切除、失血和并发症方面似乎至少与其他管状技术相当。它可能降低神经功能缺损和脊柱不稳定的风险。影像融合定制入路切除术是将术中透视图像与术前磁共振图像融合以定制IDEM切除术的一种新应用。
