Department of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
Department of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland; University of Lausanne (Unil), Lausanne, Switzerland.
World Neurosurg. 2020 Jun;138:59-60. doi: 10.1016/j.wneu.2020.02.086. Epub 2020 Feb 24.
Resection of an anterolateral intramedullary lesion requires an approach that best provides a direct in-line access to the part of the lesion that presents at the pial surface, which enables total removal without injuring the spinal tracts. In Video 1, we show the technique of resection of an anterolateral intramedullary cavernoma. The vertebral level was identified before surgery, with coils placed percutaneously within the pedicle. A partial unilateral posterolateral approach was realized. During a posterolateral durotomy, the arachnoid was opened and hitched up with stay sutures. The dentate ligament was identified, cut, and then turned medially with a stitch to allow gentle rotation of the spinal cord to enable visualization of the anterolateral surface of the cord. This allowed us to bring the anterolateral subpial part of the lesion to a relatively more posterolateral position. A pial stitch was used to enhance and maintain the visualization of the lesion. The cavernoma was dissected circumferentially and removed in toto. The endoscope was used intermittently during the dissection to enhance the microscopic view, especially for the anterolateral surface. At the end of the excision, the arachnoidal edges were apposed and welded together using fine bipolar forceps at low-current setting under saline irrigation. The dura was closed watertight. The wound was closed in layers. The posterolateral approach combined with rotation of the spinal cord by dentate ligament stitch allows direct visualization for lesions that present onto the anterolateral surface of the cord.
切除脊髓前外侧髓内病变需要一种方法，该方法最好能提供直达脊髓表面病变部位的直接直线入路，从而实现完全切除而不损伤脊髓束。在视频 1 中，我们展示了脊髓前外侧海绵状血管瘤切除术的技术。手术前先确定椎体水平，经皮将线圈置于椎弓根内。实现部分单侧后外侧入路。在进行后外侧硬脊膜切开术时，打开蛛网膜并用缝线固定。辨认齿状韧带，切断，然后用缝线向内翻转，使脊髓轻微旋转，从而能够观察到脊髓的前外侧表面。这使我们能够将病变的前侧亚皮质部分带到相对更靠后的位置。使用脑膜缝线来增强和保持对病变的可视化。海绵状血管瘤被环形解剖并全部切除。在解剖过程中，间歇性使用内镜以增强显微镜下的视野，尤其是对前外侧表面。切除结束时，蛛网膜边缘用精细双极镊子在生理盐水冲洗下以低电流设置对位并焊接在一起。硬脑膜严密缝合。伤口分层关闭。齿状韧带缝线使脊髓旋转的后外侧入路可直接观察到位于脊髓前外侧表面的病变。
