Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
World Neurosurg. 2024 Oct;190:308. doi: 10.1016/j.wneu.2024.07.167. Epub 2024 Jul 31.
Anterior intradural extramedullary meningiomas are intimidating, especially in the thoracic spine due to the spinal cord impeding conventional surgical corridor, restricted space, and precarious cord vascularity. This is possibly the first report in the literature of a minimally invasive surgery: far-lateral hybrid exoscopic and angled endoscopic approach for an anterior thoracic spine meningioma. A 60-year-old woman presented with an anterior T1-2 meningioma with a flattened cord draping over the tumor more toward the right, leaving a potential corridor on the left lateral aspect (Video 1). Under a three-dimensional exoscope, a minimally invasive retractor was placed through the left paramedian incision centered on the lamina-transverse process junction; lateral fenestration and T1-2 facetectomy were carried out with a high-speed drill and rongeurs, meticulously preserving C7-T1 articulations. Following coagulation of the anterolateral dura over the tumor, a lateral longitudinal durotomy with a T-shaped anterolateral extension was performed around the tumor. Following devascularization, disconnection, and extra-arachnoidal dissection, a unique lateral rolling technique was employed, wherein the tumor was bimanually rolled onto the bony gutter created earlier without disturbing the spinal cord. This was followed by coagulation and excision of the dural tail. A 45° endoscope was then inserted to look for any residual tumor or dural tail. As the durotomy was lateral with excision of the dural tail, a multilayered soft tissue closure without dead space was sufficient to prevent cerebrospinal fluid leak. Fixation was not needed as only a single thoracic spine facet was disrupted. The patient recovered fully with radiology confirming total excision. This minimally invasive lateral rolling technique is safe and effective for anterior meningioma with the ergonomics of exoscope & the angled optics of endoscope complementing each other.
前方硬脊膜外髓外脑膜瘤令人望而生畏，尤其是在胸椎，因为脊髓阻碍了传统的手术通道、有限的空间和脆弱的脊髓血管。这可能是文献中首例微创外科手术的报道：远外侧杂交外窥镜和斜角内镜前路胸椎脑膜瘤切除术。一位 60 岁女性因 T1-2 前方脑膜瘤就诊，脊髓变平，肿瘤偏向右侧，左侧外侧有潜在的通道（视频 1）。在三维外窥镜下，通过位于椎板-横突交界处正中的左侧旁正中切口放置微创牵开器；用高速钻头和咬骨钳进行外侧开窗和 T1-2 关节突切除术，小心保留 C7-T1 关节。在肿瘤上方的前外侧硬脑膜凝固后，围绕肿瘤进行 T 形前外侧延长的外侧纵向硬脑膜切开术。在进行血管化、分离和蛛网膜外解剖后，采用独特的外侧滚动技术，用双手将肿瘤滚到先前形成的骨槽中，而不干扰脊髓。随后进行硬脑膜尾端的电凝和切除。然后插入一个 45°的内镜，寻找任何残留的肿瘤或硬脑膜尾端。由于硬脑膜切开术是外侧的，并且切除了硬脑膜尾端，因此没有死腔的多层软组织闭合足以防止脑脊液漏。由于仅破坏了单个胸椎关节突，因此不需要固定。患者完全康复，影像学检查证实完全切除。这种微创外侧滚动技术对于前方脑膜瘤是安全有效的，外窥镜的人体工程学和内镜的斜角光学相辅相成。
