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Intradural Intramedullary Cervicothoracic Tumor with Long Segmental Localization: A Case Report with Step-by-Step Surgical Treatment Strategy with Neuromonitorization

Video Author: Askin Esen Hasturk
Published on: 03.24.2017
Associated with: Clinical Spine Surgery. 30(3):102-111, April 2017

Ependymomas are the most common gliomas of the conus and lower cord, with the cervical cord being the second most common location. These tumors can extend upward 3-4 vertebra, and some ependymomas can extend up over 15 segments. Depending on many factors, such as tumor size, lateralization, kyphotic deformity, and lordosis state, there are several posterior surgical options, including laminectomy, laminectomy and lateral mass screw-plate, and laminoplasty. In this study, we discuss a case of intradural intramedullary cervicothoracic ependymoma with long segmental localization, as well as the general surgical principles of its excision with step by step demonstrative figures

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Creator: Askin Esen Hasturk
Duration: 5:11
Ependymomas are the most common gliomas of the conus and lower cord, with the cervical cord being the second most common location. These tumors can extend upward 3-4 vertebra, and some ependymomas can extend up over 15 segments. Depending on many factors, such as tumor size, lateralization, kyphotic deformity, and lordosis state, there are several posterior surgical options, including laminectomy, laminectomy and lateral mass screw-plate, and laminoplasty. In this study, we discuss a case of intradural intramedullary cervicothoracic ependymoma with long segmental localization, as well as the general surgical principles of its excision with step by step demonstrative figures
Creator: Ken Ishii, MD, Yuta Shiono, MD, Haruki Funao, MD, Kern Singh, MD, and Morio Matsumoto, MD
Duration: 5:08
This novel technique is both safe and reliable, with low misplacement and complication rates. In hospitals in which computer image guidance or navigation is unavailable, this groove-entry technique may become the standard for thoracic PPS insertion.
Creator: Khaled M. Kebaish, MD, Benjamin D. Elder, MD, PhD, Sheng-fu L. Lo, MD, and Timothy F. Witham, MD
Duration: 4:38
The patient underwent a lumbar decompression and fusion procedure. A sublaminar decompression with bilateral foraminotomies was performed at L4–L5, combined with instrumented posterior fusion.
Creator: Jose´ A. Corredor, MD and Roger Ha¨rtl, MD
Duration: 5:17
Central displacement of the spinal cord through a dural defect, resulting in neurological impairment due to compression and vascular compromise.
Creator: Pravesh S. Gadjradj, BSc, and Biswadjiet S. Harhangi, MD, PhD
Duration: 10:00
Percutaneous Transforaminal Endoscopic Discectomy (PTED) is a minimally invasive technique to treat lumbar disk herniation (LDH). Performed under local anesthesia, the incision size for PTED is around 8mm with no paraspinal muscle cutting or detachment from their insertion. PTED has been associated with less blood loss, faster rehabilitation and less scarring of tissue than conventional open microdiscectomy (OM). High-quality randomized controlled trials comparing PTED with OM have not been conducted yet. However, PTED has been proven to be an effective technique allowing patients to return home only two hours after surgery. By the means of this article and video, we would like to show the spine surgeon the PTED-technique for treatment a single-level disk herniation.
Creator: Demirkiran, Gokhan MD; Theologis, Alexander A. MD; Pekmezci, Murat MD; Ames, Christopher MD; Deviren, Vedat MD
Duration: 8:58
Study Design: Case series.

Objective: To evaluate radiographic and clinical outcomes of adults with spinal deformity treated with multilevel anterior column releases (ACR).

Summary of Background Data: Pedicle subtraction osteotomy can be used effectively to correct spinal deformity; however, it is not without complications. ACR is an attractive alternative minimally invasive technique for spinal deformity correction, although few clinical reports on its clinical effectiveness exist.

Methods: Adults with spinal deformity who underwent multilevel ACRs (≥2) followed by open posterior instrumentation with a minimum 1-year follow-up were retrospectively reviewed. Deformity radiographic data and clinical outcomes, including the Oswestry Disability Index (ODI) and the EuroQol-5D were analyzed.

Results: Eight patients [7 female, 1 male; mean age 65 y (49–79 y)] met inclusion criteria. The mean follow-up was 18.4 months (12–28 mo). The average number of levels treated with an ACR per patient was 2.4 (2–3). There were no anterior approach–related complications. The average number of levels instrumented posteriorly was 8.1 (3–15). Six patients underwent Schwab type 1 posterior osteotomies (partial facetectomies). After the first anterior stage, there was a significant increase in the lumbar lordosis and significant decreases in the sagittal vertical axis, pelvic tilt, and lumbopelvic mismatch (P<0.05). After the second stage there was no significant change in the sagittal vertical axis, lumbar lordosis, pelvic tilt, or lumbopelvic mismatch relative to the values obtained after ACR. There was significantly less disability postoperatively [ODI: 15 (0–30)] compared with preoperatively [ODI: 46 (16–80)] (P<0.01). There was significant improvement in general health after operation, as assessed by the EuroQol-5D utility scores [preop: 0.44 (0.21–0.82) vs. postop: 0.71 (0.60–0.80)] (P=0.01). Back and leg visual analog scale pain scores improved significantly postoperatively.

Conclusions: A staged approach using multilevel ACRs with open posterior instrumentation has an acceptable complication profile and provides excellent restoration of sagittal and coronal balance and pelvic parameters in adults with spinal deformity.
Creator: Schroeder, Gregory D. MD; Kurd, Mark F. MD; Millhouse, Paul W. MD, MBA; Vaccaro, Alexander R. MD, PhD, MBA; Hilibrand, Alan S. MD
Duration: 8:22
An anterior cervical discectomy and fusion is one of the most common procedures performed in spine surgery. It allows for a direct decompression of the spinal cord and the neural foramen. When performed properly, the results of this procedure are some of the best in spine surgery.
Creator: Neil Badlani, Elizabeth Yu, Junyoung Ahn, Mark F. Kurd, Safdar N. Khan
Duration: 5:01
Herniated disks in the lumbar spine typically present with the sudden onset of back and leg pain in a myodermatomal distribution. Symptoms may include radicular pain, paresthesias, and in extreme cases weakness or foot drop. Typically patients are treated conservatively for 6–8 weeks with a combination of steroids, nonsteroidal anti-inflammatory drugs, physical therapy, epidural steroid injections, and rest. In the absence of symptom improvement, surgical intervention typically with a microdisectomy is recommended to patients who are refractory to at least 6 weeks of nonoperative treatment. Earlier intervention may be considered in patients with severe or progressive neurological deficits. This paper reviews the preoperative and postoperative considerations, as well as the surgical technique, for a minimally invasive/less invasive microdisectomy.
Creator: Paul W. Millhouse, MD, Gregory D. Schroeder, MD, Mark F. Kurd, MD, Christopher K. Kepler, MD, MBA, Alexander R. Vaccaro, MD, PhD, MBA, and Jason W. Savage, MD
Duration: 8:59
Lumbar disk herniations occur frequently and are often associated with leg pain, weakness, and paresthesias. Fortunately, the natural outcomes of radiculopathy due to a disk herniation are generally favorable, and the vast majority of patients improve with nonoperative care. Surgical intervention is reserved for patients who have significant pain that is refractory to at least 6 weeks of conservative care, patients who have a severe or progressive motor deficit, or patients who have any symptoms of bowel or bladder dysfunction. This paper reviews the preoperative and postoperative considerations, as well as the surgical technique, for a microdiscectomy for a lumbar intervertebral disk herniation.
Creator: Junyoung Ahn, Ehsan Tabaraee, and Kern Singh
Duration: 4:12
Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) is performed via tubular dilators thereby preserving the integrity of the paraspinal musculature. The decreased soft tissue disruption in the MIS technique has been associated with significantly decreased blood loss, shorter length of hospitalization, and an expedited return to work while maintaining comparable arthrodesis rates when compared with the open technique particularly in the setting of spondylolisthesis (isthmic and degenerative), recurrent symptomatic disk herniation, spinal stenosis, pseudoarthrosis, iatrogenic instability, and spinal trauma. The purpose of this video is to demonstrate the techniques for a primary, single-level MIS TLIF.
Creator: Yasushi Fujiwara, Hideki Manabe, Tadayoshi Sumida, Nobuhiro Tanaka, and Takahiko Hamasaki
Duration: 4:51
Retro-odontoid pseudotumors are noninflammatory masses formed posterior to the odontoid process. Because of their anatomy, the optimal surgical approach for resecting pseudotumors is controversial. Conventionally, 3 approaches are used: the anterior transoral approach, the lateral approach, and the posterior extradural approach; however, each approach has its limitations. The posterior extradural approach is the most common; however, it remains challenging due to severe epidural veins. Although regression of pseudotumors after fusion surgery has been reported, direct decompression and a pathologic diagnosis are ideal when the pseudotumor is large. We therefore developed a new microscopic surgical technique; transdural resection.
Creator:
Duration: 6:59
The use of lateral mass screws and rods in the subaxial spine has become the standard method of fixation for posterior cervical spine fusions. Multiple techniques have been described for the placement of lateral mass screws, including the Magerl, the Anderson, and the An techniques. While these techniques are all slightly different, the overall goal is to obtain solid bony fixation while avoiding the neurovascular structures. The use of lateral mass screws has been shown to be a safe and effective technique for achieving a posterior cervical fusion.
Creator: Themistocles S. Protopsaltis, Christine E. Choi, and Daniel J. Kaplan
Duration: 8:28
Cervical spondylotic myelopathy (CSM) is a condition resulting from cervical stenosis. Manifestations of CSM include paresthesia in the extremities, loss of fine motor skills, balance problems, and bowel and bladder dysfunction in advanced disease. Laminoplasty is one surgical treatment option. The goal of laminoplasty is to reposition the laminae to expand the spinal canal, allowing the spinal cord to migrate posteriorly. There are various laminoplasty techniques; the main ones being open-door laminoplasty and double-door laminoplasty. This video demonstrates a double-door laminoplasty otherwise known as a “French-door” laminoplasty.
Creator: Junyoung Ahn, Ehsan Tabaraee, and Kern Singh
Duration: 4:35
Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has become a popular alternative to traditional methods of lumbar decompression and fusion. When compared with the open technique, the minimally invasive approach can result in decreased pain and blood loss as well as a shorter length of hospitalization. However, the narrower working channel through the tubular retractor increases the difficulty of decortication and bone grafting. This video demonstrates a technique for defining and resecting rhBMP-2-induced heterotopic bone growth following a previous MIS-TLIF.



Creator: Askin Esen Hasturk
Duration: 5:11
Ependymomas are the most common gliomas of the conus and lower cord, with the cervical cord being the second most common location. These tumors can extend upward 3-4 vertebra, and some ependymomas can extend up over 15 segments. Depending on many factors, such as tumor size, lateralization, kyphotic deformity, and lordosis state, there are several posterior surgical options, including laminectomy, laminectomy and lateral mass screw-plate, and laminoplasty. In this study, we discuss a case of intradural intramedullary cervicothoracic ependymoma with long segmental localization, as well as the general surgical principles of its excision with step by step demonstrative figures
Creator: Ken Ishii, MD, Yuta Shiono, MD, Haruki Funao, MD, Kern Singh, MD, and Morio Matsumoto, MD
Duration: 5:08
This novel technique is both safe and reliable, with low misplacement and complication rates. In hospitals in which computer image guidance or navigation is unavailable, this groove-entry technique may become the standard for thoracic PPS insertion.
Creator: Khaled M. Kebaish, MD, Benjamin D. Elder, MD, PhD, Sheng-fu L. Lo, MD, and Timothy F. Witham, MD
Duration: 4:38
The patient underwent a lumbar decompression and fusion procedure. A sublaminar decompression with bilateral foraminotomies was performed at L4–L5, combined with instrumented posterior fusion.
Creator: Jose´ A. Corredor, MD and Roger Ha¨rtl, MD
Duration: 5:17
Central displacement of the spinal cord through a dural defect, resulting in neurological impairment due to compression and vascular compromise.
Creator: Pravesh S. Gadjradj, BSc, and Biswadjiet S. Harhangi, MD, PhD
Duration: 10:00
Percutaneous Transforaminal Endoscopic Discectomy (PTED) is a minimally invasive technique to treat lumbar disk herniation (LDH). Performed under local anesthesia, the incision size for PTED is around 8mm with no paraspinal muscle cutting or detachment from their insertion. PTED has been associated with less blood loss, faster rehabilitation and less scarring of tissue than conventional open microdiscectomy (OM). High-quality randomized controlled trials comparing PTED with OM have not been conducted yet. However, PTED has been proven to be an effective technique allowing patients to return home only two hours after surgery. By the means of this article and video, we would like to show the spine surgeon the PTED-technique for treatment a single-level disk herniation.
Creator: Demirkiran, Gokhan MD; Theologis, Alexander A. MD; Pekmezci, Murat MD; Ames, Christopher MD; Deviren, Vedat MD
Duration: 8:58
Study Design: Case series.

Objective: To evaluate radiographic and clinical outcomes of adults with spinal deformity treated with multilevel anterior column releases (ACR).

Summary of Background Data: Pedicle subtraction osteotomy can be used effectively to correct spinal deformity; however, it is not without complications. ACR is an attractive alternative minimally invasive technique for spinal deformity correction, although few clinical reports on its clinical effectiveness exist.

Methods: Adults with spinal deformity who underwent multilevel ACRs (≥2) followed by open posterior instrumentation with a minimum 1-year follow-up were retrospectively reviewed. Deformity radiographic data and clinical outcomes, including the Oswestry Disability Index (ODI) and the EuroQol-5D were analyzed.

Results: Eight patients [7 female, 1 male; mean age 65 y (49–79 y)] met inclusion criteria. The mean follow-up was 18.4 months (12–28 mo). The average number of levels treated with an ACR per patient was 2.4 (2–3). There were no anterior approach–related complications. The average number of levels instrumented posteriorly was 8.1 (3–15). Six patients underwent Schwab type 1 posterior osteotomies (partial facetectomies). After the first anterior stage, there was a significant increase in the lumbar lordosis and significant decreases in the sagittal vertical axis, pelvic tilt, and lumbopelvic mismatch (P<0.05). After the second stage there was no significant change in the sagittal vertical axis, lumbar lordosis, pelvic tilt, or lumbopelvic mismatch relative to the values obtained after ACR. There was significantly less disability postoperatively [ODI: 15 (0–30)] compared with preoperatively [ODI: 46 (16–80)] (P<0.01). There was significant improvement in general health after operation, as assessed by the EuroQol-5D utility scores [preop: 0.44 (0.21–0.82) vs. postop: 0.71 (0.60–0.80)] (P=0.01). Back and leg visual analog scale pain scores improved significantly postoperatively.

Conclusions: A staged approach using multilevel ACRs with open posterior instrumentation has an acceptable complication profile and provides excellent restoration of sagittal and coronal balance and pelvic parameters in adults with spinal deformity.
Creator: Schroeder, Gregory D. MD; Kurd, Mark F. MD; Millhouse, Paul W. MD, MBA; Vaccaro, Alexander R. MD, PhD, MBA; Hilibrand, Alan S. MD
Duration: 8:22
An anterior cervical discectomy and fusion is one of the most common procedures performed in spine surgery. It allows for a direct decompression of the spinal cord and the neural foramen. When performed properly, the results of this procedure are some of the best in spine surgery.
Creator: Neil Badlani, Elizabeth Yu, Junyoung Ahn, Mark F. Kurd, Safdar N. Khan
Duration: 5:01
Herniated disks in the lumbar spine typically present with the sudden onset of back and leg pain in a myodermatomal distribution. Symptoms may include radicular pain, paresthesias, and in extreme cases weakness or foot drop. Typically patients are treated conservatively for 6–8 weeks with a combination of steroids, nonsteroidal anti-inflammatory drugs, physical therapy, epidural steroid injections, and rest. In the absence of symptom improvement, surgical intervention typically with a microdisectomy is recommended to patients who are refractory to at least 6 weeks of nonoperative treatment. Earlier intervention may be considered in patients with severe or progressive neurological deficits. This paper reviews the preoperative and postoperative considerations, as well as the surgical technique, for a minimally invasive/less invasive microdisectomy.
Creator: Paul W. Millhouse, MD, Gregory D. Schroeder, MD, Mark F. Kurd, MD, Christopher K. Kepler, MD, MBA, Alexander R. Vaccaro, MD, PhD, MBA, and Jason W. Savage, MD
Duration: 8:59
Lumbar disk herniations occur frequently and are often associated with leg pain, weakness, and paresthesias. Fortunately, the natural outcomes of radiculopathy due to a disk herniation are generally favorable, and the vast majority of patients improve with nonoperative care. Surgical intervention is reserved for patients who have significant pain that is refractory to at least 6 weeks of conservative care, patients who have a severe or progressive motor deficit, or patients who have any symptoms of bowel or bladder dysfunction. This paper reviews the preoperative and postoperative considerations, as well as the surgical technique, for a microdiscectomy for a lumbar intervertebral disk herniation.
Creator: Junyoung Ahn, Ehsan Tabaraee, and Kern Singh
Duration: 4:12
Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) is performed via tubular dilators thereby preserving the integrity of the paraspinal musculature. The decreased soft tissue disruption in the MIS technique has been associated with significantly decreased blood loss, shorter length of hospitalization, and an expedited return to work while maintaining comparable arthrodesis rates when compared with the open technique particularly in the setting of spondylolisthesis (isthmic and degenerative), recurrent symptomatic disk herniation, spinal stenosis, pseudoarthrosis, iatrogenic instability, and spinal trauma. The purpose of this video is to demonstrate the techniques for a primary, single-level MIS TLIF.
Creator: Yasushi Fujiwara, Hideki Manabe, Tadayoshi Sumida, Nobuhiro Tanaka, and Takahiko Hamasaki
Duration: 4:51
Retro-odontoid pseudotumors are noninflammatory masses formed posterior to the odontoid process. Because of their anatomy, the optimal surgical approach for resecting pseudotumors is controversial. Conventionally, 3 approaches are used: the anterior transoral approach, the lateral approach, and the posterior extradural approach; however, each approach has its limitations. The posterior extradural approach is the most common; however, it remains challenging due to severe epidural veins. Although regression of pseudotumors after fusion surgery has been reported, direct decompression and a pathologic diagnosis are ideal when the pseudotumor is large. We therefore developed a new microscopic surgical technique; transdural resection.
Creator:
Duration: 6:59
The use of lateral mass screws and rods in the subaxial spine has become the standard method of fixation for posterior cervical spine fusions. Multiple techniques have been described for the placement of lateral mass screws, including the Magerl, the Anderson, and the An techniques. While these techniques are all slightly different, the overall goal is to obtain solid bony fixation while avoiding the neurovascular structures. The use of lateral mass screws has been shown to be a safe and effective technique for achieving a posterior cervical fusion.
Creator: Themistocles S. Protopsaltis, Christine E. Choi, and Daniel J. Kaplan
Duration: 8:28
Cervical spondylotic myelopathy (CSM) is a condition resulting from cervical stenosis. Manifestations of CSM include paresthesia in the extremities, loss of fine motor skills, balance problems, and bowel and bladder dysfunction in advanced disease. Laminoplasty is one surgical treatment option. The goal of laminoplasty is to reposition the laminae to expand the spinal canal, allowing the spinal cord to migrate posteriorly. There are various laminoplasty techniques; the main ones being open-door laminoplasty and double-door laminoplasty. This video demonstrates a double-door laminoplasty otherwise known as a “French-door” laminoplasty.
Creator: Junyoung Ahn, Ehsan Tabaraee, and Kern Singh
Duration: 4:35
Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has become a popular alternative to traditional methods of lumbar decompression and fusion. When compared with the open technique, the minimally invasive approach can result in decreased pain and blood loss as well as a shorter length of hospitalization. However, the narrower working channel through the tubular retractor increases the difficulty of decortication and bone grafting. This video demonstrates a technique for defining and resecting rhBMP-2-induced heterotopic bone growth following a previous MIS-TLIF.