Minimally Invasive Approach for the Treatment of Intradural Spinal Pathology

Ravi H. Gandhi, M.D; John W. Germ an, M.D.

Disclosures

Neurosurg Focus. 2013;35(2):e5 

In This Article

Illustrative Cases

Case 1

A 46-year-old woman presented with progressive hemisensory changes and gait difficulty. Follow-up MRI with contrast demonstrated progressive growth of a foramen magnum–C1 mass with compression of the cervicomedullary junction (Fig. 1). The patient underwent an MIS approach with partial occipital craniotomy, C-1 and C-2 hemilaminotomy, and resection of the intradural mass, which was confirmed to be a meningioma (Fig. 2). There was a 50-ml blood loss. A watertight dural closure was performed, and the patient was discharged to home on postoperative Day 3. Postoperative imaging demonstrated complete resection of the mass and no evidence of a pseudomeningocele (Fig. 3). The patient had complete resolution of her symptoms.

Figure 1.

Case 1. Preoperative MR images. T1-weighted sagittal (left) and axial (right) Gd-enhanced MR images demonstrating a lesion ventral and lateral to the spinal cord at C-1.

Figure 2.

Case 1. Intraoperative photograph demonstrating a meningioma (arrow) ventral to the C-1 nerve roots.

Figure 3.

Case 1. Postoperative T1-weighted sagittal (left) and axial (right) Gd-enhanced MR images demonstrating a complete resection of a foramen magnum–C1 meningioma.

Figure 4.

Case 2. Preoperative and postoperative MR images. T1-weighted sagittal (A) and axial (B) Gd-enhanced MR images demonstrating a lesion at L3–4 interspace. T1-weighted sagittal (C) and axial (D) Gd-enhanced MR images demonstrating a complete resection of an L3–4 hemangioblastoma.

Case 2

A 59-year-old man presented with back and bilateral leg pain. Magnetic resonance imaging showed a large enhancing mass at the L3–4 interspace with multiple flow voids (Fig. 4A and B). The patient underwent a preoperative catheter angiography that was negative for a vascular abnormality. An L3–4 laminotomy was performed via an MIS approach. The estimated blood loss was 400 ml; however, the patient did not require a blood transfusion. The patient was discharged on postoperative Day 1. Postoperative MRI did not show evidence of recurrence or pseudomeningocele (Fig. 4C and D).

Case 3

A 54-year-old woman presented with tussive headaches and paresthesia in her hands. An MR image showed a Chiari I malformation with a syrinx that exhibited progression on subsequent imaging (Fig. 5 left). The patient subsequently underwent an MIS approach for a suboccipital decompression with removal of C-1 and duraplasty. Following the operation, the patient's headache improved and follow-up imaging showed the syrinx had resolved (Fig. 5 right).

Figure 5.

Case 3. Left: Preoperative T2-weighted image demonstrating a Chiari I malformation with a syrinx at C7–T3. Right: Postoperative T2-weighted image demonstrating a Chiari decompression with resolution of the syrinx.

Case 4

A 34-year-old man presented with progressive myelopathy with severe difficulty with gait and manual dexterity that began after a stretching episode. The patient was found to have a syringomyelia from C-6 to T-1 with no other underlying abnormality (Fig. 6 left). He underwent a fenestration and subarachnoid shunting of the syrinx via an MIS approach to a C-7 hemilaminectomy. The patient's symptoms resolved except for minimal residual neck pain, and postoperative imaging demonstrated significant improvement in the size of the syrinx (Fig. 6 right).

Figure 6.

Case 4. Left: Preoperative T2-weighted image demonstrating a thoracic syringomyelia. Right: Postoperative T2-weighted image demonstrating a syringomyelia-arachnoid shunt.

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