Combined Use of Diffusion Tractography and Advanced Intraoperative Imaging for Resection of Cervical Intramedullary Spinal Cord Neoplasms: A Case Series and Technical Note

Abstract

BACKGROUND Intramedullary spinal cord neoplasms (ISCN) pose significant management challenges. Advances in magnetic resonance imaging (MRI) (such as diffusion tensor imaging, DTI) have been utilized to determine the infiltrative nature and resectability of ISCN. However, this has not been applied to intraoperative decision making. OBJECTIVE To present a case series of 2 patients with ISCN, the first to combine use of DTI, pre- and intraoperative 3-dimensional (3D) virtual reality imaging, and microscope integrated navigation with heads-up display. METHODS Two patients who underwent surgery for ISCN were included. DTI images were obtained and 3D images were created using Surgical Theater (Surgical Theater SRP, Version 7.4.0, Cleveland, Ohio). Fiducials were used to achieve accurate surface registration to C4. Navigation confirmed the levels of laminectomy necessary. The microscope was integrated with Brainlab (Brainlab AG Version 3.0.5, Feldkirchen, Germany) and the tumor projected in the heads-up display. Surgical Theater was integrated with Brainlab to allow for real time evaluation of the 3D tractography. RESULTS Case 1: All tracts were pushed away from the tumor, suggesting it was not infiltrative. Surgical Theater and Brainlab assisted in confirming midline despite the abnormal swelling of the cord so the myelotomy could be performed. The heads-up display outline demonstrated excellent correlation to the tumor. Gross total resection was achieved. Diagnosis of ependymoma was confirmed. Case 2: Some tracts were going through the tumor itself, suggesting an infiltrative process. Surgical Theater and Brainlab again allowed for confirmation of the midline raphe. Near total resection of the enhancing portion was achieved. Diagnosis of glioblastoma was confirmed. CONCLUSION This is a proof of concept application where multi-modal imaging technology was utilized for safest maximal ISCN resection.

Correlation of intraoperative neurophysiological parameters and outcomes in patients with intramedullary tumors

“…[ 6 7 8 9 10 11 12 13 14 ] Factors associated with improved outcomes for IMSCT include preoperative neurological status, presence of a tumor dissection plane, tumor size, the use of neuromonitoring, and postoperative radiation therapy. [ 6 11 12 ]…”

“…[ 1 2 3 4 5 6 7 8 9 10 ] The most common type of IMSCT is ependymoma, followed by astrocytoma. [ 11 12 13 14 15 16 17 18 19 20 21 22 ] Pain manifested as back pain, radicular pain, or neuropathic pain has been reported to be the most common presenting symptom in patients with an IMSCT. Other common symptoms include motor disturbances and sensory symptoms (dermatomal, saddle, or segmental).…”

Agreement and differentiation of intradural spinal cord lesions in dogs using magnetic resonance imaging

“…It is widely assumed that increased field strength and spatial resolution will translate to improved accuracy, but the results in neurological and musculoskeletal diseases of humans do not always support this assumption. 19 , 20 , 21 Furthermore, emerging MRI techniques (including spectroscopy and diffusion tensor imaging) 22 , 23 should be developed to improve diagnostic accuracy and surgical planning in dogs.…”

Köyde Yaşayan Spinal Tümör Tanılı Erkek Hastanın Gündoğumu Modeli ile Kültürel Değerlendirilmesi

“…Spinal tümörlerinin semptomları arasında ağrı, nöbet, bulantı ve kusma, görme ve işitme bozukluğu, uyuşukluk ve felç yer almaktadır 5 . Bu hastalığa, nörolojik muayene, özel görüntüleme teknikleri (bilgisayarlı tomografi ve manyetik rezonans görüntüleme), laboratuvar testleri ve biyopsi sonrasında tanı konur 6 . Spinal tümörler, ağır morbidite ve mortalite oranlarına sahip olmasına rağmen, erken tanı ve uygun tedavi yöntemleriyle hastalık süreci olumlu sonuçlanabilmektedir 1 .…”