Endoscopic Management of Spinal Intradural Extramedullary Tumors

Abstract

Posterior midline laminectomy is associated with risks of postoperative instability, spinal deformity, extensive bilateral subperiosteal muscle stripping, partial or total facetectomy especially in foraminal tumor extension, increased cerebrospinal fluid leakage, and wound infection. Minimally invasive approaches with the help of a microscope or endoscope using hemilaminectomy have been found to be safe and effective. We report our initial experience of 18 patients using the endoscopic technique. A retrospective study of intradural extramedullary tumors extending up to two vertebral levels was studied. Pre- and postoperative clinical status, magnetic resonance imaging was done in all patients. The Destandau technique was used, and resection of ipsilateral lamina, medial part of the facet joint, base of the spinous process, and undercutting of the opposite lamina was performed. Dura repair was done using an endoscopic technique. Fibrin glue was used to reinforce repair in the later part of the study. The sagittal and axial diameter of tumor ranged from 21 to 41 mm and 12 to 18 mm, respectively. There were four cervical, two cervicothoracic, five thoracic, three thoracolumbar, and four lumbar tumors, respectively. All 18 patients improved after total excision of tumor. Average duration of surgery and blood loss was 140 minutes and 60 mL, respectively. Postoperative stay and follow-up ranged from 3 to 7 days and 9 to 24 months, respectively. Although the study is limited by the small number of patients with a short follow-up and is a technically demanding procedure, endoscopic management of intradural extramedullary tumors was an effective and safe alternative technique to microsurgery in such patients.

Keyhole approaches to intradural pathologies

“…A number of smaller approaches have been introduced to reduce the above-described complications of laminectomy. Endoscopic procedures were evaluated by Parihar et al 19 in a small patient sample with very good success and low complication rates. However, this technique is described as technically demanding.…”

Practical Aspects and Avoidance of Complications in Microendoscopic Spine Surgeries: A Review

“…There is an increased risk of a dural tear and cerebrospinal fluid leak while addressing the contralateral compression in severe spinal canal stenosis (►Table 5). 15,21,22 Proper case selection helps prevent the dural injury, especially during the initial learning curve, and by keeping the ligamentum flavum intact until all bony work is finished. 22,23 Both 45-and 90degree Kerrison punches should be used for removal of the cranial and caudal lamina, respectively.…”

“…15,21,22 Proper case selection helps prevent the dural injury, especially during the initial learning curve, and by keeping the ligamentum flavum intact until all bony work is finished. 22,23 Both 45-and 90degree Kerrison punches should be used for removal of the cranial and caudal lamina, respectively. 17 Using an eggshell drilling technique is preferred for lamina, 17 and then the thinned-out lamina can be removed.…”

“…• Move endoscope or object/instrument in such a way that the arrangement becomes triangular • Keep endoscope in between the instrument and the surgical target over a linear movement because of the constrained space. 20,22 The first knot can be preplaced at the end of the suture to avoid wasting time tying the knot. 22 A loop for suturing can be performed inside the endoscopic field with the help of a needle holder and the suction tip.…”

“…20,22 The first knot can be preplaced at the end of the suture to avoid wasting time tying the knot. 22 A loop for suturing can be performed inside the endoscopic field with the help of a needle holder and the suction tip. The loop can also be made outside, which can be carried inside the endoscopic field with the help of the needle holder.…”