August 14, 2016
Here is an interest case of a giant cervical spinal cord lipoma. This is a 19 year old male who presented with progressive myelopathy and right-sided weakness. This lesion was known about 10 years prior to the surgery and due to the high risk of the operation that lesion was observed. However, the patient continued to worsen and subsequently underwent an operation. MRI evaluation, more specifically the T1 without contrast, demonstrates the large size of this lipoma. on the axial images you can appreciate the scoliosis and deformity associated with this tumor. The goals of the surgery are essentially just decompression of the lipoma, to relieve some of the mass effect and arthrodesis in order to stabilize the spine and relieve some of the symptoms related to spinal deformity. Laminectomy was completed. The relatively normal spinal cord above and below the giant lipoma was recognized. You can see the lateral mass screws were inserted first before the dura was opened. The lipoma is intramedullary. There was only a very thin layer of the spinal cord covering the lipoma. I used an ultrasonic aspirator device to remove the fat. Again, the cause of the surgery are partial decompression, just relieve the mass effect without getting close to any of the fiber tracts. Monopolar stimulation was also used during the operation just to estimate the location of the motor tracts. The fat is removed in layers. Hemostasis was secured relatively easily. Here is a good portion of the fat, which was located along the lower cervical spine and the lower third of the lipoma. The ultrasonic aspirator devices, very effective in removing the fat without placing the spinal cord under significant tension. Dynamic retraction is used. Further de-bulking continues and irrigation is used to dissipate the heat. Here's the more rostral part of the lipoma that is being decompressed. Again, staying away from the normal spinal cord. Good amount of de-bulking is accomplished. Here you can see the very thin layer of the spinal cord over lateral aspect of the lipoma. Again, the lipoma is not really easily dissectible from the spinal cord and therefore no aggressive attempt should be made to work around the capsule of the lipoma. The lipoma is essentially infiltrative and there are no clear planes between the lipoma and the spinal cord parenchyma. Therefore, I continued to further de-bulk the lipoma. The cord appears very relaxed. So much sensory and motor evoked potentials were monitored. Here's the use of monopolar stimulation. Activation of upper extremities were noted including stimulation on the other side of the cord capsule. A very conservative de-bulking of the lipoma was the goal. You can see how the fat is being removed in very thin layers to avoid inadvertent entry into the spinal cord parenchyma. Here's the lower pole of the lipoma and the relatively normal aspect of the spinal cord. Some of the nerve roots are clearly apparent. Here's the functional tissue covering the lipoma. Stimulation was used here and since no activation was noted further de-bulking continued in this area. Here's the final result. You can see good de-bulking of the lipoma. A more demagnified view of our operative corridor. Stimulation mapping of the spinal cord can be accomplished, although in this case, no activation of upper or lower extremities was noted. You can see that the lipoma was getting quite thin and close to the spinal cord at this location, and therefore no further removal of the lipoma was warranted. After this de-bulking, the dura was closed in a wider tight fashion, and the rest of arthrodesis was completed. Postoperative MRI revealed relatively good de-bulking of the tumor. Again, the goal of the surgery is not anywhere close to aggressive removal of the lipoma to avoid any neurological decline and this patient improved after this operation. Thank you.
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