Large Intramedullary Spinal cord Tumors: Ependymoma
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Hello ladies and gentlemen, my name is Aaron Cohen. This video will review technical nuances for resection of large intramedullary spinal cord tumors using the case of a 26-year-old female who presented with progressive hand weakness and was known to have myelopathy on examination. As you can see a cervical spine MRI with contrast reveals a giant intramedullary spinal cord tumor, extending into the lower aspect of the brain stem. She underwent surgery using somatosensory evoked potential and motor evoked potentials in a prone position. Midline incision was used and a multilevel laminectomy was completed and the dura was opened along the midline. And midline myelotomy was completed first, by coagulating the posterior midline, and then short dissection was used to complete the myelotomy along the entire aspect of the tumor. You can see after the initial myelotomy was completed, it was extended to the level of the tumor using sharp and blunt dissection. The entire length of the tumor was exposed in order to be able to remove the tumor without necessarily causing too much traction on the prin-ca-ma of the spinal cord. Here you can see the large tumor with relatively good margins against the spinal cord. This tumor ultimately was diagnosed as a grade II spinal cord ependymoma. In certain locations this tumor has a very nice planes, and as you can see here, these planes are being created. As much as possible, sharp dissection is used to mobilize the tumor away from the spinal cord rather than mobilizing spinal cord prin-ca-ma away from the tumor. Along the superior and inferior poles of this tumor often there are large cysts and here's a more de-magnified view of the exposure and peel retraction sutures over the spinal cord to be able to expose the tumor without necessarily aggressive manipulation of the spinal cord. Here is more mobilization of the inferior pole of the tumor with very nice planes against the spinal cord. You can see some of the adhesions that are going to be dissected off of the tumor. We're gonna go ahead and also use sharp dissection again as much as possible to dissect these adhesions away from the tumor. As we dissect it, the more adherent part of the tumor that will be coming up shortly, we noted some decrease in the amplitude of MEPs related to the left leg. After this was detected, we changed our maneuvers in terms of the amount of retraction that was placed on the spinal cord and increased the blood pressure and also stopped our dissection for short period of time. Although the decrease in MEP was somewhat relieved, a small reduction in the leg MEP remained. Here's the other parts of the tumor that are being carefully dissected off. The most adherent part of these tumors is mainly along the midbody of the tumor along the anterior aspect of the belly of the tumor at the level of the spinal cord. You can see the tumors more adherent in this region and short dissection as much as possible is used, and obviously the operator and the surgeon stays just over the surface of the tumor and carefully protecting the spinal cord. Here again, the spinal cord is very much adherent to the tumor more specifically in this area. And we use a Rosen knife, and various number of different dissectors in order to be able to preserve as much integrity of the spinal cord as possible. More of the area along the midbody of the tumor anteriorly where the most adherent part of tumor to the spinal cord is often present. Gentle retraction on the tumor would allow finding the appropriate planes and finally mobilizing tumor from the spinal cord You can see the tumor can be often extremely embedded within this spinal cord. Patient dissection with preservation of all the fibers and staying as close as possible to the tumor capsule would allow the most safe way to preserve function. Here's ultimately the tumor that is being removed in block and a gross total resection was completed. This patient did a walk with a small amount of leg weakness that ultimately resolved, and you can see the gross total resection of the tumor on postoperative MRI. Thank you.
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