Surgical Neurology International

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1 Surgicl Neurology Interntionl SNI: Spine, supplement to Surgicl Neurology Interntionl OPEN ACCESS For entire Editoril Bord visit : Editor: Nncy E. Epstein, MD Winthrop University Hospitl, Mineol, NY, USA Resection of n Occipitl Cervicl Junction Schwnnom through modified minimlly invsive pproch: Technicl Note Michel Feldmn, Kristopher T. Kimmell, Roert E. Replogle Deprtment of Neurosurgery, University of Rochester Medicl Center, Rochester, NY, USA E mil: Michel Feldmn ; *Kristopher T. Kimmell kristopher_kimmell@urmc.rochester.edu; Roert E. Replogle *Corresponding uthor Received: 22 Septemer 14 Accepted: 27 Novemer 14 Pulished: 07 My 15 This rticle my e cited s: Feldmn M, Kimmell KT, Replogle RE. Resection of n Occipitl-Cervicl Junction Schwnnom through modified minimlly invsive pproch: Technicl Note. Surg Neurol Int 2015;6:S Aville FREE in open ccess from: Copyright: 2015 Feldmn M. This is n open ccess rticle distriuted under the terms of the Cretive Commons Attriution License, which permits unrestricted use, distriution, nd reproduction in ny medium, provided the originl uthor nd source re credited. Astrct Bckground: Minimlly invsive spine (MIS) techniques hve een ville for mny yers, ut their ppliction hs een lrgely limited to degenertive spine diseses. There re few reports in the literture of using MIS techniques for removl of neoplsms. We report our experience using modified MIS technique for removl of n occipitl cervicl junction (OCJ) schwnnom with ttention to technicl spects of this pproch. Cse Description: A 64 yer old mle presented with severl months of neck pin rditing to the shoulder with ilterl hnd numness. The ptient hd evidence of erly myelopthy on exmintion. Mgnetic resonnce imging (MRI) demonstrted enhncing intrdurl lesion with significnt mss effect on the spinl cord. The mss extended extrdurlly through the right C1 neurl formen. Imging chrcteristics were suggestive of schwnnom. The ptient underwent minimlly invsive fr lterl pproch to the OCJ for resection of the lesion. A Depuy Pipeline expndle retrctor ws used for visuliztion. Surgicl resection ws performed with microscopic visuliztion. Somtosensory evolved potentils ( SSEP) monitoring ws used. The ptient tolerted the procedure well. Postopertive imging demonstrted gross totl resection. No intr or postopertive complictions were noted. The ptient ws dischrged home on postopertive dy 2. At 1 month follow up, his preopertive symptoms were resolved nd his wound heled excellently. Conclusion: In properly selected ptients, minimlly invsive pproches to the OCJ for resection of mss lesions re fesile, provide dequte visuliztion of tumor nd surrounding structures, nd my even e preferle given the lower moridity of smller incision nd miniml soft tissue dissection. Access this rticle online Wesite: DOI: / Quick Response Code: Key Words: Minimlly invsive spine, occipitl cervicl junction, schwnnom, technique INTRODUCTION Schwnnoms re mong the most common spinl tumors, with n nnul incidence of 3 4 per million. [12] Though these tumors re iologiclly enign, they my cuse significnt moridity through compression of surrounding neurl structures. Thus they hve een trditionlly mnged with surgicl resection. Historiclly the most common pproch to spinl schwnnoms is with n open posterior lminectomy. However, this S177

2 SNI: Spine 2015, Vol 6, Suppl 4 - A Supplement to Surgicl Neurology Interntionl pproch my cuse significnt postopertive pin nd potentil spinl instility. [14] Over the pst decde, minimlly invsive spine (MIS) techniques hve emerged nd my serve to reduce the postopertive pin nd musculoligmentous nd ony destruction fter spinl surgery. [7,10] MIS techniques, used initilly for microdiscectomies nd decompressive procedures, hve of lte developed wide indictions t ll spinl levels with well descried successful outcomes. [6,13] The use of MIS techniques for spinl neoplsms, however, seems to e progressing more slowly, despite the potentil enefits to ptients. MIS techniques for intrmedullry tumors hve, in some studies, resulted in decresed opertive time reltive to trditionl posterior lminectomies, s well s decresed lood loss nd decresed postopertive sty. The use of miniml exposure for the resection of cervicl neoplsms is n re of recently incresing study nd tremendous potentil. One smll study exmined the enefit of midline posterior pproch for upper cervicl schwnnoms with minimized ut trditionl exposures nd found this successful in tumor resection. [11] Other surgeons hve explored the potentil efficcy of minimizing exposure for tumors with intr/ extrdurl extension. Specificlly, Cvlcnti et l. were le to demonstrte the effective removl of smll upper cervicl schwnnoms with hemilminectomy nd lrger neoplsms with fr lterl pproch nd C2 lminectomy. [4] Mny of these preliminry studies suggest good clinicl outcomes with modified techniques to decrese ony nd musculoskeletl destruction. [3] Despite the pprent enefits nd incresing frequency with which such procedures re performed, some uthors express concern over the limittions of tumor visiility with MIS pproches, nd cution tht mjor procedurl limittion my e dequte tumor visuliztion or sufficient surgicl work spce. [2] Furthermore, in the region of the occipitl cervicl junction (OCJ) there is the concern of indequte visuliztion or itrogenic injury of vitl structures such s the lower crnil nerves nd the verterl rtery with its complex course in the upper cervicl region. Given the growing ody of evidence on the efficcy of MIS, we elieve tht MIS techniques re sfe for resection lrge upper cervicl enign neoplsms nd present our own experience with modified MIS technique for resection of n OCJ schwnnom. Clinicl presenttion A 64 yer old mle presented with complint of severl months of neck pin rditing into his right rm, s well s ilterl hnd nesthesi. He denied ny wekness or difficulty wlking. His pst medicl history ws notle only for hypertension nd hyperlipidemi. He hd distnt history of hnd surgery nd pilonidl cystectomy, nd denied ny pst hed or ck opertions. Neurologic exmintion ws notle for sutle drift of the right upper extremity s well s one to two ets of clonus in oth feet. Hoffmn s sign ws sent ilterlly. The reminder of his neurologic nd physicl exmintion ws norml. Mgnetic resonnce imging (MRI) of the cervicl spine demonstrted right sided extrmedullry lesion t the C1 C2 level with n intrdurl component cusing significnt compression of the spinl cord. The mss lso hd lrge extrdurl component extending through the right neurl formen nd trcking long the nerve root. The mss vidly enhnced nd showed some evidence of cystic degenertion [Figure 1]. Computed tomogrphy (CT) of the neck with ngiogrm confirmed the course of the right verterl rtery in close proximity to the mss [Figure 2]. The right C2 formen ws widened, ut there ws no evidence of significnt ony destruction y the mss. Imging chrcteristics were highly suggestive of schwnnom. Surgicl resection ws recommended due to the size of the lesion, evidence of spinl cord compression, nd erly signs of myelopthy on exmintion. Figure 1: Coronl () nd xil () ft-suppressed T1-weighted imges postgdolinium dministrtion demonstrting lrge vidly enhncing extrmedullry mss t the C1-2 level with oth intr- nd extrdurl components consistent with schwnnom Figure 2: Sgittl () nd coronl () slices from preopertive CT Angiogrm demonstrting widening of the right C2 formen ut without ony destruction. The tumor is indicted y (*) nd the verterl rtery is highlighted y the closed rrow S178

3 Opertive technique: Modified minimlly invsive fr lterl pproch Position nd preliminry incision/dissection The ptient ws rought to the operting room nd underwent generl nesthesi. SSEP monitoring ws used. The ptient ws plced in the lterl position with the right side up nd hed in three point fixtion with the neck flexed nd the contrlterl er tipped towrd the contrlterl shoulder. An incision ws mrked from the mstoid tip inferiorly 4 cm prlleling the posterior order of the sternocleidomstoid muscle. Preliminry dissection ws performed under direct visuliztion with surgicl knife nd electrocutery. Metzenum scissors were used to continue the dissection down to the suoccipitl tringle. The lmin nd trnsverse process of C2 were visulized. Multiple diltors were plced in series on the C2 lmin. Correct plcement of the diltors on C2 ws confirmed y fluoroscopy. Next the diltors were moved crnilly to llow visuliztion of the olique muscle ridging the C2 nd C1 lmine nd trnsverse processes. The muscle ws divided with electrocutery nd reflected to llow excellent visuliztion of the underlying ony ntomy, nd susequently the Depuy Pipeline retrctor ws inserted nd expnded [Figure 3]. Hemilminectomy nd tumor deulking The tumor ws redily visile underneth the rch of C1 extending oth cudlly nd cephld, s well s lterlly. Hemilminectomy of C1 nd prtil hemilminectomy of the superior spect of C2 were performed to llow visuliztion of the tumor in its entirety s well s the surrounding criticl structures. Under microscopic visuliztion, the tumor ws deulked piecemel. The verterl rtery nd its venous plexus were well visulized [Figure 4]. The extrdurl component of the mss ws resected until its entrnce into the dur could e visulized. Bleeding from the verterl venous plexus ws controlled with irrigtion nd surgifom. The dur ws opened nd the tumor ws trced long the C2 nerve root. The C2 nerve root ws divided nd the reminder of the tumor ws removed. Closure The dur ws closed using n on ly ptch of Durgen nd Dursel. The fscil nd sucutneous lyers were closed in routine interrupted wtertight fshion [Figure 5]. There were no chnges to the somtosensory potentils t ny point during the cse. Totl opertion time ws 6 h. The estimted lood loss ws 550 cc. The ptient ws tken to recovery where he woke in norml fshion. Postopertive outcome The ptient hd very good postopertive course. His men postopertive pin score ws 2. MRI of the cervicl spine on postopertive dy 2 demonstrted gross totl resection [Figure 6]. He ws dischrged home on postopertive dy 2. At 1 month follow up, the ptient SNI: Spine 2015, Vol 6, Suppl 4 - A Supplement to Surgicl Neurology Interntionl Figure 3: Intropertive photogrph demonstrting the Pipeline retrctor in plce on the posterolterl spect of the ptient s neck Figure 4: Intropertive photogrph of microscopic view of the tumor in reltion to the rch of C1 Figure 5: Postopertive photogrph of the ptient s skin incision t the end of the procedure ws doing well. Finl pthology confirmed the tumor to e World Helth Orgniztion (WHO) Grde I schwnnom. His symptoms were significntly improved, his wound ws heling quite well, nd he experienced no significnt movement restriction. The ptient did S179

4 SNI: Spine 2015, Vol 6, Suppl 4 - A Supplement to Surgicl Neurology Interntionl nd removl of complex nd lrge multilevel intr nd extrdurl schwnnom with miniml tissue disruption using n MIS pproch is significnt step forwrd for widening the indiction for MIS procedures. Figure 6: Coronl () nd xil () ft-suppressed T1-weighted imges postgdolinium dministrtion showing excellent resection of the tumor hve recurrence of the extr durl component of the tumor without neurologic sequele. The recurrence ws treted with stereotctic rdiosurgery with good effect. At 3 yers follow up, he is doing well with his only neurologic symptoms eing numness of the posterior sclp secondry to his incision nd scrifice of the C2 nerve root. DISCUSSION In this cse report, we descrie the first noted resection of n OCJ schwnnom with modified minimlly invsive fr lterl pproch. This ptient hd n excellent opertive nd functionl outcome. MIS pproches to cervicl tumor deulking re ecoming incresingly common, ut there still exists derth of descriptive literture ttesting to their sfe nd eneficil use. This my e in prt due to mny of the resons discussed previously, nmely restricted surgicl field nd concerns out dequte tumor ccess, exposure, nd visuliztion of surrounding ntomic structures. Preliminry studies hve ctully demonstrted the opposite, with one notle study showing tht MIS pproches were le to effectively remove cervicl intrdurl, extrmedullry neoplsms with less lood loss nd shorter opertive times. [15] Further, MIS procedures minimize risk to the ptient for potentil kyphosis, spondylolisthesis, or other deilitting structurl instility due to disruption of the ony nd ligmentous rchitecture or posterior muscle ttchments. [1,5] Some uthors hve voiced cution over the use of MIS techniques for the OCJ. However, this cse demonstrtes tht this region cn e sfely pproched with MIS techniques. Although there re pucity of reports, Lu et l. hve previously descried their experience with the use of MIS pproch for tretment of Bowhunter s syndrome in n dolescent cused y suocciptl ony spur with excellent technicl nd clinicl results. [8] Our cse furthers the rgument tht MIS techniques re techniclly fesile for cervicl tumors nd in prticulr for the OCJ. The demonstrted complete visuliztion The key for our opertive pproch ws the use of creful dissection to identify ony lndmrks; in our cse the lmin nd lterl mss of C2, followed y the use of diltors nd n expndle retrctor to otin suitle corridor for visuliztion of the tumor nd surrounding ntomy. Our technique ws predicted on severl key items: First, n excellent working knowledge of OCJ ntomy. The senior uthor hs performed mny procedures in this region. Second, the pproch ws predicted on sustntive exposure to MIS techniques, s the senior uthor hs performed hundreds of previous MIS procedures. With this solid foundtion, this novel modified MIS pproch could e ttempted with resonle sfety to the ptient. Becuse of their novelty, especilly for neoplstic indictions, MIS procedures re opertor dependent nd there is n expected lerning curve for MIS procedures. With the prolifertion of MIS techniques ccelerting, Mnnion et l. proposed criteri for the use of MIS, suggesting tht these pproches should e tken only if they do not hve incresed risk, offer some tngile enefit to the ptient, nd cn chieve the sme surgicl gols. [9] We would offer tht MIS techniques, in the setting of tumor resections or pproches to ntomiclly complex regions, should e reserved for surgeons who hve ccumulted significnt experience with the use of MIS. We posit tht our experience with this cse shows tht MIS techniques cn e used for pproches to the OCJ, even for tumors more complex nd expnsive thn my e suggested y the current literture. Furthermore, we suggest tht the descried fr lterl pproch chieves good surgicl field ccess while minimizing the postopertive pin nd risks of instility ssocited with more extensive procedures. REFERENCES 1. Alvisi C, Borromei A, Cerisoli M, Giulioni M. Long term evlution of cervicl spine disorders following lminectomy. J Neurosurg Sci 1988;32: Angevine PD, Kellner C, Hque RM, McCormick PC. Surgicl mngement of ventrl intrdurl spinl lesions. J Neurosurg Spine 2011;15: Bnczerowski P, Veres R, Vjd J. Modified minimlly invsive surgicl pproch to cervicl neuroms with intrforminl components: Hemi semi lminectomy nd suprforminl urr hole (modified forminotomy) technique. Minim Invsive Neurosurg 2009;52: Cvlcnti DD, Mrtirosyn NL, Verm K, Sfvi Asi S, Porter RW, Theodore N, et l. Surgicl mngement nd outcome of schwnnoms in the crniocervicl region. J Neurosurg 2011;114: Fssett DR, Clrk R, Brockmeyer DL, Schmidt MH. Cervicl spine deformity ssocited with resection of spinl cord tumors. Neurosurg Focus 2006;20:E2. 6. Hji FA, Cenic A, Crevier L, Murty N, Reddy K. Minimlly invsive S180

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