Minimally Invasive Approach for Dorsal Arachnoid Web: 2-Dimensional Operative Video.

International audienceA 67-yr-old patient presented with severe paraparesis and lower limb spasticity. The spinal cord magnetic resonance imaging (MRI) revealed the “scalpel sign” 1,2 at the T7 level, suggesting a diagnosis of a dorsal arachnoid web. This video demonstrates a microsurgical technique for the excision of a dorsal arachnoid web with a minimally invasive approach. A paramedian skin incision, understanding the muscular aponeurosis, was performed from T7 to T8. Then, we inserted the tubular dilators until the lamina, to perform a muscle-sparing approach. An expandable tubular retractor of adequate length was passed over the widest dilator and docked into place along the subperiosteal plane. The T7 lamina was drilled, and the resection of the superior and inferior adjacent spine levels was completed with a rongeur. Additional contralateral bone resection was performed after tubular retractor tilt to the midline.3 After dura mater opening, it was carefully suspended and the dorsal arachnoid leaflet was cut to drain the dorsolateral and lateral spinal cisterns.4 The dorsal arachnoid web was, first, disconnected from its lateral anchorages. It was then gently removed with microsurgical forceps, to help its microdissection from the spinal cord surface. At this step, peculiar attention was paid to limit the traction or displacements of the spinal cord and surrounding vessels. Once the dorsal arachnoid web was removed, the quality of the spinal cord decompression was confirmed by its re-expansion. In conclusion, the minimally invasive approach is a safe and appropriate technique for dorsal arachnoid web excision.2,5,6-

How to differentiate spinal cord hemangiopericytoma from common spinal cord tumor?

International audienceIntroduction: Tumors of the spinal cord are rare and some can be confused with each other. We report a rare spinal cord solitary fibrous tumor/hemangiopericytoma (SFT/HPC), and propose keys to differentiate spinal cord tumors from each other.Case report: A 67-year-old man presented weakness with recent diffuse sensory disorders in the right lower limb. Spinal MRI revealed a T8-T9 intradural extramedullary mass with spinal cord compression. Gross total resection of a poorly vascularized intradural tumor was achieved. It was an encapsulated extramedullary tumor, which was difficult to separate from the spinal cord due to the presence of pial adhesions. Definitive diagnosis was grade 1 SFT/HPC of the spinal cord. One-year follow-up MRI revealed complete excision without any evidence of residual tumor.Conclusion: SFT/HPC is a very rare spinal tumor that can be extramedullary, intramedullary or both. It may perfectly mimic meningioma. The maximal resection is the best treatment, but can be challenging because of the tumor's firm consistency and pial adherences to the spinal cord. Outcome is good in case of gross total resection, but there is a risk of very late recurrence, requiring long-term follow-up

Spinal cord tractography and neuromonitoring-based surgical strategy for intramedullary ependymoma

Because the spinal cord contains a rich concentration of longitudinal and transversal fibers in a very small area, intramedullary surgery could result in a high likelihood of morbidity. In this video, the authors demonstrate the microsurgical technique and surgical skills used to perform excision of an intramedullary ependyma. The authors also present tools (electrophysiology and neuroimaging) that are useful for surgical decision-making and planning, and thus are used intraoperatively, that allow safer and more effective resection of an intramedullary tumor

Minimally invasive surgery for intradural spinal meningioma: a new standard? A comparative study between minimally invasive and open approaches.

International audienceBackgroundSome authors used minimally invasive surgery (MIS) in the treatment of spinal cord tumor, but these studies had a small sample sizes and mixed extra- and intra-medullary tumors, resulting in confounding biases. The objectives of the present study were to evaluate the effectiveness and safety of MIS for spinal meningioma resection in comparison with open surgery (OS).MethodsConsecutive patients with spinal meningioma who received either MIS or OS were included. Data for extent of resection, functional outcome, postoperative morbidity and recurrence were collected.ResultsA total of 48 patients (with 51 spinal meningiomas) were included. Eighteen underwent MIS and 30 OS. Meningioma volume and location did not differ significantly between groups: tumors were predominantly thoracic (n = 39, 76.5%) and voluminous (occupying more than 50% of the spinal canal: n = 43, 84.3%). In the MIS group, patients were older (mean age: 66.5 vs. 56.4 years, P = 0.02) and more fragile (mean ASA score: 2.0 vs. 1.6, P = 0.06). In the MIS group, the surgical procedure was shorter (mean duration: 2.07 vs. 2.56 h, P = 0.04), blood loss lower (mean: 252 vs. 456 mL, P = 0.02), and hospital stay shorter (mean: 6.6 vs. 8.1 days). Surgery improved the modified McCormick scale (P < 0.0001) irrespective of the surgical technique. MIS led to no significant differences in extent of resection or postoperative morbidity. Mean follow-up was 46.6 months. At last follow-up, 91.7% (n = 44) of patients were free of progression; all cases of tumor progression (n = 4) occurred in the OS group.ConclusionsMIS outperformed OS in the management of intradural spinal meningioma, irrespective of location and volume. MIS appears to be particularly suitable for elderly and fragile patients

Locked-in syndrome after central pontine myelinolysis, an outstanding outcome of two patients

Objective: Central pontine myelinolysis (CPM) is a rare demyelinating disease that affects the pons and which can cause extreme disabilities such as locked-in syndrome (LIS) in the initial phase. The aim of the study was to describe the evolution over a 12-month period of two patients with CPM causing an initial LIS.Method: We retrospectively report the unexpected clinical outcome of these two patients in relation with the anatomical damages documented by brain MRI, associated with diffusion tensor imaging and reconstruction of corticospinal tracts in tractography. The following clinical parameters systematically assessed at 3, 6, 9, and 12 months: muscle testing on 12 key muscles (Medical Research Council), prehension metrics (box and block test and purdue pegboard), and independence for acts of daily living (functional independence measure).Results: Both patients showed a progressive recovery beginning between 2 and 3 months after the onset of symptoms, leading to almost complete autonomy at 12 months (FIM > 110), with motor strength greater than 4/5 in all joint segments (MRC > 50/60). On brain MRI with tractography, CST appeared partially preserved at pons level.Interpretation: The possibility of a near-complete functional recovery at 12 months is important to consider given the ethical issues at stake and the discussions about limiting care that may take place initially. It seems to be the consequence of reversible myelin damage combined with partially preserved neurons. Development of collateral pathways or resolution of conduction block may explain this recovery. MRI comprising DTI and tractography could play a key role in the prognosis of motor recovery