Neurosurgery Outlines - Paul E. Kaloostian Surgical Outlines

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      • Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life

      Prognosis

      • Most patient are discharged home the same day for single level foraminotomy

      • Typically, 4 to 6 weeks post operation most patients are able to return to normal day-to-day activities

      • PT/OT can be performed as outpatient to regain strength

      • Most patients do very well and are happy with the results

      Fig. 1.10 Guide for patient selection considering between anterior cervical diskectomy and fusion (ACDF) and posterior foraminotomy (PF). Patients selected for PF will have mediolateral or lateral disk herniation and are without relevant osseous component. (Source: Scholz T, Geiger M, Mainz V, et al. Anterior cervical decompression and fusion or posterior foraminotomy for cervical radiculopathy: results of a single-center series. J Neurol Surg A Cent Eur Neurosurg 2018;79(03):211–217).

      1.3 Tumor/Vascular

      1.3.1 Cervical Tumor Resection (Vertebral Pathology)

      Symptoms and Signs

      • Incidental with symptoms (depending on size and location)

      • Moderate/Severe numbness in upper extremities

      Fig. 1.11 A spinal needle marks entrance site for a lower cervical (C6–C7) foraminotomy. It is recommended to enter the skin rostral to the foramen. (Source: Operative procedure. In: Wolfla C, Resnick D, eds. Neurosurgical Operative Atlas: Spine and Peripheral Nerves. 3rd ed. Thieme; 2016).

      • Paresthesias in upper body extremities

      • Neck pain and loss of mobility due to neck pain

      • Radiating pain down the arms

      • Pain in moving shoulders

      • Muscle weakness in arms

      • Inability to conduct fine motor skills with hands

      Surgical Pathology

      • Cervical spine benign/malignant tumor

      Diagnostic Modalities

      • CT of cervical spine with and without contrast to assess whether there is bony involvement of tumor

      • MRI of cervical spine with and without contrast to assess if there is spinal cord, epidural space, or nerve root involvement of tumor

      • PET scan of body to look for other foci of tumor

      • CT of chest/abdomen/pelvis to rule out metastatic disease

      Differential Diagnosis

      • Metastatic tumor

      – Breast, prostate, lung, renal cell

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      Fig. 1.12 (a–h) Higher cervical (C2) resection of giant cell tumor via endoscopic transnasal and transoral approaches. Radiology reveals the location of the tumor. Gross total tumor resection was achieved. (Source: Surgical technique. In: Stamm A, ed. Transnasal Endoscopic Skull Base and Brain Surgery: Surgical Anatomy and Its Applications. 2nd ed. Thieme; 2019).

      • Primary tumor (see ▶Fig. 1.12)

      – Schwannoma, myeloma, plasmacytoma, meningioma

      Treatment Options

      • Acute pain control with medications and pain management

      • If asymptomatic or mildly symptomatic with neck pain/radiculopathy with small focus of tumor:

      – Radiation treatment (radiation oncology consultation)

      – Chemotherapy (medical oncology consultation)

      – Kyphoplasty (to treat pain)

      – Surgical instrumentation and fusion (if there is concern for deformity, instability, or cord compression)

      • If symptomatic with cord compression and myelopathy with large tumor burden:

      – Urgent surgical decompression and fusion over multiple segments with tumor resection if deemed suitable candidate for surgery; may be followed by radiation treatment after resection if considered necessary by the radiation oncologist

      ◦ The oncologist will need to determine overall prognosis, Karnofsky performance score, and extent of visceral disease

      ◦ If poor surgical candidate with poor life expectancy, medical management is recommended

      ◦ Surgery may be done anteriorly, posteriorly, or combined two-stage approach for added stabilization (see ▶Fig. 1.13)

      – Preoperative embolization may be indicated for select vascular tumors to the spine such as renal cell cancer, thyroid cancer, breast cancer, etc. in order to decrease vascularity intraoperatively

      Fig. 1.13 (a, b) Radiology revealed presence of lower cervical tumor in teenage girl who presented with symptoms of myelopathy. Tumor embolization, anterior corpectomy (C6) with tumor resection and reconstruction, and fusion (C4–C6) were performed. Improved alignment was achieved and the tumor was confirmed to be totally resected. (Source: Introduction and background. In: Cohen A, ed. Pediatric Neurosurgery: Tricks of the Trade. 1st ed. Thieme; 2015).

      Indications for Surgical Intervention

      • Intractable neck and radicular pain refractory to all conservative routes

      • Cord compression with or without myelopathy

      • To obtain diagnosis if no other site for biopsy is available

      Surgical Procedure for Posterior Cervical Spine

      1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/other anticoagulants for at least 2 weeks for elective cases

      2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist

      3. Patient placed prone with Mayfield pins in neutral alignment on Jackson Table with all pressure points padded

      4. Neuromonitoring may be present to monitor nerves (if necessary and indicated)

      5. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed

      6. Make an incision over the vertebrae where laminectomy is to be performed

      7. Perform subperiosteal dissection of muscles bilaterally to expose the vertebra

      8. Once the bone is exposed, it is best to localize and verify the correct vertebra via X-ray or fluoroscopic imaging and

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