•.~

SURGICAL TREATMENT OF CORD DISEASE

L11'1~dfl~fln~~nl1lnu spinal cord 'l::V1ul~u<lun~1t1.l' i~l;acranial ~J1n L~I'l:;~'l1.llJ1nL\fl'l

~d<l~tJnt1.l spinal cord lJm:;~i:I'U benign ~~11i1~'l1n intracranial tumor LLI'l:;lJn'l:;lJ1LLI'l1ll~iII'lU

<I1n11~fl~ compression lJ1nn~1 <I1n11'l1<1~invasion

L11LLti~'hfl'lltN spinal canallPiLi:J1.l 3 nfjlJt~qi1 ~<1

1. Extradural YtUUliU1::lJ1ru 55% (ED) lJn'l:;lJ1'l1n vertebral bodies ~1<1epidural

tissue

2. Intradural extramedullary (ID-EM) Yiultlru1:;lJ1ru 40% lJn'l::lJ1'l1n. ..

leptomeninges ~1<1neNe roots

3. Intramedullary spinal cord tumor (IMSGT) Viuli11u1:;lJ1ru 5%

~1n,r~~::~,n1r~~~~t'UL1fl-k~ 3 nfjl-l ,r1.llJn"l:;lJ1YtULLVilltlclf'lu<}1 n11~ Lii11I'l1nl'l1I11.l~i1'~~nnCIILU[J1IILt'ltu'itl1.l

Lntl~~tl m i:l1.l~'l1.ll-l1n "l :;jjtJ1~ L1f1Lvh,ru~ Lii1'1<11n11'l ~n'hfl,rul U~11'l1m~1.lU1:;1'l1V1~1fll 'lJ1I1.l

~ i1'~LI1IU111N ~~,r1.lnfjlJ L1f1Lmh~'l :;LLUn'l1 nn1.l1~[J1nLI1IU<I1~Ufl1 n11LYlu~fl!.h~ L~fJ'l ~~.hd:J1.l, , •...

iIi<l~t o!f n11m'l "ll'l<lu<I!h~ ~1.li'll-l ~'l [J LLI1i'l:;jjn fj l-Itl1 n11V1~ 1A'f1J1iI~i:l.-,., ..J ~..J

1. Pain : L1J1.lfl1n11V1l-11YtULLYiVlUlJ1n'lli'j11\

: radicular pain .••::;tht1l).J,n~ut')")lilvalsalva maneuver LLn::spine

movement "l:;Li:l1.li\'nl;"ru:;fl1n11'!J<I~ extradural lesion

: local, stiff neck or back t'hjj'1l1n11U'll1lt1.lvh recumbency ("nocturnal

pain") t,"l'l~lu spinal canal tumor

: medullary pain 'l:;i:lli'n,;-ru:; oppressive, burning, dysesthetic non

radicular, often bilateral, unaffected by valsava maneuver

2. Motor disturbances. ",no rj ."'-

: weakness IS 2 or 3 most common complaint LL~:;lJn'l:;l-ItJ1n11

1II1l-1~li'~sensory symptoms•••. 11'.

: LliinlJn"l:;l-I1i1bU'1I1n11 gait disturbances

.....-~

2

: tl1n1r"DfJ~central cord syndrome 't1XM6EJlesion "I::'!I~~ IMSCT

: Ll'ltJ"l::JJ'!l1n1rupper extremities '1i'1lULLNmnn'hlower extremitia

decreased DTR, dissociative anesthesia

: long tract involvement -.. clumsiness and ataxia

: atrophy, musele twitches, fasciculations

3. Non painful sensory disturbances

: dissociated sensory loss L1UBrown - Sequard Syndrome, central

cord syndrome

: paresthesia L1Uradicular ",i"1l medullary distribution

4. Sphincter disturbances

: usually urogenital (anal less common) L'IlUdifficulty evacuating,

retention urine, Incontinence and impotence

5. Miscellaneous Symptoms

; scoliosis or torticolis

: sub arachnoid hemorrhage

: visibie mass over spine

Diagnostic studies

I. Pain radiographs : H'~vertebral body destruction enlarged intervertebral

••foramen ",r'!l Increases interpedicular distance suggests ED SCT

II. Lumbar puncture : L~'1l\l1CSF ttJlllr1"11(l"'1'YltJ1~I'lI11'r'1U1~'1lt11~t'"L'I!Uprotein

\1~'r'IU11LlIUIMSCT 'lJli1~95% LLl'l::glucose ri~n"l::tJniiitJnL.j'u'tun~~

meningeal tumor• ..,J • ~ ,., X

1. FroJnssyndrome : L~fJ'Yl1valsava maneuver LLI'l1pressure UJ\1~'IIU.• ~ ,., X

2. Queckenstedts test L;.J'1ln£;ljuqular vein LLft1presssure UJ\1~'IIU

3. Barrier to flow of myelographic contrast media

III Myelography L~'il~1IIcontrast media LolhhJ'tuspinal canal "::L~U'lJiIii'~U.•

1. 1M SCT "l::LiiuLi'h.l~n~tu:: fusiform widening

. .

3

2. ID.EM "I::LililLUU capping effect with a sharp cutoff

3. ED "I::LiluLUU hourglass deformity t'hd'lulncomplete block1 ih complete'

block "~I\lUIl'lUpaintbrush "ffect

IV CT scan

V MRI L-li\UU••.•inLumr7iU"I'i!lJtrFl'll'lN spine

VI Spinal angiography: rarely indicated "I::'t.;nunnll?\~~lJ AVM ••.•rtl

hemangioblastoma

LU~~"I::mh1 Ci~t1Fl'l1tl~spinal canal ~L~lJ1~'ll~LL!\::Vjl.J'lil\'tu~l'llJnmJ"I11~r::1.J1.J

t]1::1\1"11Lvi1,rU

1. Extradural lesion (ED)

1.1 Spinal epidural metastases

: HI\~~lJ~1"1::LU1..Itumor LUFlUH back pain ~ persists in recumbency

: Vjl.J'l~10% 'l1tl~all cancer patients LLI'l::LUUmost common 'IItl~ spinal tumor

: 80% 'IItl~ primary site "I::~1"11n lung, breast, GI, prostate, melanoma LL!\::

lymphoma, ~'II1lJci1U~1n"1::~1"11nprostate gland ~••.•t\l~l!n"l:::~1"11n CA

breast

: mrl"m,n'W1t1i prolong sssurvival LLI1i"l::l'lilltl1mr pain LL!\::neurologic deficit

: Routes of metastasis, arterial venous spinal epidural vein (Batson's plexus)

LLI'l::direct spread

: the most common site is thoracic spine (50-60%)

: tii1LL••.•l.i~~1U~1n"l::~tJ~ epidural ci1U intradural V'l1.J1~2-4 % intramedullary

Vjl.J~1.2%

'.11n11 : Pain ~1.J1t1ititllJ~l'lillCi~95% '1I1"1"1::d'l1..lIlmtru::focal, radicular or referred 'll1n1r pain

pain "i:::LUU~1n~u uitl movement, recumbency (classic finding), neck-flexion,

straight -leg-raising, coughing sneezing or straining

: cord involvement develops, leg stiffness or weakness, paresthesias, autonomic

disturbances (urinary urgency, constipation, impotence)

4

m11n~, ,!11I111::i'l~Pl"t,.n11fnl;1spinal melastasis ;}tllj'EJ~n"h1:l1Yi"'HU11n L"J!,.

paraplegia, quadriplegia ~'i::Liil1l"l1mJ::~r~n",,ju'l'JI~"~fl~

'wAn'lum11n~,

1. 'l'JI~,.~i~!T~hiLiiIJ~~1~

tl1V111U'JIill1i'JI'EJ~~::Ii'~tl1LU"'IIill1l chemosensitive t-.\' chemotherapy \\!Jit'h

tumor '~\4\iJU'JIill1lradio and chemoiesistant 1111::metastasis ~'WVl11U'lJ

'JIill1lcell type f'I'l1";1e.hllT",

2. h~"~~~lii!J\\~1~1J1~~1'"

n111nl;1 ili'EJdecompressive excision laminectomy LIll~1I11~i/(~!J

radiotherapy ~1'EJchemotherapy 1II1~'IIill1l'!J'EJ~~::Li'~

3. h~u~i~liitJ\\~1~tl1ltJ~"I:n~

'lun~~e\-l~'~'IIfJ~ 'l'IIi.••\\i~'l~mfJn'i'l~\.Iti n n111nl;1 ItJ\.I~11liIYlIJ~'Il111,•

mn11Ivh\!"n11t-.\' radiotherapy ~1'iJchemotherapy "l::"J!1IJMlmn1nhl1l, .... ,... . . .

11ft::11l'ln1m ti1n1::'i'tJ'!I £J~~::IH 'lI~'i::'Vl1t.J1III111excIsion laminectomy

1'il,((1::t,.ntJ~'l~Vl111Jprimary site 111\::cell type Lvh~,.

2. Spinal epidural hematoma

'Il'LW'l

2.1 traumatic 1'Ii,.spine injury 1il1~~~~LP \-I1'EJepidural anesthesia tI1lIJlJn"l::

..,~n\.l5ri1.J1111;;1coaqulopathls ~'~1~'Iiuantlcoaqulated thrombocytopenia

2.2 spontaneous I'I!•••hemorshage 'i,n spinal AVM ~1'EJvetebra; hemangioma

il1n11 : severe back pain with radicular component

: spinal neurologic deficits and progessed~

n171n~1 : immediated decompressive laminectomy and removed hematoma

3. Spinal epidural abscess•• •• • 'l'..I.. .: fl11Untl~ ~"'1'I'"'II'11~'EJ1n11back pam, fever 1111::spine tenderness

: major risk factors; diabetes, IV drug abuse, chronic renal failure, alcoholism, ..l

: Thoracic level tiu'ltlimnliql1ltJ1::1-J1tU 50% HI~iN~1ti1.JVllumbar (35%),

cervical (15%)

-..,

\

5.I~ .I

: 82% YltJ abscess Vl11I1\1 posterior, 18 % YltJYl anterior

'il101'i : fever, weats or rigors are common

: furuncle (skin boil) YlUUi15%

: pain localized over spine, tender to percussion. radicular distension.

weakness progressing to para and quadriplegia

: f:::tJ:::L~fl1'[l1Im'!l~tJ\l11'~"l1nile1011back pain U6~ 31'\4 ~hi\\'ilmn11 root•.•..•. ".-1 •..

symptoms: 4.5 'lU \lfl~'l1n~ root pain LLfl~"l:::~mn11weakness LLfl:::24 'lI~. \lfl~'110

ile1011 weakness LL~~"l:::Lijuparaplegia

Source of infection,~ .I ~ .••

1. Hematogenous spread ~u \11I~1n'rlql1l\illtJ'!l1'l'l:::~source ~1"l1n skin

Infection (most common). parenteral injection. bacterial endocarditis.

UTI. respiratory infection pharyngeal or dental

2. Direct extension from, decubitus ulcer, psoas abscess. penetrating

Trauma. pharyngeal infections, mediasiinitis; pyelonephritis with

perinephric abscess

3. Following spinal proceudre

Organism

1. Staph aureus: the most common

2. Aerobic and anaerobic streptococcus; second most common~ .

3. '!l\41 L'IlU E. coli. Pseudomonas areuginosa. diplococcus pneumoniac.

seratia marcescens

: ,lhLi:I\4 chronic infection TB is most common

: multiple organism 'l'Iuli1i' 10%

Diagnostic test

: CBC; leukocytosis

: ESR; elevated in most, usually> 30

: lP; CSF protein and WBC usually elevated, glucose normal

Radiographic studies

6

Plain films, usually normal L-i'uLLIIi~1'l::i:if11'l::osteomyelitis

MRI; imaging study of choice

. Myelogram and CT scan

Treatment

Surgical evacuation combined with antibiotics

Indication for nonsurgical management

1. Prohibitive operative risk factors

2. Involvement of an extensive length of the spinal canal

3. Complete paralysis for> 3 days

4. Absence of significant neurological deficit (controversial)

2. Intradural extramedullary tumor

2.1 Meningiomal'I J' oJ - .1- -: L1JULU'!l~'iln'/lLnln'l1narachnoid cell '/IllIIlIn1Jdura

: ~ulu~~ni~~1nn~1~'.II1U. ." . .- ..: YiUl.m'lru thoracid ~1n'/l~ill

: tl1n1~L1il1lCol1nrl'iJuhJn illLii[J1nhlu~~~

: n1~fnl;'1~1 laminectomy LLlI'ltJilldura L;hhh'iJ1 tumor '!I'iln

2.2 Neurilemmomal'I J' .1 _ .I '0

: L1JULU'iJ~'!ln'IJ'iJ~11n1J~::1'I1'/1~n"l::~lJ'/Idorsal sensory nerve root LLlJIn'!l19.I ~.!'.. _ • ~.!'~

YilJVIventral motor nerve root wlL~~'!lUnU LLIllYilJWI'U'!lU

: lJn'l::YilJ~ cervical LLi\::lumbar region 1';;~1nn~1~ thoracic

: \lcY~'.II1tJ~lJl@iYitJ1riu~.!' J' •• "oJ ~. I.J ~.., - .: t1111'iJ'UL'UtJ~'!ImJ'lIU11nmC1JUU'iJ'!InL1JU'!ln-D'!l~nr::c:lnL'!I•.•'U~i\~ plain pllm 'I::

dlu intervertebral foramen i:i'llu1",1~rU LLi\::n1~1CT ~1tJ1 MRI9::LMUr1'!lU

..- .. '" -~i\n1jru:: dum-bell '.II~L1JUi\n1jru::L'llYi1::

: n1~fnl;'1Yi1 laminectomy ~1~InLtJilldura LLlI'lL'iJ1tumor '!l'!ln

. "

7

3.lntramedullary spinal cord tumor

3,1 Ependymoma

: the most common qlioma of lower cord, conus and film terminate

: WU1tJ'II1fJlJ1nn~'mqj-l lfin1JtJfJ

: wUlJ1n1tJ'rl'l~tJ1'1 20-60 tJ: lJ1nn~1 50% YiU~ filum terminale ~'1l-lIl~lJ1YiU~ceNical cord

: 'lItJUI'll111'11tJ-l~~tJ~'1lmlun1ilfil1lL"ltJ"l1n1'IIltJ'I-l'ii~•

n1'l,n'l!l1 n1~ej1~l1Itl1luHnfttJ-l microscope "l::'ji'lu1,x11l1::n'!ltJL\ltJ~tJn

'!l'!ln1~'I-llJ111tl1lfJ1l.hi1ti'tJ111~1UoitJ1'IIl tJ'I-li-l lloilh1lJ1'l1lJ1~nL'!l1n'!ltJ~~tJ-l'11n

tltlnUi'l-llJl1In1,xradiation therapy 1II1lJ

3.2 Astrocy1oma

: WU1tJ'lI1UlJ1nn~1'1-lqj-l 1.5:1

: YiUlJ1n1tJ'Ii'l-ltl1'1 20-50 n: ralio of benign: malignant = 3-1

••: thoracic Is most common site ~'!l~II-llJ1fltl ceNlcal':' .

n1'l,n'l!l1 ItJtJ-ltlnn~lJ;j 'll'!lUI'llI111l.ii'I1II"ltJ~-l1!tJ n1n.h~I1IR'l~";1• •

laminectomy";1 biopsy ItJ1:ntJl\l'1llJ1111~'l"lLI~'l1,xradiation therapy IiitJ

3.3 Dermoid 1111::Epidermoid tumor~ J' ..J":' ~,_

: lutJltJtJ~tln"'l~lJlJ1111~luJ1Ln1'1'I. • _ L<...l..J .

: YiUlJ1n ,tJll1InU~I'ln.llumbo - sacral tJtJEJlJ1n.,,"l::WU'"ceNICallJ.fl::

upper thoracic, g _ ..J.J

: YiUlJ1n ,tJIl1InU~L'ln.llumbo.sacral tJtlEJlJ1n.""l::YiU.,,ceNicai LII1::upper

thoracic

: 1'l1mIJlI~tl~11tJ'rl'l~3 ~~ 51i1l11l11.1Ilm~'1l~1tJflml~-lltltJ"Ii'l-l~ neural tube

ri1i~i1(/1IJ.~'liJ epithelium cell 1~111ltJ~'1~1tJLlft'lL"l1t'\JIJi'!llJ1Ijj'UI~'!l~tJn'•

: ll-l 2 'II'lI1ll!n"l::iJdermal sinus tract ~lJIlJitJriuskin

8

IV .1''' •...: flnl1ru~rJtl'\UJ'JI'!llH'DrIJ'DI1I~"l"':

Epidermoid "l~lJi/i'lU stratified squamous epithelium ~~fl~contents l11ui •••

"l~lh~ntllJi/i'lU keratin, cellular debris ~~fl::cholesterol

: Dermoid "l::lJiII'llJ stratified squamous epithelium ~~fl'l!i~lh::n'!llJil\'lU

dermal appendage organs ~'l!\lhair follicles ~~fl::sebaceous giands l'l'l'"

contents "l::~....,jj'!l'"epidermoid u.l'i,,::jj hair ~~fl::sebum iIl'lU

: '!l1n1: •••tln"l1 n'!l1n1:1'1ttl~hi •••'\olli~~nnl11."lJ~~fl'ltl1"ll-J1i/r'lU'!l1n1:'IItl~ ~~fl•

".\l-Jfll-J'MLLfl::1'lIi •••....,i\~~mfllJ-n11'till

m1rn~1 ~1~I1IL'!l1r'itl"'Ldtl~tlnfl'!lfln i~""'l-J111....,1flH1i1lm n~ql11

3.4 Syringomyelia

: Cystic cavitation of the spinal cord t'i'1~~J1~fl~~ brain stem "l::i1unn~1

syringobulbia

LL1j~1Ji2 type 'l'\olQJ1 ~fl

1. Communicating syringomyelia: primary dilatation of the

central canal LLfl::l!n"l ::il-J~"'€ rllJfl'l1l-JilD'ltlninlJ1L'l ru'llfl~

foramen magnum L'Ii•••

Chiari type I malformation basilar arachnoidits,~

basilar impression '\ol:t) Dandy Walker Syndrome

fl1n1: : Sensory loss suspended ("cape") sensory loss

: Cervical and occipital pain

: Lower motor neuron hand and arm weakness

Investigation

MRI LU•••1 test of choice l'l'l'" CT scan ....,r'!lmyelogram i~t1:::1lJ'!IU\(flU

Management

Surgical treatment: options include

1. posterior decompression, procedure of choice when posterior abnormaiier L'Ii•••chian

malformation

2. Shunt: peritoneum or subarachnoid space

9

3. Plugging the obex wilh muscle or telon

4. Syrlngostomy

5. Percutaneous aspiration of the cyst

II. non communicating syringomyelia fillf11')::~jj cyst '!!1,I'1ucord t"'!Jhi'lM,,'\tllllJ cenlral

canal ',ifll subarachnoid space tl'1tl1l19"l::jj ~1l'>1l1J"nntrauma lumor 'lire arachnoidlUs

Im:;d"l:;YllJ'lili' 0.3-3% 'lI'!!~fl1M~jj cord injury

'il1n1' : pain. numbness. increased motor deficit, Increased spasticity Increased

sweating (hyperhidrosis) (autonomic dysreflexla

Evaluation MRI LiJu test of choice

Management Medical (conservative) Yl1J1131% stable. 69% progressed

Surgical option ~::L",illlurllJ communlcaling syrlngomy clia

3.5 Spinal AVM

Liluf'l,)1~~",un ~,'!!~ \~u\i\,!!(i\um ru\'lI \\'u,"fl~~jj1J1\\1IIri1\il",ntl~ 'l~ \lju' 3 mliJ ~'!I..-1. Dural AVM ~1J'ltl(50-80 % ~1J1J1n\urJl"'cY~')umn"l::TilJ\u'l!'NfJ1!j1J1n

n11 40 iIil1",' Chronic progressive '!!19"l::i:Jacute deterioration 'lillI11,):; subarachnoid

11emorrhagehiftfltlYlti•• ,.J -' .J .•i/l1U\l.••~'YIY1lJrt,)U~1n"1:;YltI'YIthoracic m'l1 lhoracolumbar

'2. Perirnedullary AVM l'llJ'l~ 10-15 %. l'llJ'l6itlflulu'li,)~'lI1!j 20--40 n'\ •.• ",1

'inn1' rapid progressive neurological deficit T11,):: subarachnoid hemo(fhage 'VllJ~"lJ'N• I oJ ••• ~..J ..•l!I1\LVIU~'YIY1lJ~n"l::LuU"l1thoracic ""ll thoraolumbar

n1,fn~' surgical excision ,"1!l selective embolization

3. Inlramedullary AVM•.•.•ut'" 15.40 % nUUtlULU childhood ,,1n Young

abult

il1n" Lengthy progressive. improvement alternate with acute deterioration 111')::

subarachnoid hemorrhage ~lJ'lrJithJtJ

11i1L\'1nl~TilJLtIi'1J1L')Ncervical thoracic Uf\:: lur:nbar

n1,rn~1 surgical excision .,.i1'!!selective embolization