Management Of Spinal Tumors

poles. The rostral and caudal poles are the least voluminous and manipulation there may be dangerous to the normal tissue.

Intramedullary lipomas appear well demarcated from the adjacent spinal cord, but they are intimately adherent to the normal tissue. Therefore, total removal is impossible without incurring neurological deficits and should not be attempted. The microsurgical laser is the instrument of choice for debulking a spinal cord lipoma. The laser vaporizes fatty tissue without surgical trauma to the spinal cord. The debulk-ing of the lipoma may result in improvement of pain but rarely in improvement of neurological function. Further growth of a lipoma is unlikely or at least very slow. However, in adolescence, probably due to endocrine factors, lipomas of the cord may increase in size and may, at that time, cause progressive neurological dysfunction.

Following tumor removal, hemostasis is obtained with saline irrigation and local application of microfibrillar collagen (Avitene(r), C. R. Bard, Inc., 730 Central Avenue, Murray Hill, NJ). The dura is closed primarily in a watertight fashion. If an osteoplastic laminotomy was performed, the segments of bone are replaced and secured with a non-absorbable suture on each lamina bilaterally. One tissue layer must be closed in a cerebrospinal fluid (CSF)-tight fashion. The muscle and fascial closure must not be under tension. A subcutaneous drain is placed in large incisions, and particularly in re-operations, or when the patient had undergone prior radiation therapy. The skin is closed with running, locked sutures. Patients who have had previous surgery and received radiation therapy are at higher risk for wound dehiscence and CSF leak.

The resection of extramedullary tumors follows these same lines. The vast majority of them are tackled with a posterior approach. Dorsolateral approaches are rarely needed and anterior approaches are only required in the exceptional case. After laminectomy or lamino-tomy, adequate bony exposure and location of the lesion are assured with the intraoperative ultrasound. Depending upon their individual locations, schwannomas, meningiomas or myxopapillary ependymomas can be removed in toto. Large tumors, particularly when located ventrally or ventrolaterally, may require piecemeal resection. Firm texture of the tumor, particularly in meningiomas, requires use of the microsurgical laser. We have found the use of this instrument to be by far the safest way to resect firm tumor attached to the cord. Manipulation of a firm mass with forceps, scissors or the CUSA may cause significant injury to the cord. The dural attachment of menin-giomas need not be resected [11]; extensive coagulation of the dural layer after excision of the tumor bulk appears to be associated with the same small recurrence rate.

The most important strategy for the resection of completely intradural schwannomas is to sacrifice the nerve root that they are arising from. This greatly facilitates their resection and does not usually result in a significant neurological deficit.

In toto, resection of myxopapillary ependy-momas of the filum should be attempted whenever the tumor has not yet spread into the arachnoid space (Fig. 29.7). Only disseminated ependymomas need to be resected in a piecemeal fashion, mostly using bipolar and suction. In this situation, there is invariably some residual tumor tissue left on the pia or the nerve root epineurium.

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