Minimally Invasive Resection of Ventral and Ventrolateral Intradural Extramedullary Spinal Lesions. Clinical Outcomes and the Addition of Image Merge Technique

Aims: Posterior translaminar approaches for resection of ventral and ventrolaterally placed intradural extramedullary lesions is challenging.

Minimally access surgery (MAS) with image guidance minimizes soft tissue morbidity, and may potentially facilitate tumor resection and lower complication rates for tumors ventral to the spinal cord. We present our results of MAS image guided surgery for intradural ventral and ventrolateral lesions resected through a paramedian oblique tubular MAS approach.

Methods: We included patients operated for intradural mass lesions with MAS technique from 2004 to 2016. Surgical results and complications were documented according to the type of MAS technique (image merged vs classic image guided).

Results: 54 patients operated using tubular techniques for intradural lesions, there were 12 ventrally located lesions. Mean age was 57 years (range 23–92), 6 males and 6 females.

Surgery was performed with fluoroscopic guided tubular MAS technique in 7 cases while 5 patients were treated using the IMTAR technique (Maduri et al 2016), both using a posterolateral oblique transmuscular trajectory. Bone removal was tailored to resection needs.

Mean blood loss was 253 mL. Minicostotrasversectomy was necessary in 3 patients, complete facetectomy in 3 patients and complete pediculectomy in 1 patient. Postoperatively, there were no neurological complication and no CSF fistula. 1 patient had wound infection.

2 patients with Schwannoma underwent deliberate nerve root sacrifice with expected postoperative radicular sensory loss.

GRT was achieved in 13 patients.

Mean FU was 24.8 months (1–60), only 1 patient presents myelopathy, 3 patients with dysesthesia controlled with medical treatment. Axial pain is present in 1 patient operated for a C2-C3 meningioma with no radiological signs of instability.

Conclusions: Translaminar approach for ventral intradural spinal tumors has been reported to have a 41.6% overall complication rate (25% of postoperative neurological deficit) and 1.5% of mortality (Mehta et al, 2013).

MAS facilitates surgical access to ventral and ventrolateral tumors with almost a 180° range of access. Furthermore, implementation of intraoperative image guidance allows customization of surgical trajectory, bone resection and tumor removal thus reducing the risk of neurological complication.

In the present series, the rate of overall complication and neurological aggravation is low despite the ventral location of the lesions.