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Transforaminal endoscopic surgery under local analgesia for ventral epidural thoracic spinal tumor: Case report
Clinical Neurology and Neurosurgery 134 (2015) 1–3
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Case Report
Transforaminal endoscopic surgery under local analgesia for ventral epidural thoracic spinal tumor: Case report Albert E. Telfeian ∗ , David B. Choi, Daniel M. Aghion Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, USA
a r t i c l e
i n f o
Article history: Received 10 February 2015 Received in revised form 23 March 2015 Accepted 25 March 2015 Available online 4 April 2015 Keywords: Endoscopic Minimally invasive Transforaminal Thoracic spine Sarcoma
1. Introduction Operative management for ventral epidural spinal tumors typically involves either a costotransversectomy approach or, less frequently, a trans-thoracic approach that requires a corpectomy and fusion. Transforaminal endoscopic spine surgery has been reported for the treatment of lumbar herniated discs (including far lateral and extruded), lumbar spondylolisthesis, lumbar juxtafacet cysts, lumbar discitis and even in the treatment neuropathic pain caused by a T11 colon metastases [1–7]. We report here the first case of a ventral thoracic epidural spine tumor surgically treated with a complete endoscopic spinal procedure via the foramen in an awake patient. 2. Case report 2.1. History and clinical examinations A 16-year-old female patient presented 1 year ago with mid thoracic back pain, left posterior rib pain, and subjective lower extremity numbness. Magnetic resonance imaging (MRI) revealed a T6 ventral spinal lesion. She underwent a T4–7 laminectomy
∗ Corresponding author at: Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA. Tel.: +1 401 793 9132; fax: +1 401 444 2788. E-mail address: [email protected] (A.E. Telfeian). http://dx.doi.org/10.1016/j.clineuro.2015.03.022 0303-8467/© 2015 Elsevier B.V. All rights reserved.
and costotransversectomy, and despite a gross total resection, pathological review at multiple academic centers only yielded the diagnosis of malignant lesion (not otherwise specified). The patient underwent radiation treatment 3 months postoperatively when surveillance MRI indicated recurrence. At 1 year post-resection, surveillance MRI indicated significant recurrence in the ventral epidural space from T2 to T8 with moderate spinal cord compression at T6. Spinal tap, PET imaging, and bone marrow biopsy did not yield additional information. 2.2. Radiological findings Thoracic MRI performed at original admission (Fig. 1A and B) confirmed the presence of the T6 ventral epidural spinal lesion and its gross total resection. Thoracic MRI performed 1 year after laminectomy and costotransversectomy demonstrates the epidural extent of the now T2–T8 lesion and its compression of the spinal cord at the level of the T6 pedicle (Fig. 2A and B). 2.3. Operation and postoperative course Given the MRI demonstrated tumor progression (despite radiation treatment) and the need for definitive pathologic diagnosis, the decision to proceed with repeat surgery was made: the patient was offered the option of a transforaminal endoscopic biopsy and partial resection. The procedure was performed with the patient awake, in the prone position, on a Jackson table on hip and chest bolsters (Fig. 1G). Anesthesia consisted of mild sedation using
2
A.E. Telfeian et al. / Clinical Neurology and Neurosurgery 134 (2015) 1–3
Fig. 1. Preoperative sagittal T1 MRI thoracic spine with gadolinium (left) demonstrating ventral extradural mass at T5–6. Postoperative sagittal T1 MRI thoracic spine with gadolinium (right) showing decompression of the spinal cord.
Fig. 2. (A) Sagittal T1 MRI with gadolinium of the thoracic spine demonstrating recurrence of the ventral extradural tumor. (B) Axial T2 MRI with gadolinium showing preoperative planning for spinal needle trajectory for transforaminal approach. (C) Intraoperative AP fluoroscopic image demonstrating passage of spinal needle into the left T5–6 neural foramen. (D) Intraoperative AP fluoroscopy showing reeming of the superior articular process. (E) Intraoperative AP fluoroscopic image showing working channel within the left T5–6 neural foramen, along with ball probe passed to confirm position of T6 pedicle. (F) Intraoperative AP fluoroscopy confirms position of malleable curved grasping forcep. (G) Patient positioned prone with working channel 5 cm lateral to midline and communicating author shown manipulating bendable grasper in working channel. (H) Intraoperative endoscopic view with ball probe pushing on the dorsal aspect of the tumor capsule. (I) Intraoperative endoscopic view demonstrating the bendable grasper reaching inside the tumor capsule.
A.E. Telfeian et al. / Clinical Neurology and Neurosurgery 134 (2015) 1–3
midazolam and fentanyl and 1% lidocaine local anesthetic. Entry was established at the T5–6 foramen entering through a 5 mm skin incision 5 cm lateral to the midline. Using anteroposterior (AP) and lateral fluoroscopy, a 25 cm 18-gauge needle was placed in the left T5–6 neural foramen, just docking at the floor of the foramen on the lateral view and at the midpoint of the T6 pedicle on the AP view (Fig. 2C). This ensured that the needle was not in the central spinal canal. After fluoroscopy confirmed needle docking at the left T5–6 neural foramen adjacent to the T6 pedicle, the spinal needle stylet was removed and a K-wire was placed into the needle. The approach is essentially a Seldinger approach using a flexible wire and sequential dilators to first, establish access to the foramen, and, second, enlarge the foramen with sequential reemers by removing a portion of the ventral aspect of the superior articulating process of T6 and the superior edge of the T6 pedicle to gain better visualization of the ventral epidural space (Fig. 2D). A 7.5 mm beveled cannula was then placed through the 5 mm incision and a 30◦ endoscope with a 2.7 mm working channel was inserted into the working sleeve; a probe confirmed the position of the T6 pedicle (Fig. 2E). The tumor tissue was visualized elevating the thecal sac dorsally (Fig. 2H). Fixed and malleable grasping forceps were used to remove fragments of tumor for decompression and histologic analysis (Fig. 2F, G and I). Intra-operative evaluation of the frozen specimen confirmed pathologic tissue, and the working channel was removed, and the wound was closed with a single 4-0 Monocryl suture and overlying DermabondTM . The procedure lasted a total of 1 h and 17 min, and blood loss was minimal. Postoperatively, the patient was able to ambulate without difficulty, and she was discharged on postoperative day 1. Pathology confirmed the diagnosis of Ewings sarcoma and the patient began chemotherapy according to standard Ewing sarcoma treatment. 3. Discussion Here we present the first case reported in the literature of a working channel endoscope used exclusively for the biopsy/resection of a ventral thoracic epidural spinal lesion. A Medline search of the term “endoscopic spine surgery” yields 120 references in 2014, 84 references in 2004, and 36 references in 1994: approaching spinal pathologies using endoscopic technologies certainly appears to be a growing trend. When anatomic favorable conditions exist, such as pathology situated in or adjacent to the neural foramen, a transforaminal endoscopic approach offers a minimally invasive approach that does not require general anesthesia. In the case presented, had the senior author opted for a more open surgical approach (the use of a minimally invasive tubular retractor system with pathology visualized through a
3
microscope), somatosensory evoked potentials would have been used for the case. With an endoscopic approach, the patient can report to the surgeon the sensations of pain and numbness as well as cooperate in motor testing during the procedure. The equipment today available to the spinal endoscopist includes: high definition visualization, multiple configuration graspers, probes, bipolar cautery, reemers, dissectors, drills, chisels, and thrombotic injectable agents. There are several obstacles to consider in approaching a tumor through an endoscopic approach. First, if the tumor is firm, ultrasonic aspiration is not yet available for endoscopic approaches. Second, targeting in the approach puts the surgeon in or on the tumor; the surgeon does not have the perspective of what is happening to the spinal cord when the tumor is manipulated. Third, if uncontrollable bleeding were to ensue or if there were a significant change in the patient’s neurologic exam, the patient is awake and prone, and the time to put the patient under general anesthesia and perform an open surgical approach could lead to permanent neurologic damage. These obstacles to endoscopic tumor surgery need to be considered and weighed against the obvious benefits of an extremely minimally invasive approach. 4. Conclusion Endoscopic biopsy/resection of a ventral spinal canal lesion through the neural foramen could represent a feasible and safe procedure for the prompt pathological identification of tumor tissue in a minimally invasive manner. References [1] Fu TS, Chen LH, Chen WJ. Minimally invasive percutaneous endoscopic discectomy and drainage for infectious spondylodiscitis. Biomed J 2013;36(4): 168–74. [2] Jasper GP, Francisco GM, Aghion D, Telfeian AE. Technical considerations in transforaminal endoscopic discectomy with foraminoplasty for the treatment of spondylolisthesis: case report. Clin Neurol Neurosurg 2014;119:84–7. [3] Jasper GP, Francisco GM, Telfeian AE. Endoscopic transforaminal discectomy for an extruded lumbar disc herniation. Pain Physician 2013;16(1):E31–5. [4] Jasper GP, Francisco GM, Telfeian AE. Transforaminal endoscopic discectomy with foraminoplasty for the treatment of spondylolisthesis. Pain Physician 2014;17(6):E703–8. [5] Joo YC, Ok WK, Baik SH, Kim HJ, Kwon OS, Kim KH. Removal of a vertebral metastatic tumor compressing the spinal nerve roots via a single-port, transforaminal, endoscopic approach under monitored anesthesia care. Pain Physician 2012;15:297–302. [6] Komp M, Hahn P, Ozdemir S, Merk H, Kasch R, Godolias G, et al. Operation of lumbar zygoapophyseal joint cysts using a full-endoscopic interlaminar and transforaminal approach: prospective 2-year results of 74 patients. Surg Innov 2014;21(6):605–14. [7] Liao Z, Chen W, Wang CH. Transforaminal percutaneous endoscopic surgery for far lateral lumbar intervertebral disk herniation. Orthopedics 2014;37:717–27.
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Case Report
Transforaminal endoscopic surgery under local analgesia for ventral epidural thoracic spinal tumor: Case report Albert E. Telfeian ∗ , David B. Choi, Daniel M. Aghion Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, USA
a r t i c l e
i n f o
Article history: Received 10 February 2015 Received in revised form 23 March 2015 Accepted 25 March 2015 Available online 4 April 2015 Keywords: Endoscopic Minimally invasive Transforaminal Thoracic spine Sarcoma
1. Introduction Operative management for ventral epidural spinal tumors typically involves either a costotransversectomy approach or, less frequently, a trans-thoracic approach that requires a corpectomy and fusion. Transforaminal endoscopic spine surgery has been reported for the treatment of lumbar herniated discs (including far lateral and extruded), lumbar spondylolisthesis, lumbar juxtafacet cysts, lumbar discitis and even in the treatment neuropathic pain caused by a T11 colon metastases [1–7]. We report here the first case of a ventral thoracic epidural spine tumor surgically treated with a complete endoscopic spinal procedure via the foramen in an awake patient. 2. Case report 2.1. History and clinical examinations A 16-year-old female patient presented 1 year ago with mid thoracic back pain, left posterior rib pain, and subjective lower extremity numbness. Magnetic resonance imaging (MRI) revealed a T6 ventral spinal lesion. She underwent a T4–7 laminectomy
∗ Corresponding author at: Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA. Tel.: +1 401 793 9132; fax: +1 401 444 2788. E-mail address: [email protected] (A.E. Telfeian). http://dx.doi.org/10.1016/j.clineuro.2015.03.022 0303-8467/© 2015 Elsevier B.V. All rights reserved.
and costotransversectomy, and despite a gross total resection, pathological review at multiple academic centers only yielded the diagnosis of malignant lesion (not otherwise specified). The patient underwent radiation treatment 3 months postoperatively when surveillance MRI indicated recurrence. At 1 year post-resection, surveillance MRI indicated significant recurrence in the ventral epidural space from T2 to T8 with moderate spinal cord compression at T6. Spinal tap, PET imaging, and bone marrow biopsy did not yield additional information. 2.2. Radiological findings Thoracic MRI performed at original admission (Fig. 1A and B) confirmed the presence of the T6 ventral epidural spinal lesion and its gross total resection. Thoracic MRI performed 1 year after laminectomy and costotransversectomy demonstrates the epidural extent of the now T2–T8 lesion and its compression of the spinal cord at the level of the T6 pedicle (Fig. 2A and B). 2.3. Operation and postoperative course Given the MRI demonstrated tumor progression (despite radiation treatment) and the need for definitive pathologic diagnosis, the decision to proceed with repeat surgery was made: the patient was offered the option of a transforaminal endoscopic biopsy and partial resection. The procedure was performed with the patient awake, in the prone position, on a Jackson table on hip and chest bolsters (Fig. 1G). Anesthesia consisted of mild sedation using
2
A.E. Telfeian et al. / Clinical Neurology and Neurosurgery 134 (2015) 1–3
Fig. 1. Preoperative sagittal T1 MRI thoracic spine with gadolinium (left) demonstrating ventral extradural mass at T5–6. Postoperative sagittal T1 MRI thoracic spine with gadolinium (right) showing decompression of the spinal cord.
Fig. 2. (A) Sagittal T1 MRI with gadolinium of the thoracic spine demonstrating recurrence of the ventral extradural tumor. (B) Axial T2 MRI with gadolinium showing preoperative planning for spinal needle trajectory for transforaminal approach. (C) Intraoperative AP fluoroscopic image demonstrating passage of spinal needle into the left T5–6 neural foramen. (D) Intraoperative AP fluoroscopy showing reeming of the superior articular process. (E) Intraoperative AP fluoroscopic image showing working channel within the left T5–6 neural foramen, along with ball probe passed to confirm position of T6 pedicle. (F) Intraoperative AP fluoroscopy confirms position of malleable curved grasping forcep. (G) Patient positioned prone with working channel 5 cm lateral to midline and communicating author shown manipulating bendable grasper in working channel. (H) Intraoperative endoscopic view with ball probe pushing on the dorsal aspect of the tumor capsule. (I) Intraoperative endoscopic view demonstrating the bendable grasper reaching inside the tumor capsule.
A.E. Telfeian et al. / Clinical Neurology and Neurosurgery 134 (2015) 1–3
midazolam and fentanyl and 1% lidocaine local anesthetic. Entry was established at the T5–6 foramen entering through a 5 mm skin incision 5 cm lateral to the midline. Using anteroposterior (AP) and lateral fluoroscopy, a 25 cm 18-gauge needle was placed in the left T5–6 neural foramen, just docking at the floor of the foramen on the lateral view and at the midpoint of the T6 pedicle on the AP view (Fig. 2C). This ensured that the needle was not in the central spinal canal. After fluoroscopy confirmed needle docking at the left T5–6 neural foramen adjacent to the T6 pedicle, the spinal needle stylet was removed and a K-wire was placed into the needle. The approach is essentially a Seldinger approach using a flexible wire and sequential dilators to first, establish access to the foramen, and, second, enlarge the foramen with sequential reemers by removing a portion of the ventral aspect of the superior articulating process of T6 and the superior edge of the T6 pedicle to gain better visualization of the ventral epidural space (Fig. 2D). A 7.5 mm beveled cannula was then placed through the 5 mm incision and a 30◦ endoscope with a 2.7 mm working channel was inserted into the working sleeve; a probe confirmed the position of the T6 pedicle (Fig. 2E). The tumor tissue was visualized elevating the thecal sac dorsally (Fig. 2H). Fixed and malleable grasping forceps were used to remove fragments of tumor for decompression and histologic analysis (Fig. 2F, G and I). Intra-operative evaluation of the frozen specimen confirmed pathologic tissue, and the working channel was removed, and the wound was closed with a single 4-0 Monocryl suture and overlying DermabondTM . The procedure lasted a total of 1 h and 17 min, and blood loss was minimal. Postoperatively, the patient was able to ambulate without difficulty, and she was discharged on postoperative day 1. Pathology confirmed the diagnosis of Ewings sarcoma and the patient began chemotherapy according to standard Ewing sarcoma treatment. 3. Discussion Here we present the first case reported in the literature of a working channel endoscope used exclusively for the biopsy/resection of a ventral thoracic epidural spinal lesion. A Medline search of the term “endoscopic spine surgery” yields 120 references in 2014, 84 references in 2004, and 36 references in 1994: approaching spinal pathologies using endoscopic technologies certainly appears to be a growing trend. When anatomic favorable conditions exist, such as pathology situated in or adjacent to the neural foramen, a transforaminal endoscopic approach offers a minimally invasive approach that does not require general anesthesia. In the case presented, had the senior author opted for a more open surgical approach (the use of a minimally invasive tubular retractor system with pathology visualized through a
3
microscope), somatosensory evoked potentials would have been used for the case. With an endoscopic approach, the patient can report to the surgeon the sensations of pain and numbness as well as cooperate in motor testing during the procedure. The equipment today available to the spinal endoscopist includes: high definition visualization, multiple configuration graspers, probes, bipolar cautery, reemers, dissectors, drills, chisels, and thrombotic injectable agents. There are several obstacles to consider in approaching a tumor through an endoscopic approach. First, if the tumor is firm, ultrasonic aspiration is not yet available for endoscopic approaches. Second, targeting in the approach puts the surgeon in or on the tumor; the surgeon does not have the perspective of what is happening to the spinal cord when the tumor is manipulated. Third, if uncontrollable bleeding were to ensue or if there were a significant change in the patient’s neurologic exam, the patient is awake and prone, and the time to put the patient under general anesthesia and perform an open surgical approach could lead to permanent neurologic damage. These obstacles to endoscopic tumor surgery need to be considered and weighed against the obvious benefits of an extremely minimally invasive approach. 4. Conclusion Endoscopic biopsy/resection of a ventral spinal canal lesion through the neural foramen could represent a feasible and safe procedure for the prompt pathological identification of tumor tissue in a minimally invasive manner. References [1] Fu TS, Chen LH, Chen WJ. Minimally invasive percutaneous endoscopic discectomy and drainage for infectious spondylodiscitis. Biomed J 2013;36(4): 168–74. [2] Jasper GP, Francisco GM, Aghion D, Telfeian AE. Technical considerations in transforaminal endoscopic discectomy with foraminoplasty for the treatment of spondylolisthesis: case report. Clin Neurol Neurosurg 2014;119:84–7. [3] Jasper GP, Francisco GM, Telfeian AE. Endoscopic transforaminal discectomy for an extruded lumbar disc herniation. Pain Physician 2013;16(1):E31–5. [4] Jasper GP, Francisco GM, Telfeian AE. Transforaminal endoscopic discectomy with foraminoplasty for the treatment of spondylolisthesis. Pain Physician 2014;17(6):E703–8. [5] Joo YC, Ok WK, Baik SH, Kim HJ, Kwon OS, Kim KH. Removal of a vertebral metastatic tumor compressing the spinal nerve roots via a single-port, transforaminal, endoscopic approach under monitored anesthesia care. Pain Physician 2012;15:297–302. [6] Komp M, Hahn P, Ozdemir S, Merk H, Kasch R, Godolias G, et al. Operation of lumbar zygoapophyseal joint cysts using a full-endoscopic interlaminar and transforaminal approach: prospective 2-year results of 74 patients. Surg Innov 2014;21(6):605–14. [7] Liao Z, Chen W, Wang CH. Transforaminal percutaneous endoscopic surgery for far lateral lumbar intervertebral disk herniation. Orthopedics 2014;37:717–27.