♦ Preoperative
Operative Planning
- Review imaging: magnetic resonance imaging is exam of choice, computed tomography myelogram optional
- Note location within the cord: thoracic location most common
- Identify ventral-to-dorsal and rostral-to-caudal extents of the lesion
- Consider preoperative fluoroscopic localization of level in thoracic lesions; otherwise, intraoperative radiographs are used to identify the correct level
Equipment
- Basic spine tray
- High-speed drill (Midas Rex with AM-8 bit)
- Operating microscope with bridge
- Ultrasonic aspiratory (optional)
Anesthetic Issues
- Arterial line for blood pressure monitoring optional
- Intravenous dexamethasone and cefazolin administration preoperatively
- In cases of severe cord compression, make sure blood pressure does not fall below baseline during induction to prevent ischemic cord injury
♦ Intraoperative
Positioning
- Patient prone with pressure points well padded
- Mayfield head fixation in cervical lesions
Posterior Cervical Approach
- For lesions of the cervical cord or cervicothoracic junction
- For lesions of the thoracic cord, cervicothoracic junction, or thoracolumbar junction
Posterior Lumbar Approach
- For lesions of the lumbar cord, thoracolumbar junction, or conus
Tumor Resection (Fig. 131.1)
- Standard laminectomy using one of the described approaches that exposes a level both above and below the tumor
- The dura is opened in the midline and epidural Cottonoids are placed longitudinally
- Arachnoid adhesions are dissected from the dura to allow the dura to be reflected laterally with 4–0 silk tack-up sutures to the muscle
- The operating microscope is then brought into the field
- The tumor is usually visible underneath the arachnoid
- If the meningioma is ventrally located, exposure is gained by the division of the dentate ligaments and, if necessary, dorsal rootlets
- The arachnoid is sharply divided and reflected to allow internal decompression of the tumor using either bipolar coagulation and suction or, if the tumor if the tumor consistency requires, a Cavitron ultrasonic aspirator.
- The plane between the tumor and spinal cord is then developed with progressive infolding of the tumor edges
- Circumferential dissection in the arachnoid plane is continued until the tumor capsule is delivered in its entirety
- Meticulous hemostasis is achieved
- Watertight closure of the dura is performed with a running 5–0 Prolene suture
- Consider using Duragen and/or Duraseal to reduce chances of postoperative cerebrospinal fluid (CSF) leak
- Careful, layered closure of the muscle, fascia, and subcutaneous tissue is performed
♦ Postoperative
- Quick steroid taper
- Antibiotics continued for 24 hours
- Patient is confined to bed rest for 24–48 hours and mobilized gradually
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