132 Intramedullary Astrocytomas
Tanvir F. Choudhri and Paul C. McCormick

♦ Preoperative

• Typical
  
  
  
  
  • Standard spine equipment
    
  • Microinstruments
    
  • Microscissors
    
    
    
    
    • Microforceps
      
    • Microbipolar cautery
      
    • Microsurgical suction tubes
      
    • Microneedle drivers (Castroviejo)
  
  
• Operating microscope with bridge
  
• Consider having available
  
• Ultrasonic aspirator with small tip (for debulking larger lesions)
  
  
  
  • Intraoperative ultrasound (may be helpful for localization)
    
  • Lumbar drain kit (for cases with higher risk of dural leak)
    
  • Dural patch material (e.g., AlloDerm, suturable DuraGen)
    
  • Dural sealant (e.g., Tisseel, DuraSeal)
  
  
• Monitoring generally used
  
  
  
  
  • Somatosensory evoked potentials
    
  • Motor evoked potentials
    
  • Sphincter electromyography may be helpful for some lesions (e.g., conus)
  
  
• Preoperative marking
  
  
  
  
  • Consider using to aid intraoperative localization for areas that are harder to image intraoperatively (e.g., mid-thoracic)

♦ Intraoperative

Tumor Resection (Fig. 132.1)

• Identify dorsal midline by visualizing exiting nerve roots bilaterally (cord often rotated by tumor)
  
• Identify tumor: usually identifiable below dorsal pia; ultrasound may be helpful
  
• Longitudinal pial incision (typically midline but can be paramedian; e.g., for lateral tumors that come to surface)
  
• Place pial sutures (5–0 or 6–0 Prolene) and gently secure laterally
  
• Drain cyst, syrinx, hematoma (if present)
  
• Biopsy tumor (recognize frozen section may be nondiagnostic)
  
• Internal debulking, with ultrasonic aspirator where appropriate
  
• Vessels clearly supplying tumor may be cauterized.
  
• Ventral vessels should never be cauterized, use Avitene, Surgicel, Gelfoam, or Surgifoam
  
• Since astrocytomas typically have poor plane, attempting to define planes to achieve full resection may be unsafe

Closure

• Watertight dural closure (with dural patch where needed)
  
• Consider using Duragen and/or Duraseal to reduce chances of postoperative cerebrospinal fluid leak
  
• Test dural closure with intraoperative Valsalva challenge
  
• The author generally avoids subfascial surgical drains but recognizes that there is some disagreement on this topic
  
• Consider muscle sutures to reduce dead space
  
• Meticulous fascial closure

Fig. 132.1 Transverse and sagittal schematic of intramedullary spinal cord astrocytoma.

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