Principles of Intradural Spine Surgery

129 Principles of Intradural Spine SurgeryTanvir F. Choudhri and Paul C. McCormick

♦ Preoperative

Imaging

  • Magnetic resonance imaging (MRI) with or without contrast
    • Establishes rostrocaudal extent of lesion and relationship to cord
    • Helps with axial plane location
    • Presence of cystic caps may suggest ependymoma
    • May show additional lesions (e.g., tumor or syrinx) elsewhere
  • Computed tomography: can show spinal dysraphism
    • May show calcification of pathology
    • Can give idea of bone quality
    • Helpful if instrumentation may be needed
  • Myelography
    • Gives basic localization of pathology
    • With delayed views can give idea of CSF flow, syrinx uptake
    • Helpful if patient cannot have MRI (e.g., pacemaker)
    • Does not show intramedullary details
    • May have risk if complete block; consider C1-2 puncture

Equipment

♦ Intraoperative

Anesthesia

  • General anesthesia, attention to monitoring
  • Dexamethasone 10 mg intravenous at start of case

Positioning/Approach

  • Prone position (generally have operative area flat and at the highest point)
  • Posterior midline incision
  • Wide laminectomy generally used
  • Midline dural opening
  • Dural retracting sutures (e.g., 4–0 Nurolon)
  • Arachnoid dissection

Intradural Procedure

  • Dictated by pathology, operative goals

Closure

  • Watertight dural closure (with dural patch where needed)
  • Test dural closure with intraoperative Valsalva challenge
  • The author generally minimizes use of subfascial surgical drains as they potentially could promote CSF leak but recognizes that there is disagreement on this topic
  • Consider a layer of muscle sutures to reduce dead-space
  • Meticulous fascial closure (e.g., 0 Vicryl)
  • Running locked skin suture (e.g., 3–0 nylon)
  • Consider intraoperative spinal drain with high dural leak risk

♦ Postoperative

  • Rapid steroid taper if neurologically unchanged
  • Perioperative antibiotics
  • Bed rest for 48 hour (e.g., head of bed 0 to 15 degrees for 24 hours, 0 to 30 degrees for 24 hours, then mobilize; perhaps can accelerate for cervical levels)

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Jul 11, 2016 | Posted by in NEUROSURGERY | Comments Off on Principles of Intradural Spine Surgery

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