2. intradural extramedullary (id-em) yiultlru1:;lj1ru 40% ... · 2.2 spontaneous...
TRANSCRIPT
•.~
SURGICAL TREATMENT OF CORD DISEASE
L11'1~dfl~fln~~nl1lnu spinal cord 'l::V1ul~u<lun~1t1.l' i~l;acranial ~J1n L~I'l:;~'l1.llJ1nL\fl'l
~d<l~tJnt1.l spinal cord lJm:;~i:I'U benign ~~11i1~'l1n intracranial tumor LLI'l:;lJn'l:;lJ1LLI'l1ll~iII'lU
<I1n11~fl~ compression lJ1nn~1 <I1n11'l1<1~invasion
L11LLti~'hfl'lltN spinal canallPiLi:J1.l 3 nfjlJt~qi1 ~<1
1. Extradural YtUUliU1::lJ1ru 55% (ED) lJn'l:;lJ1'l1n vertebral bodies ~1<1epidural
tissue
2. Intradural extramedullary (ID-EM) Yiultlru1:;lJ1ru 40% lJn'l::lJ1'l1n. ..
leptomeninges ~1<1neNe roots
3. Intramedullary spinal cord tumor (IMSGT) Viuli11u1:;lJ1ru 5%
~1n,r~~::~,n1r~~~~t'UL1fl-k~ 3 nfjl-l ,r1.llJn"l:;lJ1YtULLVilltlclf'lu<}1 n11~ Lii11I'l1nl'l1I11.l~i1'~~nnCIILU[J1IILt'ltu'itl1.l
Lntl~~tl m i:l1.l~'l1.ll-l1n "l :;jjtJ1~ L1f1Lvh,ru~ Lii1'1<11n11'l ~n'hfl,rul U~11'l1m~1.lU1:;1'l1V1~1fll 'lJ1I1.l
~ i1'~LI1IU111N ~~,r1.lnfjlJ L1f1Lmh~'l :;LLUn'l1 nn1.l1~[J1nLI1IU<I1~Ufl1 n11LYlu~fl!.h~ L~fJ'l ~~.hd:J1.l, , •...
iIi<l~t o!f n11m'l "ll'l<lu<I!h~ ~1.li'll-l ~'l [J LLI1i'l:;jjn fj l-Itl1 n11V1~ 1A'f1J1iI~i:l.-,., ..J ~..J
1. Pain : L1J1.lfl1n11V1l-11YtULLYiVlUlJ1n'lli'j11\
: radicular pain .••::;tht1l).J,n~ut')")lilvalsalva maneuver LLn::spine
movement "l:;Li:l1.li\'nl;"ru:;fl1n11'!J<I~ extradural lesion
: local, stiff neck or back t'hjj'1l1n11U'll1lt1.lvh recumbency ("nocturnal
pain") t,"l'l~lu spinal canal tumor
: medullary pain 'l:;i:lli'n,;-ru:; oppressive, burning, dysesthetic non
radicular, often bilateral, unaffected by valsava maneuver
2. Motor disturbances. ",no rj ."'-
: weakness IS 2 or 3 most common complaint LL~:;lJn'l:;l-ItJ1n11
1II1l-1~li'~sensory symptoms•••. 11'.
: LliinlJn"l:;l-I1i1bU'1I1n11 gait disturbances
.....-~
2
: tl1n1r"DfJ~central cord syndrome 't1XM6EJlesion "I::'!I~~ IMSCT
: Ll'ltJ"l::JJ'!l1n1rupper extremities '1i'1lULLNmnn'hlower extremitia
decreased DTR, dissociative anesthesia
: long tract involvement -.. clumsiness and ataxia
: atrophy, musele twitches, fasciculations
3. Non painful sensory disturbances
: dissociated sensory loss L1UBrown - Sequard Syndrome, central
cord syndrome
: paresthesia L1Uradicular ",i"1l medullary distribution
4. Sphincter disturbances
: usually urogenital (anal less common) L'IlUdifficulty evacuating,
retention urine, Incontinence and impotence
5. Miscellaneous Symptoms
; scoliosis or torticolis
: sub arachnoid hemorrhage
: visibie mass over spine
Diagnostic studies
I. Pain radiographs : H'~vertebral body destruction enlarged intervertebral
••foramen ",r'!l Increases interpedicular distance suggests ED SCT
II. Lumbar puncture : L~'1l\l1CSF ttJlllr1"11(l"'1'YltJ1~I'lI11'r'1U1~'1lt11~t'"L'I!Uprotein
\1~'r'IU11LlIUIMSCT 'lJli1~95% LLl'l::glucose ri~n"l::tJniiitJnL.j'u'tun~~
meningeal tumor• ..,J • ~ ,., X
1. FroJnssyndrome : L~fJ'Yl1valsava maneuver LLI'l1pressure UJ\1~'IIU.• ~ ,., X
2. Queckenstedts test L;.J'1ln£;ljuqular vein LLft1presssure UJ\1~'IIU
3. Barrier to flow of myelographic contrast media
III Myelography L~'il~1IIcontrast media LolhhJ'tuspinal canal "::L~U'lJiIii'~U.•
1. 1M SCT "l::LiiuLi'h.l~n~tu:: fusiform widening
. .
3
2. ID.EM "I::LililLUU capping effect with a sharp cutoff
3. ED "I::LiluLUU hourglass deformity t'hd'lulncomplete block1 ih complete'
block "~I\lUIl'lUpaintbrush "ffect
IV CT scan
V MRI L-li\UU••.•inLumr7iU"I'i!lJtrFl'll'lN spine
VI Spinal angiography: rarely indicated "I::'t.;nunnll?\~~lJ AVM ••.•rtl
hemangioblastoma
LU~~"I::mh1 Ci~t1Fl'l1tl~spinal canal ~L~lJ1~'ll~LL!\::Vjl.J'lil\'tu~l'llJnmJ"I11~r::1.J1.J
t]1::1\1"11Lvi1,rU
1. Extradural lesion (ED)
1.1 Spinal epidural metastases
: HI\~~lJ~1"1::LU1..Itumor LUFlUH back pain ~ persists in recumbency
: Vjl.J'l~10% 'l1tl~all cancer patients LLI'l::LUUmost common 'IItl~ spinal tumor
: 80% 'IItl~ primary site "I::~1"11n lung, breast, GI, prostate, melanoma LL!\::
lymphoma, ~'II1lJci1U~1n"1::~1"11nprostate gland ~••.•t\l~l!n"l:::~1"11n CA
breast
: mrl"m,n'W1t1i prolong sssurvival LLI1i"l::l'lilltl1mr pain LL!\::neurologic deficit
: Routes of metastasis, arterial venous spinal epidural vein (Batson's plexus)
LLI'l::direct spread
: the most common site is thoracic spine (50-60%)
: tii1LL••.•l.i~~1U~1n"l::~tJ~ epidural ci1U intradural V'l1.J1~2-4 % intramedullary
Vjl.J~1.2%
'.11n11 : Pain ~1.J1t1ititllJ~l'lillCi~95% '1I1"1"1::d'l1..lIlmtru::focal, radicular or referred 'll1n1r pain
pain "i:::LUU~1n~u uitl movement, recumbency (classic finding), neck-flexion,
straight -leg-raising, coughing sneezing or straining
: cord involvement develops, leg stiffness or weakness, paresthesias, autonomic
disturbances (urinary urgency, constipation, impotence)
4
m11n~, ,!11I111::i'l~Pl"t,.n11fnl;1spinal melastasis ;}tllj'EJ~n"h1:l1Yi"'HU11n L"J!,.
paraplegia, quadriplegia ~'i::Liil1l"l1mJ::~r~n",,ju'l'JI~"~fl~
'wAn'lum11n~,
1. 'l'JI~,.~i~!T~hiLiiIJ~~1~
tl1V111U'JIill1i'JI'EJ~~::Ii'~tl1LU"'IIill1l chemosensitive t-.\' chemotherapy \\!Jit'h
tumor '~\4\iJU'JIill1lradio and chemoiesistant 1111::metastasis ~'WVl11U'lJ
'JIill1lcell type f'I'l1";1e.hllT",
2. h~"~~~lii!J\\~1~1J1~~1'"
n111nl;1 ili'EJdecompressive excision laminectomy LIll~1I11~i/(~!J
radiotherapy ~1'EJchemotherapy 1II1~'IIill1l'!J'EJ~~::Li'~
3. h~u~i~liitJ\\~1~tl1ltJ~"I:n~
'lun~~e\-l~'~'IIfJ~ 'l'IIi.••\\i~'l~mfJn'i'l~\.Iti n n111nl;1 ItJ\.I~11liIYlIJ~'Il111,•
mn11Ivh\!"n11t-.\' radiotherapy ~1'iJchemotherapy "l::"J!1IJMlmn1nhl1l, .... ,... . . .
11ft::11l'ln1m ti1n1::'i'tJ'!I £J~~::IH 'lI~'i::'Vl1t.J1III111excIsion laminectomy
1'il,((1::t,.ntJ~'l~Vl111Jprimary site 111\::cell type Lvh~,.
2. Spinal epidural hematoma
'Il'LW'l
2.1 traumatic 1'Ii,.spine injury 1il1~~~~LP \-I1'EJepidural anesthesia tI1lIJlJn"l::
..,~n\.l5ri1.J1111;;1coaqulopathls ~'~1~'Iiuantlcoaqulated thrombocytopenia
2.2 spontaneous I'I!•••hemorshage 'i,n spinal AVM ~1'EJvetebra; hemangioma
il1n11 : severe back pain with radicular component
: spinal neurologic deficits and progessed~
n171n~1 : immediated decompressive laminectomy and removed hematoma
3. Spinal epidural abscess•• •• • 'l'..I.. .: fl11Untl~ ~"'1'I'"'II'11~'EJ1n11back pam, fever 1111::spine tenderness
: major risk factors; diabetes, IV drug abuse, chronic renal failure, alcoholism, ..l
: Thoracic level tiu'ltlimnliql1ltJ1::1-J1tU 50% HI~iN~1ti1.JVllumbar (35%),
cervical (15%)
-..,
\
5.I~ .I
: 82% YltJ abscess Vl11I1\1 posterior, 18 % YltJYl anterior
'il101'i : fever, weats or rigors are common
: furuncle (skin boil) YlUUi15%
: pain localized over spine, tender to percussion. radicular distension.
weakness progressing to para and quadriplegia
: f:::tJ:::L~fl1'[l1Im'!l~tJ\l11'~"l1nile1011back pain U6~ 31'\4 ~hi\\'ilmn11 root•.•..•. ".-1 •..
symptoms: 4.5 'lU \lfl~'l1n~ root pain LLfl~"l:::~mn11weakness LLfl:::24 'lI~. \lfl~'110
ile1011 weakness LL~~"l:::Lijuparaplegia
Source of infection,~ .I ~ .••
1. Hematogenous spread ~u \11I~1n'rlql1l\illtJ'!l1'l'l:::~source ~1"l1n skin
Infection (most common). parenteral injection. bacterial endocarditis.
UTI. respiratory infection pharyngeal or dental
2. Direct extension from, decubitus ulcer, psoas abscess. penetrating
Trauma. pharyngeal infections, mediasiinitis; pyelonephritis with
perinephric abscess
3. Following spinal proceudre
Organism
1. Staph aureus: the most common
2. Aerobic and anaerobic streptococcus; second most common~ .
3. '!l\41 L'IlU E. coli. Pseudomonas areuginosa. diplococcus pneumoniac.
seratia marcescens
: ,lhLi:I\4 chronic infection TB is most common
: multiple organism 'l'Iuli1i' 10%
Diagnostic test
: CBC; leukocytosis
: ESR; elevated in most, usually> 30
: lP; CSF protein and WBC usually elevated, glucose normal
Radiographic studies
6
Plain films, usually normal L-i'uLLIIi~1'l::i:if11'l::osteomyelitis
MRI; imaging study of choice
. Myelogram and CT scan
Treatment
Surgical evacuation combined with antibiotics
Indication for nonsurgical management
1. Prohibitive operative risk factors
2. Involvement of an extensive length of the spinal canal
3. Complete paralysis for> 3 days
4. Absence of significant neurological deficit (controversial)
2. Intradural extramedullary tumor
2.1 Meningiomal'I J' oJ - .1- -: L1JULU'!l~'iln'/lLnln'l1narachnoid cell '/IllIIlIn1Jdura
: ~ulu~~ni~~1nn~1~'.II1U. ." . .- ..: YiUl.m'lru thoracid ~1n'/l~ill
: tl1n1~L1il1lCol1nrl'iJuhJn illLii[J1nhlu~~~
: n1~fnl;'1~1 laminectomy LLlI'ltJilldura L;hhh'iJ1 tumor '!I'iln
2.2 Neurilemmomal'I J' .1 _ .I '0
: L1JULU'iJ~'!ln'IJ'iJ~11n1J~::1'I1'/1~n"l::~lJ'/Idorsal sensory nerve root LLlJIn'!l19.I ~.!'.. _ • ~.!'~
YilJVIventral motor nerve root wlL~~'!lUnU LLIllYilJWI'U'!lU
: lJn'l::YilJ~ cervical LLi\::lumbar region 1';;~1nn~1~ thoracic
: \lcY~'.II1tJ~lJl@iYitJ1riu~.!' J' •• "oJ ~. I.J ~.., - .: t1111'iJ'UL'UtJ~'!ImJ'lIU11nmC1JUU'iJ'!InL1JU'!ln-D'!l~nr::c:lnL'!I•.•'U~i\~ plain pllm 'I::
dlu intervertebral foramen i:i'llu1",1~rU LLi\::n1~1CT ~1tJ1 MRI9::LMUr1'!lU
..- .. '" -~i\n1jru:: dum-bell '.II~L1JUi\n1jru::L'llYi1::
: n1~fnl;'1Yi1 laminectomy ~1~InLtJilldura LLlI'lL'iJ1tumor '!l'!ln
. "
7
3.lntramedullary spinal cord tumor
3,1 Ependymoma
: the most common qlioma of lower cord, conus and film terminate
: WU1tJ'II1fJlJ1nn~'mqj-l lfin1JtJfJ
: wUlJ1n1tJ'rl'l~tJ1'1 20-60 tJ: lJ1nn~1 50% YiU~ filum terminale ~'1l-lIl~lJ1YiU~ceNical cord
: 'lItJUI'll111'11tJ-l~~tJ~'1lmlun1ilfil1lL"ltJ"l1n1'IIltJ'I-l'ii~•
n1'l,n'l!l1 n1~ej1~l1Itl1luHnfttJ-l microscope "l::'ji'lu1,x11l1::n'!ltJL\ltJ~tJn
'!l'!ln1~'I-llJ111tl1lfJ1l.hi1ti'tJ111~1UoitJ1'IIl tJ'I-li-l lloilh1lJ1'l1lJ1~nL'!l1n'!ltJ~~tJ-l'11n
tltlnUi'l-llJl1In1,xradiation therapy 1II1lJ
3.2 Astrocy1oma
: WU1tJ'lI1UlJ1nn~1'1-lqj-l 1.5:1
: YiUlJ1n1tJ'Ii'l-ltl1'1 20-50 n: ralio of benign: malignant = 3-1
••: thoracic Is most common site ~'!l~II-llJ1fltl ceNlcal':' .
n1'l,n'l!l1 ItJtJ-ltlnn~lJ;j 'll'!lUI'llI111l.ii'I1II"ltJ~-l1!tJ n1n.h~I1IR'l~";1• •
laminectomy";1 biopsy ItJ1:ntJl\l'1llJ1111~'l"lLI~'l1,xradiation therapy IiitJ
3.3 Dermoid 1111::Epidermoid tumor~ J' ..J":' ~,_
: lutJltJtJ~tln"'l~lJlJ1111~luJ1Ln1'1'I. • _ L<...l..J .
: YiUlJ1n ,tJll1InU~I'ln.llumbo - sacral tJtJEJlJ1n.,,"l::WU'"ceNICallJ.fl::
upper thoracic, g _ ..J.J
: YiUlJ1n ,tJIl1InU~L'ln.llumbo.sacral tJtlEJlJ1n.""l::YiU.,,ceNicai LII1::upper
thoracic
: 1'l1mIJlI~tl~11tJ'rl'l~3 ~~ 51i1l11l11.1Ilm~'1l~1tJflml~-lltltJ"Ii'l-l~ neural tube
ri1i~i1(/1IJ.~'liJ epithelium cell 1~111ltJ~'1~1tJLlft'lL"l1t'\JIJi'!llJ1Ijj'UI~'!l~tJn'•
: ll-l 2 'II'lI1ll!n"l::iJdermal sinus tract ~lJIlJitJriuskin
8
IV .1''' •...: flnl1ru~rJtl'\UJ'JI'!llH'DrIJ'DI1I~"l"':
Epidermoid "l~lJi/i'lU stratified squamous epithelium ~~fl~contents l11ui •••
"l~lh~ntllJi/i'lU keratin, cellular debris ~~fl::cholesterol
: Dermoid "l::lJiII'llJ stratified squamous epithelium ~~fl'l!i~lh::n'!llJil\'lU
dermal appendage organs ~'l!\lhair follicles ~~fl::sebaceous giands l'l'l'"
contents "l::~....,jj'!l'"epidermoid u.l'i,,::jj hair ~~fl::sebum iIl'lU
: '!l1n1: •••tln"l1 n'!l1n1:1'1ttl~hi •••'\olli~~nnl11."lJ~~fl'ltl1"ll-J1i/r'lU'!l1n1:'IItl~ ~~fl•
".\l-Jfll-J'MLLfl::1'lIi •••....,i\~~mfllJ-n11'till
m1rn~1 ~1~I1IL'!l1r'itl"'Ldtl~tlnfl'!lfln i~""'l-J111....,1flH1i1lm n~ql11
3.4 Syringomyelia
: Cystic cavitation of the spinal cord t'i'1~~J1~fl~~ brain stem "l::i1unn~1
syringobulbia
LL1j~1Ji2 type 'l'\olQJ1 ~fl
1. Communicating syringomyelia: primary dilatation of the
central canal LLfl::l!n"l ::il-J~"'€ rllJfl'l1l-JilD'ltlninlJ1L'l ru'llfl~
foramen magnum L'Ii•••
Chiari type I malformation basilar arachnoidits,~
basilar impression '\ol:t) Dandy Walker Syndrome
fl1n1: : Sensory loss suspended ("cape") sensory loss
: Cervical and occipital pain
: Lower motor neuron hand and arm weakness
Investigation
MRI LU•••1 test of choice l'l'l'" CT scan ....,r'!lmyelogram i~t1:::1lJ'!IU\(flU
Management
Surgical treatment: options include
1. posterior decompression, procedure of choice when posterior abnormaiier L'Ii•••chian
malformation
2. Shunt: peritoneum or subarachnoid space
9
3. Plugging the obex wilh muscle or telon
4. Syrlngostomy
5. Percutaneous aspiration of the cyst
II. non communicating syringomyelia fillf11')::~jj cyst '!!1,I'1ucord t"'!Jhi'lM,,'\tllllJ cenlral
canal ',ifll subarachnoid space tl'1tl1l19"l::jj ~1l'>1l1J"nntrauma lumor 'lire arachnoidlUs
Im:;d"l:;YllJ'lili' 0.3-3% 'lI'!!~fl1M~jj cord injury
'il1n1' : pain. numbness. increased motor deficit, Increased spasticity Increased
sweating (hyperhidrosis) (autonomic dysreflexla
Evaluation MRI LiJu test of choice
Management Medical (conservative) Yl1J1131% stable. 69% progressed
Surgical option ~::L",illlurllJ communlcaling syrlngomy clia
3.5 Spinal AVM
Liluf'l,)1~~",un ~,'!!~ \~u\i\,!!(i\um ru\'lI \\'u,"fl~~jj1J1\\1IIri1\il",ntl~ 'l~ \lju' 3 mliJ ~'!I..-1. Dural AVM ~1J'ltl(50-80 % ~1J1J1n\urJl"'cY~')umn"l::TilJ\u'l!'NfJ1!j1J1n
n11 40 iIil1",' Chronic progressive '!!19"l::i:Jacute deterioration 'lillI11,):; subarachnoid
11emorrhagehiftfltlYlti•• ,.J -' .J .•i/l1U\l.••~'YIY1lJrt,)U~1n"1:;YltI'YIthoracic m'l1 lhoracolumbar
'2. Perirnedullary AVM l'llJ'l~ 10-15 %. l'llJ'l6itlflulu'li,)~'lI1!j 20--40 n'\ •.• ",1
'inn1' rapid progressive neurological deficit T11,):: subarachnoid hemo(fhage 'VllJ~"lJ'N• I oJ ••• ~..J ..•l!I1\LVIU~'YIY1lJ~n"l::LuU"l1thoracic ""ll thoraolumbar
n1,fn~' surgical excision ,"1!l selective embolization
3. Inlramedullary AVM•.•.•ut'" 15.40 % nUUtlULU childhood ,,1n Young
abult
il1n" Lengthy progressive. improvement alternate with acute deterioration 111')::
subarachnoid hemorrhage ~lJ'lrJithJtJ
11i1L\'1nl~TilJLtIi'1J1L')Ncervical thoracic Uf\:: lur:nbar
n1,rn~1 surgical excision .,.i1'!!selective embolization