Introduction: Intradural/extramedullary tumors comprise nearly half of all intraspinal tumors and 20%
are intramedullary tumors. Intradural tumors remain a challenging problem when deciding the correct procedure.
Methods: We are presenting an algorithm for decision-making regarding the need for surgery and the surgical approaches, based upon anatomy and unique surgical factors.
Results: RASMA is the acronym for the algorithm based upon the following five components: Radiological diagnosis, Axial dorso-ventral location, Sagittal extent of the tumor, Medullary or extramedullary component, Approach towards surgery. A posterior midline approach with laminectomy can be utilized for most posterior or
posterolateral lesions. For a posterior midline myelotomy, the dura is opened in the
midline providing the safest approach for intramedullary lesions. A posterolateral lesion
may be approached through the dorsal root entry zone. The plane of cleavage leads to
substantia gelatinosa at the posterior and medial aspect of the dorsal root. For lateral
lesions, a more liberal bony removal involving facetectomy and removal of pedicles may
be needed. Division of dentate ligaments with gentle traction provides further
visualization of the lateral aspect of the spinal cord. Anterior lesions that reach the pial
surface may be approached with excision of the vertebral body. Anterior myelotomy can
be associated with significant vascular injury to the spinal cord with devastating results.
A transthoracic (or possibly thoacoscopic) approach may be applied for ventrally located
thoracic tumors. A posterolateral sulcus approach may be offered for intramedullary
tumors situated eccentric or laterally in the spinal cord that do not contact the pial surface
at the posterior midline or laterally.
Conclusions: The primary deciding factor for surgery in tumors of the spinal cord remains the location of the lesion. The goal of modern surgery for a spinal cord tumor is to provide a safe resection that minimizes neurological deficits.
Patient Care: RASMA provides a framework that facilitates decision-making and can improve patient care.
Learning Objectives: By the conclusion of this session participants should be able to:
1)Various intradural tumor in the spinal cord
2)Surgical decision making for tumors within the spinal cord
3)Approach for surgical resection in intradural tumors
References: 1. Ahn D-K, Park H-S, Choi D-J, Kim K-S, Kim T-W, Park S-Y: The surgical
treatment for spinal intradural extramedullary tumors. Clin Orthop Surg 1:165–
2. Gebauer GP, Farjoodi P, Sciubba DM, Gokaslan ZL, Riley LH, Wasserman BA, et
al.: Magnetic resonance imaging of spine tumors: classification, differential
diagnosis, and spectrum of disease. J Bone Joint Surg Am 90 Suppl 4:146–162,
3. Manzano G, Green BA, Vanni S, Levi AD: Contemporary management of adult
intramedullary spinal tumors-pathology and neurological outcomes related to
surgical resection. Spinal Cord 46:540–546, 2008
4. Martin NA, Khanna RK, Batzdorf U: Posterolateral cervical or thoracic approach
with spinal cord rotation for vascular malformations or tumors of the ventrolateral
spinal cord. J Neurosurg 83:254-61, 1995
5. Martirosyan NL, Feuerstein JS, Theodore N, Cavalcanti DD, Spetzler RF, Preul
MC: Blood supply and vascular reactivity of the spinal cord under normal and
pathological conditions. Journal of Neurosurgery: Spine 15:238–251, 2011
6. Mitha AP, Turner JD, Spetzler RF: Surgical approaches to intramedullary cavernous
malformations of the spinal cord. Neurosurgery 68:317–24– discussion 324, 2011
7. Shirzadi A, Drazin D, Gates M, Shirzadi N, Bannykh S, Banykh S, et al.: Surgical
management of primary spinal hemangiopericytomas: an institutional case series
and review of the literature. Eur Spine J 22 Suppl 3:S450–9, 2013
8. Takami T, Naito K, Yamagata T, Ohata, K: Surgical Management of Spinal