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  • RASMA, A Decision-Making Approach to the Surgical Treatment of Spinal Intradural Tumors

    Final Number:

    Harish Babu MD PhD; Doniel Drazin MD MA; J. Patrick Johnson MD, MS, FACS

    Study Design:

    Subject Category:

    Meeting: Section on Disorders of the Spine and Peripheral Nerves 2016 Annual Meeting

    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– 172, 2009 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, 2008 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 Intramedullary Tumor

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