Thoracic Spinal Cord Tumor
The patient is a 76-year-old female who was complaining of progressive lower extremity numbness and subjective weakness. Imaging revealed a pial-intramedullary lesion in the high thoracic spine. She had no focal weakness on exam, but had a T6 sensory level. She was not myelopathic.
Figure 1 (below): Sagittal T2 weighted image shows extensive spinal cord edema.
Figure 2 (below): Sagittal T1 contrasted imaged shows a discrete enhancing lesion at the T4 level.
Thoracic pial-intramedullary spinal cord tumor
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Posterior thoracic laminectomy and surgical resection.
Surgical Rationale and Technique
The patient was clearly symptomatic, and the lesion had caused significant cord swelling. She had a good neurological status and was otherwise active. Despite the inherent risks, surgical resection provides the best chance of preventing progression of symptoms.
Figure 3 (below): Intraoperative photograph demonstrating highly vascular lesion.
Figure 4 (below): Circumferential isolation of the lesion.
Figure 5 (below): En bloc resection of the lesion.
Figure 6 (below): Postsurgical bed demonstrating complete resection.
The patient tolerated the procedure very well. Final pathology demonstrated benign hemangioblastoma. She had no postoperative deficits. Her paresthesias improved over the next few weeks. Imaging at three months (Fig. 7) demonstrated no residual or recurrence. Given total resection of this benign lesion, no postoperative adjuvant therapy was indicated.
Figure 7 (below): Postsurgical contrast MRI at 3 months demonstrating no residual or recurrence of the lesion. Spinal cord swelling was significantly reduced.
This patient has an intradural, intramedullary-enhancing mass clearly shown on the T1 weighted, sagittal, contrast-enhanced MRI. There is associated spinal cord edema. The differential diagnosis includes hemangioblastoma, high-grade glioma, or an atypical tumor such as a malignant intradural meningioma.
The lesion should be excised. If a hemangioblastoma is suspected, some surgeons may consider obtaining a preoperative MR angiogram. In any case, this lesion needs to be biopsied and excised if possible.
Typically, intraoperative spinal cord monitoring is used for such cases, including motor evoked potentials (MEP) and somatosensory evoked potentials (SSEP) to give the surgeon feedback on the neurological status of the spinal cord during surgery.
Upon dural opening, this lesion is clearly seen to be a hemangioblastoma with feeding and draining vessels. Such tumors need to be approached from their periphery to slowly isolate and sacrifice arterial feeding vessels while maintaining venous drainage vessels until the end of the excision. If the venous drainage is sacrificed before the arterial feeders, then the tumor can become quite bloody. By carefully circumnavigating the tumor periphery the surgeon can "carve" the tumor from the cord substance and excise it, typically in one piece.
Dr. Baaj has done an excellent job removing the tumor presented here.