Comparison of efficacy and safety of posterior and paramedian minimally invasive approaches to intradural extramedullary tumors of ventral and ventrolateral localization. Experience of the Spinal Neurosurgery Department of the Burdenko Neurosurgical Institute

SUMMARY. Extradural and intramedullary tumors are classified as intradural neoplasms of the spinal cord. The median approach followed by laminectomy is considered to be the traditional approach to removal of intradural neoplasms of the spinal cord. In recent decades, hemilaminectomy has become the most commonly used technique due to its many benefits. Traditionally, hemilaminectomy was performed through a median approach, however, this approach limited the viewing angle in patients with ventrally located neoplasms. The use of paramedian approaches for tumors located ventrally and ventrolaterally from the spinal cord improves the view and angle of surgical attack.

OBJECTIVE. To conduct a comparative analysis of paramedian and posterior minimally invasive approaches in the surgical treatment of ventral and ventrolateral tumors, as well as to compare the effectiveness and safety of their use in terms of the radical removal of the tumor, the time of operation, the volume of intraoperative blood loss, the time spent in the hospital, postoperative liquorrhea, the time of suturing solid meninges (dura mater), the severity of postoperative pain syndrome according to the visual analogue scale (VAS) and the assessment of quality of life according to the EQ-5D-5L VS scale.

MATERIAL AND METHODS. One hundred twenty-one (121) patients with vental and ventro-lateral intradural extramedullary tumors were treated in spinal department of Burdenko Neurosurgical Center between 2016 and 2020. The study included only patients with extramedullary neoplasms that did not extend to more than 1 segment of the spine, patients with tumors of the upper cervical spine were excluded. The median age of the patients was 49[20;81]. The average follow-up period was 12±3 months. The patients were divided into 2 groups: the first group (group I) of 53 patients underwent minimally invasive tumor removal with hemilaminectomy and partial joint resection window via paramedian approach, the second group (group II) of 68 patients underwent minimally invasive tumor removal through the hemilaminectomy window using the posterior approach. After surgery, the radicality of tumor removal, the time of the operation, the volume of intraoperative blood loss, in-hospital stay, postoperative liquorrhea, time for duraplasty, and severity of postoperative pain syndrome according to VAS were estimated. The degree of tumor resection was assessed by MRI with intravenous contrast. Time for dura suturing and sealing was estimated using intraoperative videorecording.

RESULTS. The Group of patients underwent surgery with paramedian approach (I group) showed a decrease in the duration of surgery (90±34 to 95±39 min), a decrease in the frequency of postoperative liquorrhea (2 to 6 cases) and provides better view on the ventral and ventrolateral tumors, that, in turn, improves the treatment radicality. The time of in-hospital stay was equal between groups (4±1 to 5±1 days), volume of intraoperative blood loss was equal in both groups (55±19 to 54±15 ml). The severity of pain syndrome on the first day was slightly higher in the I group (3.1±0.8 to 2.9±0.7 points), but on the third day, the results did not differ significantly (2.2±0.7 to 2±0.7 points). Also, it was found that the paramedian approach provides a better intraoperative view of the lesions of the ventral and ventrolateral localization and allows the paramedian incision of the dura mater to be performed, which in turn reduces the time required for suturing and sealing the dura mater 8.7±3.7 to 12±3.9 min.

CONCLUSION: The use of minimally invasive paramedian approach for ventral and ventrolateral extramedullary intradural tumors surgery is an effective method that provides better angle of surgical attack and allows to increase safety and radicality of tumor resection.

1. McCormick P.C., Post K.D., Stein B.M. Intradural extramedullary tumors in adults. // Neurosurgery clinics of North America. 1990. – Т. 1. – №. 3. – С. 591- PMID: 2136160

2. Raysi Dehcordi S., Marzi S., Ricci A., Di Cola F., Galzio R. J. Less invasive approaches for the treatment of cervical schwannomas: Our experience // European Spine Journal. 2012. May;21(5):887-96. https://doi.org/10.1007/s00586-011-2118-6.

3. Raimondi A.J., Gutierrez F.A., Di Rocco C. Laminotomy and total reconstruction of the posterior spinal arch for spinal canal surgery in childhood // J. Neurosurg. 1976; 45: 5: 555-560. https://doi.org/10.3171/jns.1976.45.5.0555

4. Öktem I.S., Akdemir H., Kurtsoy A., Koç R. K., Menkü A., Tucer, B. Hemilaminectomy for the removal of the spinal lesions // Spinal Cord. 2000. - Т.38. - №. 2. - С. 92-96. https://doi.org/10.1038/sj.sc.3100963

5. Pompili A., Caroli F., Crispo F., Giovannetti M., Raus L., Vidiri A., Telera, S. Unilateral Laminectomy Approach for the Removal of Spinal Meningiomas and Schwannomas: Impact on Pain, Spinal Stability, and Neurologic Results // World Neurosurg. 2016. - Т. 85. - С. 282-291. https://doi.org/10.1016/j.wneu.2015.09.099

6. Millward C.P., Bhagawati D., Chan H. W., Bestwick J., Brecknell J. E. Retrospective observational comparative study of Hemilaminectomy versus Laminectomy for intraspinal tumour resection; Shorter Stays, Lower Analgesic Usage and Less Kyphotic Deformity // Br. J. Neurosurg. 2015. - Т. 29. - №. 3. - С. 390-395. https://doi.org/10.3109/02688697.2014.1003026

7. Afathi M., Peltier E., Adetchessi T., Graillon T., Dufour H., Fuentes, S. Minimally invasive transmuscular approach for the treatment of benign intradural extramedullary spinal cord tumours: Technical note and results // Neurochirurgie. 2015. - 61(5), 333-338. https://doi.org/10.1016/j.neuchi.2015.05.001

8. Lee S.E., Jahng T.A., Kim H.J. Different surgical approaches for spinal schwannoma: A single surgeon’s experience with 49 consecutive cases // World Neurosurg. 2015. 84(6), 1894-1902. https://doi.org/10.1016/j.wneu.2015.08.027

9. Angevine P.D., Kellner C. E. R., Haque R. M., McCormick, P. C. Surgical management of ventral intradural spinal lesions: Clinical article // J. Neurosurg. Spine. 2011. - Т. 15. - №.1. - С. 28-37. https://doi.org/10.3171/2011.3.SPINE1095

10. H.S. C. Posterior Paramedian Approach to Ventrally Located Spinal Meningioma // World Neurosurg. 2017. - Т. 105. - С. 755-759. https://doi.org/10.1016/j.wneu.2017.06.085

11. Naganawa T., Miyamoto K., Hosoe H., Suzuki N., Shimizu, K. Hemilaminectomy for removal of extramedullary or extradural spinal cord tumors: Medium to long-term clinical outcomes // Yonsei Med. J. 2011. - Т. 52. - №. 1. - С. 121-129. https://doi.org/10.3349/ymj.2011.52.1.121

12. Lei D., Zhou, Y., Yao D., Zhang, F., Wang, X., Jiang X., Xiong N., Zhao H. Efficacy of unilateral hemilaminectomy for intraspinal tumor resection: A systematic review and meta-analysis // Ann. Palliat. Med. 2021 Feb;10(2):984-999. https://doi.org/10.21037/apm-20-499.

13. He Z., Li C. Y., Mak C. H.-K., Tse T. S., Cheung F. C. Minimally Invasive Tubular Retractor Surgery for Intradural Extramedullary Spinal Tumor Reduces Postoperative Degeneration of Paraspinal Muscle // Asian J. Neurosurg. 2022 Jul 5;17(1):74-84. https://doi.org/10.1055/s-0042-1749127

14. Özkan N., Dammann P., Chen B., Schoemberg T., Schlamann M., Sandalcioglu I. E., Sure U. Operative strategies in ventrally and ventrolaterally located spinal meningiomas and review of the literature // Neurosurg. Rev. 2013. 36(4), 611-619. https://doi.org/10.1007/s10143-013-0462-1.

15. Gull H.H., Chihi M., Gembruch O., Schoemberg T., Dinger T. F., Stein K. P., Ahmadipour Y., Sandalcioglu, I. E., Sure U., Özkan, N. Spinal Meningioma Surgery through the Ages-Single-Center Experience over Three Decades // Med. 2022 Oct 28;58(11):1549. https://doi.org/10.3390/medicina58111549.

16. Sandalcioglu I.E., Hunold A., Müller O., Bassiouni H., Stolke D., Asgari, S. Spinal meningiomas: Critical review of 131 surgically treated patients // Eur. Spine J. 2008;17:1035-1041. https://doi.org/10.1007/s00586-008-0685-y.

17. KrishnanKutty R., Sreemathyamma S., Sivanandapanicker J., Asher P., Prabhakar R., Peethambaran A. Hemilaminectomy for spinal cord intradural tumors: An institutional experience // Asian J. Neurosurg. 2018 Jul-Sep;13(3):760-765. https://doi.org/10.4103/ajns.AJNS_106_18.

18. Goodarzi A., Clouse J., Capizzano T., Kim K.D., Panchal, R. The Optimal Surgical Approach to Intradural Spinal Tumors: Laminectomy or Hemilaminectomy? // Cureus. 2020 Feb 23;12(2):e7084. https://doi.org/10.7759/cureus.7084.

19. Mobbs R.J., Maharaj M.M., Phan K., Rao P. J. Unilateral Hemilaminectomy for Intradural Lesions // Orthop. Surg. 2015. Vol. 7, № 3. P. 244–249. https://doi.org/10.1111/os.12184

20. Mitani S. Otani, M., Toya S., Bertalanffy H., Ichikizaki, K. Usefulness of Hemilaminectomy for Microsurgical Management of Intraspinal Lesions // Keio J. Med. 1992 Jun;41(2):76-9. https://doi.org/10.2302/kjm.41.76.

21. Takami T., Naito K., Yamagata T., Yoshimura M., Arima, H., Ohata, K. Posterolateral approach for spinal intradural meningioma with ventral attachment // J. Craniovertebr. Junction Spine. 2015 Oct- Dec;6(4):173-8. https://doi.org/10.4103/0974-8237.167862.

22. Kasliwal M.K., O’toole J.E., Deutsch H. Unilateral paramedian transpedicular approach for repair of anterior transdural spinal cord herniation: Report of a case and literature review // Asian Spine J. 2012 Mar;6(1):55-9. https://doi.org/10.4184/asj.2012.6.1.55.

23. Acosta F.L. Aryan H. E., Chi J., Parsa, A.T., Ames C. P. Modified paramedian transpedicular approach and spinal reconstruction for intradural tumors of the cervical and cervicothoracic spine: Clinical experience // Spine (Phila. Pa. 1976). 2007 Mar 15;32(6):E203-10. https://doi.org/10.1097/01.brs.0000257567.91176.76.