- Neurosurgical Service, Department of Clinical Neurosciences, University of Lausanne Hospital, CHUV, Lausanne, Switzerland
- Department of Ear, Nose, and Throat, University of Lausanne Hospital, CHUV, Lausanne, Switzerland
John Michael Duff
Neurosurgical Service, Department of Clinical Neurosciences, University of Lausanne Hospital, CHUV, Lausanne, Switzerland
DOI:10.4103/2152-7806.154453Copyright: © 2015 Bobinski L. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Bobinski L, Henchoz Y, Sandu K, Duff JM. Single stage transforaminal retrojugular tumor resection: The spinal keyhole for dumbbell tumors in the cervical spine. Surg Neurol Int 01-Apr-2015;6:53
How to cite this URL: Bobinski L, Henchoz Y, Sandu K, Duff JM. Single stage transforaminal retrojugular tumor resection: The spinal keyhole for dumbbell tumors in the cervical spine. Surg Neurol Int 01-Apr-2015;6:53. Available from: http://sni.wpengine.com/surgicalint_articles/single-stage-transforaminal-retrojugular-tumor-resection-spinal-keyhole-dumbbell-tumors-cervical-spine/
Background:Dumbbell tumors are defined as having an intradural and extradural component with an intermediate component within an expanded neural foramen. Complete resection of these lesions in the subaxial cervical spine is a challenge, and it has been achieved through a combined posterior/anterior or anterolateral approach. This study describes a single stage transforaminal retrojugular (TFR) approach for dumbbell tumors resection in the cervical spine.
Methods:This is a retrospective review of a series of 17 patients treated for cervical benign tumors, 4 of which were “true” cervical dumbbell tumors operated by a simplified retrojugular approach. The TFR approach allows a single stage gross total resection of both the extraspinal and intraspinal/intradural components of the tumor, taking advantage of the expanded neural foramen. All patients were followed clinically and radiologically with magnetic resonance imaging (MRI).
Results:Gross total resection was confirmed in all four patients by postoperative MRI. Minimal to no bone resection was performed. No fusion procedure was performed and no delayed instability was seen. At follow up, one patient had a persistent mild hand weakness and Horners syndrome following resection of a hemangioblastoma of the C8 nerve root. The other three patients were neurologically normal.
Conclusions:The TFR approach appears to be a feasible surgical option for single stage resection in selective cases of dumbbell tumors of the cervical spine.
Historically, the term “dumbbell” tumor was used to describe an intraextraspinal tumor of neural origin growing across a constricting anatomical space confined by the boundaries of the bony neural foramen and investing dural nerve root sleeve.[
Nerve sheath tumors with at C1 and C2 root levels do not have a bony foramen, so the entire tumor is accessible through a standard posterior approach. Such tumors pose a different surgical challenge and are not considered here.
For the purpose of this study, we report single stage surgical resection of both intradural and extradural components of dumbbell tumors of the subaxial cervical spine in four patients through a transforaminal approach. As examples, the magnetic resonance imaging (MRI) findings of a patient with a predominantly intradural component and of another patient with predominantly extradural component are shown in [Figures
Following hospital ethics committee approval, a retrospective chart review was carried out. Between 2007 and 2013, 17 patients underwent retrojugular resection of laterally placed cervical spinal tumors. Among these were four “true” dumbbell tumors resected using a transforaminal retrojugular (TFR) approach. The lead surgeon was the same in all cases (JMD). Clinical and radiological presentation is outlined in
A skin incision is taken along the anterior border of the sternocleidomastoid (SCM) muscle. A subplatysmal flap is raised anteriorly until the midline and posteriorly up to the trapezius. The SCM is mobilized to expose the carotid sheath, and superiorly, the spinal accessory nerve. The inferior belly of omohyoid is incised as posteriorly as possible and mobilized antero-superiorly up to its insertion on the hyoid bone, for later use as a vascularized muscle flap for dural closure. The internal jugular vein (IJV) is skeletonized and mobilized along with the vagus nerve. The transverse cervical artery, scalene muscles, phrenic nerve, and trunks of the brachial plexus are identified. The V1 segment of vertebral artery (VA) is identified, and controlled with vessel loops, but is not mobilized or transposed.
For the tumor resection, standard microsurgical technique is used to internally debulk the extraspinal tumor component and amputate it at the neural foramen. The distal parent nerve root is divided. The tumor mass is followed through the expanded neural foramen and intradural portion is resected with division of the proximal parent root/fascicle. The foramen can be surgically enlarged (patient 4). The overlying VA is protected with a small spatula during bone drilling. Final transforaminal tumor resection inevitably results in a gush of cerebrospinal fluid (CSF). Dural closure is performed with local vascularized omohyoid or SCM flaps sutured onto the dural sleeve of the neural foramen, and reinforced with a synthetic dural sealant (Duraseal®).
No fusion was performed in any patient.
Average clinical follow was 30 months (range 6–78 months) [
Patient 1 had a delayed pseudomeningocele in the neck several weeks after surgery. In this case, the muscle flap had not been sutured in place, and was found to have displaced with a resultant CSF leak. The dural closure was successfully revised. Patient 2 succumbed to disseminated meningeal metastatic disease from a malignant peripheral nerve sheath tumor (MPNST) with hydrocephalus and multiple radiculopathies 9 months after surgery, despite radiotherapy and chemotherapy. Patient 4 had a persistent Horner's syndrome likely due to dissection and manipulation of the stellate ganglion, lying beneath the C8 tumor. He also had mild hand weakness and transient neuropathic pain treated with pregabaline. None of the three patients with benign tumors showed evidence of recurrence at last follow up [
Spinal intradural tumors are rare with an incidence of 0.3–10/100,000.[
Cervical dumbbell tumors are most commonly treated using a posterior laminectomy approach to access posterior or posterolaterally placed intradural tumors.[
The anterolateral retrojugular approach described by George and co-workers allows single stage tumor resection without fusion.[
The TFR approach is a simplification of the anterolateral retrojugular approach. Neither the sympathetic chain nor the VA is transposed. There is minimal to no bone resection. No fusion is required. Dural reconstruction is achieved using a novel local vascularized muscle flap.
The TFR approach exploits a surgical pathway created by the tumor. Early identification and control of the proximal VA in TFR is possible. It may decrease complications due to facetectomy and fusion.[
The TFR approach is a feasible surgical option for resection of true dumbbell tumors of the cervical spine. The results in this small series are encouraging and comparable with those previously reported in the literature.[
We believe that the TFR approach can be a useful option for surgical treatment of cervical dumbbell tumors.
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