Discussions:

Question

Dear Dr Pant
Your have presented well on spinal cord tumours! For large and huge Intramedulary spinal spinal cord tumors can we perform staged operation i.e. intially, midline myelotomy and wait for delivery of tumor and then safely resect the tumour.

Thanks
Farsad Sadlou Parizi
Yard
Iran

Answer

Dear Dr Farzad
Thank you very much for the comment. Staged surgery as you have mentioned is an interesting thought, unfortunately I have never tried it so I do not know if the cleavage becomes better or not.

In all our case we have done one stage operation but, in intramedullary tumor surgery we change dissecting plane frequently because if you leave it for some time tumor becomes darker in colour and easier to identify and dissect. So may be there is some meaning in what you are saying in selected cases. Others with similar experience can give input

With regards,
Basant Pant
Kathmandu, Nepal

Question

Dear List members

Although I have heard this over the years, I have never performed midline myelotomy and then coming back for the tumor. In cases of ependymoma, usually there is a nice plane to dissect the tumor. In cases of astrocytoma, boundaries are less defined but the histology is usually malignant so we usually perform biopsy, wait for the frozen section and then we debulk what we consider is reasonable.

So in the event of a poorly defined tumor can myelotomy play a safer role? Are there any studies on the matter? If you perfer this procedure, do you leave the dura open? When do you come back? Is this latter decision based on timing, imaging or clinical findings? If the dura is left open, is a lumbar drain left in place cephalad to the blockage?
Thanks in advance for bringing up such an interesting subject!

Adrian Caceres
San Jose, Costa Rica

Comment

As a neuropathologist perhaps I should not offer an opinion on a neurosurgical technique question, but I can tell you that the late Fred Epstein, a strong advocate of radical excision of spinal cord tumors, did not approve of doing a myelotomy and biopsy and then “waiting for the tumor to deliver itself”. The issues of dissemination in CSF pathways were serious enough with radical excisions, this procedure made those risks worse. He felt that an experienced and careful surgeon, using modern monitoring of both sensory and motor potentials, could safely do major resections of all kinds of spinal cord tumors, albeit the relatively rare glioblastomas did not significantly benefit.’

DCM

Douglas C Miller
Columbia, Missouri, USA

Comment

Dear list members,

I agree with Dr Miller; we must resect tumors as possible.

Another question is role of local chemotherapy and brachytherapy in malignant Intramedulary tumors.

Farzad Sadlou Parizi
Yazd, Iran

Comment

I think that the two step process was historically interesting and represented a step in the progress toward the attempt to remove these tumors in toto that Dr. Epstein taught us was possible with contemporary imaging, technology and evoked potentials. Once the concept that it was possible to discern an interface in benign tumors there was no longer a need for the delivery of the tumor.

Dr. Epstein deserves credit also for pushing the concept that the attempt to remove the tumor should be done at the time of the diagnosis and that the better the neurologic condition going in the better it was coming out. He actually questioned whether patients whose neurologic condition was a non-ambulator should be operated at all.

Happy New Year to All.

Hal
Harold Rekate
New York, USA

Question

Dear Dr Pant,
congratulations on your excellent presentation on intramedullary tumours!

i) Have you looked at what is the delay to presentation or diagnosis for intramedullary in Nepal? ii) What is the set-up for neuro-rahab in your practice?

ii) We use MEP (as well SSEP) when operating on intramedullary tumours? Is MEP available in your institution? If not what peri-op pre-cautions do you take.

iii) What is the current gold-standard for neurophysiological monitoring during intramedullary tumours?

Thank you very much and look forward to hearing from you.

Yours sincerely,
Naren
G Narenthiran
Southampton, UK

Answer

Dear Dr Naren

Thanks for the comment. These are our comments to the questions.

i) Have you looked at what is the delay to presentation or diagnosis for intramedullary in Nepal? ii) What is the set-up for neuro-rahab in your practice?

We have not looked at the time delay of presentation but generally they present very late, most of them present with profound neurological deficit; very few present early if there is considerable pain. So late presentation, profound neurological deficit, limited resources but patient's expectation is very high. A really challenging situation. Except for the monitoring system we think you do not need much of equipments for this surgery.

I am fortunate to have a good team of Neuro-rehab in our institute, and they are dong wonderful work.

ii) We use MEP (as well SSEP) when operating on intramedullary tumours? Is MEP available in your institution? If not what peri-op pre-cautions do you take.

We do not use MEP or SSEP intraop, which I would like to use. They should increase the intra-operative confidence of the surgeon and marginally help in the safety of tumor removal but many times it will give you false alarm. So you may stop surgery which could otherwise have been possible (my resident-time experience). So I go with strictly maintaining the tumor-cord cleavage. But MEP SSEP should supplement your intraop judgement.

iii) What is the current gold-standard for neurophysiological monitoring during intramedullary tumours?

We are more interested in getting MEP (motor) information than SSEP (sensory). We routinely use nerve stimulator and stop muscle relaxtant and differentiate motor from sensory nerve. You can also do that with low power monopolar (although not recommended) if you have no access to stimulator. We never encountered any problem cutting dorsal nerve rootlets.

Thank you
Basant Pant
Kathmandu, Nepal

(The e-mail address to contribute your questions and comments is: neurosurgeryresearch@jiscmail.ac.uk)

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