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Surgical Technique for Ependymoma of the Spine – Posterior Approach

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Diagnosis and Patient Evaluation


Ependymoma of the spine is diagnosed through imaging studies such as magnetic resonance imaging (MRI) or computed tomography (CT) scans. Patient evaluation includes assessing general health, neurological status, and other factors that may impact the surgical approach.

Preoperative Planning


Review of imaging studies in detail to determine the location, size, and extent of the tumor. Optimal surgical approach is planned based on tumor characteristics, patient factors, and surgeon expertise.

Anesthesia and Patient Positioning


The patient is placed under general anesthesia, and positioned in the prone (face-down) position on the operating table to provide adequate exposure of the spine for the posterior approach.

Skin Incision and Exposure


A midline incision is made in the back over the affected spinal segment. Muscles and soft tissues are carefully dissected to expose the vertebral lamina, which may be removed to access the tumor.

Tumor Resection


Once the tumor is visualized, the surgeon carefully removes it while preserving the surrounding healthy spinal cord tissue. This requires meticulous dissection and careful monitoring of the spinal cord function during surgery to minimize the risk of damage to the nervous tissue.

Hemostasis and Closure


Bleeding is carefully controlled using surgical techniques, and the wound is closed using appropriate sutures or staples. Hemostasis is crucial to minimize the risk of postoperative bleeding.

Postoperative Care


The patient is closely monitored in the intensive care unit (ICU) or a specialized neurosurgical ward. Pain management, wound care, and early mobilization are important aspects of postoperative care. Physical and occupational therapy may also be initiated to help the patient regain strength and function.

Risks and Complications


Like any surgical procedure, surgery for ependymoma of the spine via the posterior approach carries risks and potential complications, including infection, bleeding, nerve injury, spinal cord damage, and complications related to anesthesia. The risk of complications can be minimized through careful patient selection, meticulous surgical technique, and postoperative monitoring.

Conclusion


The posterior approach is a common surgical technique for resecting ependymomas of the spine, with careful preoperative planning, precise surgical technique, and diligent postoperative care being crucial for successful outcomes.


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Intramedullary Ependymomas

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• Clinical features of intramedullary ependymomas are variable
• Classic central cord syndrome is infrequent
• Early symptoms are usually non-specific and may subtly progress
• Symptom duration prior to diagnosis is often 3-4 years, although intratumoral hemorrhage may lead to rapid decline

Sensory Symptoms


• Sensory symptoms are the earliest to present in up to 70% of patients
• Dysesthesias are particularly common
• Painful aching sensations localized to the tumor site are rarely radicular
• Distribution and progression of symptoms depend on tumor location
• Upper extremity symptoms predominate with cervical tumors
• Thoracic cord tumors produce spasticity and sensory disturbances in the lower extremities

Numbness and Weakness


• Numbness is a common complaint and typically begins distally in the legs with proximal progression
• Tumors of the lumbar enlargement often present with back and leg pain, which may be radicular
• Urogenital and anorectal dysfunction tend to occur early
• Weakness usually occurs late in disease progression, is usually asymmetric and indicates significant thinning of the surrounding spinal cord

Imaging


• MRI with gadolinium contrast is the imaging modality of choice
• Ependymomas are homogeneously enhancing lesions
• May be associated with syringomyelia or cysts
• Discreteness of the lesion is a characteristic feature

Conclusion


• Intramedullary ependymomas have variable clinical presentations
• Sensory symptoms are the most common early complaint
• Weakness usually indicates significant thinning of the surrounding spinal cord
• MRI with gadolinium contrast is the imaging modality of choice for diagnosis


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Ultrasonic Aspirator in Spinal Cord Tumor Surgery.

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Introduction: Welcome to the presentation on the use of ultrasonic aspirator in surgery for spinal cord tumors, specifically focusing on ependymomas

What is ependymoma?


Definition: Ependymoma is a type of brain or spinal cord tumor that arises from ependymal cells.
Location: Ependymomas can occur at various levels of the spinal cord, including cervical, thoracic, and lumbar regions.
Characteristics: Ependymomas are typically slow-growing tumors that can compress the spinal cord, causing neurological symptoms.

Ultrasonic Aspirator Overview


Definition: An ultrasonic aspirator is a surgical tool that uses ultrasonic energy to fragment and remove tumor tissue.
Function: Ultrasonic aspirators break down tumor tissue into smaller pieces, which can be aspirated or suctioned out.
Benefits: Ultrasonic aspirators offer precise tissue removal, tissue preservation, hemostasis, and can be used in minimally invasive approaches.

Tumor Resection


Importance: Ultrasonic aspirators are effective in debulking or removing tumor tissue from the spinal cord.
Technique: Ultrasonic energy emitted by the aspirator helps to break down the tumor, allowing for precise removal while minimizing damage to healthy tissue.
Hemostasis: Ultrasonic aspirators provide coagulation of blood vessels, which helps control bleeding during surgery.

Tissue Preservation


Importance: Preservation of normal tissue and neural structures is crucial in spinal cord tumor surgery.
Selectivity: Ultrasonic aspirators selectively target and remove tumor tissue while preserving normal healthy tissue.
Patient Outcomes: Tissue preservation helps minimize postoperative complications and optimize patient outcomes.

Precision


Importance: Precise tissue removal is critical in spinal cord surgery to avoid damage to surrounding structures.
Controlled Approach: Ultrasonic aspirators provide controlled tissue removal, allowing surgeons to precisely remove tumor tissue while minimizing the risk of complications.
Improved Visibility: Precise removal of tumor tissue improves visibility for the surgeon, facilitating safe and effective tumor resection.

Minimally Invasive Approach


Benefits: Ultrasonic aspirators can be used in minimally invasive spinal surgery, such as endoscopic or keyhole approaches.
Reduced Trauma: Minimally invasive approaches result in smaller incisions, reduced tissue trauma, and faster recovery times compared to traditional open surgery.
Versatility: Ultrasonic aspirators are versatile and can be used in various surgical approaches, making them suitable for different types of spinal cord tumors, including ependymomas.

Safety Considerations


Expertise: The use of ultrasonic aspirators should be performed by experienced surgeons who are well-versed in their appropriate usage and safety precautions.
Patient Selection: Patient selection should be carefully considered to ensure optimal outcomes and minimize risks.
Follow-up Care: Proper postoperative care and monitoring are essential for patient recovery and long-term outcomes.

Conclusion

Ultrasonic aspirators are valuable tools in spinal cord tumor surgery, including for ependymomas, providing precise tumor resection, tissue preservation, hemostasis, and versatility.


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Complications caused by Spondylolisthesis.

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Depending upon the cause and severity, Spondylolisthesis can be serious in some cases. Constant low back pain, leg pain, numbness, or tingling sensation may result in extreme discomfort which may reduce a person’s ability to perform daily life activities. This can significantly lower the quality of life.

Potential complications caused by Spondylolisthesis are explained in this article by Dr. Kalyan Bommakanti the best neurosurgeon in Hyderabad, India.

 If not diagnosed and treated on time, the compression and stress exerted on the surrounding nerves and blood vessels may increase with time resulting in a condition called spinal stenosis at the lumbar region. It causes severe back pain that may radiate to one or both legs and weakness.

Spinal fractures can also be caused because of the excessive stress exerted on the underlying vertebra. Individuals who are already diagnosed with arthritis, osteoporosis, or any bone disease are at high risk of these fractures. The fractured vertebra may cause some serious damage to the surrounding nerves and blood vessels.

In extreme cases, the nerves present at the lowest part of the spine are compressed resulting in a serious condition called cauda equina syndrome. This syndrome is considered a medical emergency because if not treated properly, it can affect the feeling sensations in the legs, the functional ability of the bladder, and even paralysis.

Apart from spinal stenosis and fractures, Spondylolisthesis can also increase lordosis initially and when the upper back keeps exerting pressure on the lower back increasing forward spinal angulation it can cause kyphosis. Hamstrings tightness is a common feature of this. Spinal infection can also occur in rare cases.

Advanced radiological imaging can help in identifying the problematic area and the level of the damage. Usually, after diagnosing Spondylolisthesis it is advised to treat it with conservative methods first because of the possible risks associated with spinal surgery. But in severe cases where all conservative methods are exhausted yet no outcome is gained, then surgery is necessary.


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How is Spondylolisthesis treated?  

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Spondylolisthesis can lead to some serious complications if not diagnosed and treated properly on time. According to the symptoms, the physical examination, and the radiological examination, a proper treatment plan should be started with immediate effect. The treatment of Spondylolisthesis depends on the severity of the condition. If the condition is not serious then it can be managed by non-surgical methods for pain management. But in severe cases surgical intervention is necessary.

Various surgical and non-surgical treatment options for Spondylolisthesis are explained in this article by India’s best neurosurgeon Dr. Kalyan Bommakanti.

Non-surgical treatment:

  • Rest:

Adequate rest and a break from strenuous activities should be taken. Sports and activities that put pressure on the low back should be avoided.

  • Physical therapy:

A physical therapist can teach a set of exercises that strengthen the muscles of the back and the abdomen. Doing these exercises regularly can reduce pain after some time.

  • Medications:

Anti-inflammatory drugs can be used to reduce the pain.

  • Back brace:

A brace can also be used to stabilize the spine and to limit the movements on the spine. It will help in the process of healing.

  • Injections:

Epidural steroid injections can also be used if the medications are not able to manage pain properly.

Surgical treatment:

It is always recommended to try out non-surgical methods first, but in severe cases surgery might be necessary. The goals and expected outcomes of the surgery include stability, pain relief, and functional restoration. The surgical procedure performed for this process is called spinal fusion. Firstly, spinal decompression is performed in which disc and bone are removed in order to reduce the pressure on the nerve. Then, in order to prevent any future slippage the affected vertebra are fused.

Functional activities can be resumed gradually. In most cases, pain is settled down after the recovery. It usually takes 4-8 months to fully fuse the bones.


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How can spondylolisthesis be diagnosed?

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Spondylolisthesis is a condition resulting in a painful experience including low back pain and other symptoms as well. It can be very painful in some patients and quite bearable in others depending on the severity of the condition. The symptoms may aggravate if the nerves passing are pinched causing altered sensations in the affected part. Early diagnosis and proper treatment and precautions are key to leading a healthy life.

Methods that are considered when seeing a patient with Spondylolisthesis are described in this article by Dr. Kalyan Bommakanti who is well-known as the Best neurosurgeon in India.

The healthcare provider starts off the process by asking about the symptoms first. This correlation of the signs and symptoms gives an idea about the condition.

Further investigation is done through physical examination, in which several movements and special tests are performed on the affected area to differentiate it from other possible conditions.

Straight leg raise is performed while the patient is lying supine resulting in pain. At the lumbosacral region, a prominent Step off sign is seen indicating the slippage of the vertebra. Range of motion at the lumbosacral region i.e. flexion and extension are limited.

Several imaging tests are also advised to make sure of the condition.

X-rays of the lumbosacral region are done to see if the vertebra is displaced and how much is the displacement. Other than X-rays a CT scan or MRI may be advised to observe the spinal contents in more detail to see whether the nerves are compressed or not and how much damage has happened to the discs and the nerves.

Based on these investigations, the condition of the patient is usually categorized as Grade I or II determining less serious condition usually cured without any surgery, and Grade III or IV as high grade and more serious which can require surgery as the only treatment option. The healthcare provider makes a final diagnosis and starts the treatment as required.


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