MR revealed an intraspinal space-occupying lesion in C5-6 level and osteolysis of C5-6 were seen, with mild disc bulging at the C2-3, C3-4, C4-5, C5-6 and C6-7 intervertebral disc levels. Enhanced MR confirmed C5-6 level space-occupying lesion and considered highly suggestive of Neurilemmoma. [Figure1]
MR revealed an intraspinal space-occupying lesion in C2-4 level, with mild disc bulging at the C2-3, C3-4 intervertebral disc levels. Enhanced MR confirmed C2-4 level space-occupying lesion. [Figure2]
Clinical and surgical course
After 3 days, the patient underwent posterior C4-6 tumor resection, C4-6 spinal canal decompression, and the resection and replantation of spinous process-lamina complex. All patients underwent general anesthesia, the patient was positioned in a prone position, the sterile towel was routinely sterilized, and the surgical space was determined by C-arm fluoroscopy. We made an incision of about 10cm via the posterior approach with surgical gap at the center, and incised the skin and subcutaneous tissue successively, retaining supranational and interspinous ligaments.Determine the C4-6 bilateral lamina. The bilateral laminae and caudal spinous processes were incised as a whole using an ultrasonic bone knife, grinding drill and gun forceps, removing the entire spinous process lamina complex. [Figure3] In case 1, we incised the bilateral laminae and caudal spinous processes perpendicular to the body. In case 2, we improved our method by inclining the section to increase contact area and stability. [Figure4] The dura mater was suspended under the operating microscope. The arachnoid on the surface of the tumor was cut, and the tumor was isolated and exposed, about 1*1.5*2cm. During the operation, it was found that the tumor was mainly located on the left ventral side of the spinal cord. The upper and lower poles of the tumor were connected to the spinal nerve and were not closely related to the dura mater. Resect tumor under operating microscope. Due to the large size of the tumor and Severe spinal cord compression, the tumor was performed piecemeal resection. Then replanting the autologous spinous process-lamina complex with 6 Arch steel plates fixing separated location of C4-6 lamina. We used some bone granule from patient replanting on contact area to improve bone fusion.
The pathology of case 1: The frozen section diagnosis Neurilemmoma, immunohistochemically: GFAP(+),NSE(-),S100(+),P53(+),EMA(-),Desmin(-),SMA(+),PGP9.5(+),SOX- 10(+),Syn(-). Special staining results: AB(-)，PAS(-).And the pathology of case 2: The frozen section diagnosis meningioma, and immunohistochemically EMA (+), Vimentin (+), P53(+), Ki-67(2%+), STAT6 (-), S100(+), CD34(+), GFAP (-), SSTR2(meningioma) (+), PR (+). Special staining results: PAS(+)
The two patients were followed up for at least 12 months. Data was recorded, including surgical time, blood loss, type of tumor, and any complications. To determine the level of internal fixation and spinal stability, frontal and lateral X-ray plain films of the spine were performed at 1, 3, 6, 12 months. Lumbar CT scans were carried out to evaluate the bone growth of the replanted spinous process-lamina complex at 3, 6, and 12 months postoperatively. At 6 months after the operation, MRI was performed to detect tumor recurrence and scar oppression in the vertebral canal, as well as the repair of the ligaments. Postoperatively, the patients underwent physiotherapy, rehabilitation. One year later, they fully recovered neurological function, and radiographs confirmed stability of the surgical construct [Figure 5-6]. Further, the CT scan showed no evidence of any other lesions.
Oswestry Disability Index (ODI) Scale
The neurological status was assessed using ODI scale preoperatively and at 1 month post-operation and the final follow-up. The ODI score system includes 10 sections: pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex life, social life, and traveling. For each section of six statements the total score is five. If all 10 sections are completed the score is calculated as follows: total scored out of total possible score × 100. If one section is missed (or not applicable) the score is calculated: (total score / (5 Number of questions answered)) × 100%. Score of 0%–20% is considered mild dysfunction, 21%–40% is moderate dysfunction,41%–60% is severe dysfunction, and 61%–80% is considered as disability. The mean preoperative ODI score was 72.5%, while the mean last follow-up ODI score was 13.2% with statistically significant differences
Visual Analog Scale (VAS)
Low back and leg pain was assessed using VAS preoperatively, at 1 month post-operation, and at the final follow-up. VAS refers to a ruler about 10cm long, marked with 10 scales on one side. The two ends of the ruler are “0” and “10,” respectively. A score of “0” indicates no pain, and a score of “10” indicates the most severe pain. Patients were invited to mark the corresponding position on the ruler to represent the degree of their pain as the score. According to the clinical evaluation, “0–2” was classified as “excellent,” “3–5” as “good,” “6–8” as “poor,” and “>8” as “worst”. VAS score of case 1 patient was reduced from 8 points to admission to 4 points at discharge. And the VAS score of the other patient with limb radiating pain was reduced from 9 points to admission to 4 points. Both of them had a continuous declination VAS score, even decreased to 1 point 12 months post-operation.