Surgical Resection of Intramedullary Epidermoid Cyst: 2-Dimensional Operative Video

Surgical Resection of Intramedullary Epidermoid Cyst: 2-Dimensional Operative Video Abstract Intramedullary epidermoid cysts are extremely rare lesions. Preoperative diagnosis can be challenging due to non-specific imaging futures. We illustrate the case of a 32-year-old man who presented with a symptomatic intramedullary mass, which at surgery proved to be an epidermoid cyst. The spinal cord was decompressed by removing the pearl-white keratin material, although the capsule, which was tenaciously adherent to the surrounding spinal cord parenchyma, was only partially removed. In this video, we illustrate the salient surgical points for the resection of this very unusual intramedullary lesion. Thoracic, spine, epidermoid, microsurgery Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy067 View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy067 Surgical Resection of Intramedullary Epidermoid Cyst: 2-Dimensional Operative Video Surgical Resection of Intramedullary Epidermoid Cyst: 2-Dimensional Operative Video Close COMMENTS The authors present a beautiful example of resection of a rare intramedullary epidermoid cyst of the thoracic cord. There is mention of the capsule being adherent to the cord at several areas. They decided not to pursue aggressive total resection of the capsule in order to preserve neurologic function. This keenly illustrates the ever recurring dilemma of how aggressive or retreating to be in the resection of a central nervous system tumor. With so few of these lesions reported in the literature, the actual recurrence rate which would be useful to have when making such a decision is probably unknown. This makes it difficult to weigh the risk of recurrence versus the risk of producing a neurologic deficit. The biologic behavior of this tumor may be similar to the behavior of epidermoid tumors in the posterior fossa. As such it may be reasonable to use this recurrence rate as a best approximation of recurrence in a decision making process. In the posterior fossa it has been reported that 30% of the patients with subtotal removal experienced symptomatic recurrences after 8.1 years, whereas all patients with total removal were still asymptomatic. The recurrence-free survival rate was 95% at 13 years for patients with total removal compared with 65% for patients with subtotal removal.1 Considering these numbers there may be some rational for careful attempt at complete resection of the capsule at initial surgery if at all possible. This decision of course is best made by the surgeon at the time of resection. As illustrated by this case there is no substitute for intraoperative decision making based on experience, monitoring, and the success at removing the capsule in an atraumatic manor. Anthony Alberico Huntington, West Virginia 1. Talachi A, Sala F, Alessandrini F. et al. Assessment and surgical management of posterior fossa epidermoid tumors: report of 28 cases. Neurosurgery . 1998; 42( 2): 242- 252. Google Scholar CrossRef Search ADS PubMed  The surgical video is a clear demonstration on how to operate on a rare, but challenging, intramedullary tumor with an ethical sense of primum non nocere. The authors adopted a state-of-art surgical strategy which included evoked potentials and microsurgical removal. I only would question the possibility to perform a minimally invasive paramedian incision through fascial planes and laminectomy, as I usually do for any thoracolumbar intradural tumors that extend from 1 to 2 vertebral bodies on sagittal plane. The final clinical result is a very good one, though nothing is mentioned about postoperative axial pain and discussion on need for instrumentation to give biomechanical support. The key point with epidermoid is to balance between being completely curative with radical capsule removal, far more easy in extramedullary tumors where arachnoid plane is preserved to the spinal cord, or to achieve a good functional postoperative result. Óscar L. Alves Porto, Portugal Copyright © 2018 by the Congress of Neurological Surgeons http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Operative Neurosurgery Oxford University Press

Surgical Resection of Intramedullary Epidermoid Cyst: 2-Dimensional Operative Video

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Publisher
Congress of Neurological Surgeons
Copyright
Copyright © 2018 by the Congress of Neurological Surgeons
ISSN
2332-4252
eISSN
2332-4260
D.O.I.
10.1093/ons/opy067
Publisher site
See Article on Publisher Site

Abstract

Abstract Intramedullary epidermoid cysts are extremely rare lesions. Preoperative diagnosis can be challenging due to non-specific imaging futures. We illustrate the case of a 32-year-old man who presented with a symptomatic intramedullary mass, which at surgery proved to be an epidermoid cyst. The spinal cord was decompressed by removing the pearl-white keratin material, although the capsule, which was tenaciously adherent to the surrounding spinal cord parenchyma, was only partially removed. In this video, we illustrate the salient surgical points for the resection of this very unusual intramedullary lesion. Thoracic, spine, epidermoid, microsurgery Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy067 View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy067 Surgical Resection of Intramedullary Epidermoid Cyst: 2-Dimensional Operative Video Surgical Resection of Intramedullary Epidermoid Cyst: 2-Dimensional Operative Video Close COMMENTS The authors present a beautiful example of resection of a rare intramedullary epidermoid cyst of the thoracic cord. There is mention of the capsule being adherent to the cord at several areas. They decided not to pursue aggressive total resection of the capsule in order to preserve neurologic function. This keenly illustrates the ever recurring dilemma of how aggressive or retreating to be in the resection of a central nervous system tumor. With so few of these lesions reported in the literature, the actual recurrence rate which would be useful to have when making such a decision is probably unknown. This makes it difficult to weigh the risk of recurrence versus the risk of producing a neurologic deficit. The biologic behavior of this tumor may be similar to the behavior of epidermoid tumors in the posterior fossa. As such it may be reasonable to use this recurrence rate as a best approximation of recurrence in a decision making process. In the posterior fossa it has been reported that 30% of the patients with subtotal removal experienced symptomatic recurrences after 8.1 years, whereas all patients with total removal were still asymptomatic. The recurrence-free survival rate was 95% at 13 years for patients with total removal compared with 65% for patients with subtotal removal.1 Considering these numbers there may be some rational for careful attempt at complete resection of the capsule at initial surgery if at all possible. This decision of course is best made by the surgeon at the time of resection. As illustrated by this case there is no substitute for intraoperative decision making based on experience, monitoring, and the success at removing the capsule in an atraumatic manor. Anthony Alberico Huntington, West Virginia 1. Talachi A, Sala F, Alessandrini F. et al. Assessment and surgical management of posterior fossa epidermoid tumors: report of 28 cases. Neurosurgery . 1998; 42( 2): 242- 252. Google Scholar CrossRef Search ADS PubMed  The surgical video is a clear demonstration on how to operate on a rare, but challenging, intramedullary tumor with an ethical sense of primum non nocere. The authors adopted a state-of-art surgical strategy which included evoked potentials and microsurgical removal. I only would question the possibility to perform a minimally invasive paramedian incision through fascial planes and laminectomy, as I usually do for any thoracolumbar intradural tumors that extend from 1 to 2 vertebral bodies on sagittal plane. The final clinical result is a very good one, though nothing is mentioned about postoperative axial pain and discussion on need for instrumentation to give biomechanical support. The key point with epidermoid is to balance between being completely curative with radical capsule removal, far more easy in extramedullary tumors where arachnoid plane is preserved to the spinal cord, or to achieve a good functional postoperative result. Óscar L. Alves Porto, Portugal Copyright © 2018 by the Congress of Neurological Surgeons

Journal

Operative NeurosurgeryOxford University Press

Published: Mar 30, 2018

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