CASE REPORT SPINE SURGERY AND RELATED RESEARCH

Total Resection of Cervical Ventral Intramedullary Cavernous

Hemangiomas with an Anterior Corpectomy

Narihito Nagoshi1), Ken Ishii1)2)3), Kaori Kameyama4), Osahiko Tsuji1), Eijiro Okada1), Nobuyuki Fujita1), Mitsuru Yagi1),
Morio Matsumoto1), Masaya Nakamura1) and Kota Watanabe1)

1) Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan

2) Spine and Spinal Cord Center, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
3) Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan
4) Division of Diagnostic Pathology, Keio University School of Medicine, Tokyo, Japan

Abstract:
Introduction: Intramedullary lesions and tumors are generally accessed by a posterior approach. However, if the lesion is
located on the ventral side of the spinal cord, a posterior resection with myelotomy poses technical difficulties. We report
two cases of complete resection of a cervical ventral intramedullary cavernous hemangioma using an anterior approach.
Case Report: Two cases of intramedullary cavernous hemangioma located on the ventral side of the spinal cord were
successfully treated by total resection with anterior cervical corpectomy followed by anterior spinal fusion with an autolo-
gous bone strut from the iliac crest. In both cases, the postoperative course was uneventful, and there was no neurological
deficit. Bony fusion was achieved, and there was no recurrence or complication during a follow-up period of at least two
years.
Conclusions: Here, we describe an anterior approach for total resection of cavernous hemangiomas on the ventral side of
the cervical spinal cord. Outcomes were stable two years after the operations. Although the method should be assessed with
more patients and a longer follow-up time, this anterior approach may be useful for the radical resection of a vascular mal-
formation or tumor.
Keywords:
Cavernous hemangiomas, Ventral side of spinal cord, Intramedullary lesions, Anterior approach, Surgical outcomes
Spine Surg Relat Res 2018; 2(4): 331-334
dx.doi.org/10.22603/ssrr.2017-0088

Introduction Case Report

Intramedullary spinal cord cavernous hemangioma (CH)

Case 1
accounts for 5%-12% of all spinal cord vascular lesions1).
The clinical course of symptomatic CH is aggressive, with a A 47-year-old male presented with sensory disturbance of
high bleeding rate, so surgical resection is recommended2). the left upper extremity. T2-weighted magnetic resonance
Myelotomy through a posterior or posterolateral approach imaging (MRI) showed a heterogeneous intensity mass with
generally is conducted for the tumor resection1). However, a hemosiderin deposition in the ventral region of the spinal
lesion on the ventral side of the spinal cord is technically cord at the C6 level (Fig. 1). The diagnosis was suspected to
difficult to access by the posterior approach. Here we report be CH, and surgical resection was performed (Video, Sup-
the technique and surgical outcomes of tumor resection fol- plemental Digital Content 1). C6 corpectomy was performed
lowed by anterior cervical corpectomy and fusion (ACCF). over a wide region, with partial resection of the C5 and C7
vertebral bodies, especially at the dorsal side of the verte-
brae, to ease the subsequent procedure. The Luschka’s joints
were completely preserved. The obtainment of a sufficient

Corresponding author: Narihito Nagoshi, [email protected]

Received: November 29, 2017, Accepted: January 6, 2018, Advance Publication: April 27, 2018
Copyright 2018 The Japanese Society for Spine Surgery and Related Research

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Spine Surg Relat Res 2018; 2(4): 331-334 dx.doi.org/10.22603/ssrr.2017-0088

Figure 1. Preoperative T2-weighted MRI at sagittal (left) and axial (right) sections. Note the het-
erogeneous intensity mass with hemosiderin deposition in the ventral region of the spinal cord at the
C6 level (arrowheads).

Figure 2. Hematoxylin-eosin staining of resected lesions at lower (left) and higher (right) magnifica-
tions. Dilated thin-walled vessels with flattened endothelial cells are prominent.

operating field for tumor resection was confirmed by use of

Case 2
an ultrasound probe. The dura mater and arachnoid mem-
brane were opened longitudinally. The CH was identified A 28-year-old male presented with sudden right shoulder
and completely dissected from the surrounding spinal cord. pain and motor weakness of the right upper extremity. MRI
Myelotomy was not performed during the resection. Histo- showed an intramedullary heterogeneous lesion at the ven-
pathological examination indicated CH (Fig. 2). The dura tral side of the C6 level, suggesting CH (Fig. 3). The surgi-
mater with arachnoid membrane was sutured with 5-0 nylon cal technique was similar to that used in Case 1, including
string and covered with a patch sprayed with fibrin glue, to tumor resection from an anterior approach and ACCF. In-
prevent leakage of cerebrospinal fluid (CSF). An autologous traoperative spinal cord monitoring showed no deterioration
bone strut from the iliac crest was grafted without hardware. in the MEP amplitude or latency. The estimated blood loss
The muscles were sutured, and the wound was closed. Tran- was 80 ml, and the operative time was 3 hours 40 minutes.
scranial electrical stimulation motor evoked potentials Histopathological examination indicated CH.
(MEPs) were used for intraoperative spinal cord monitoring, The postoperative course was uneventful, without CSF
and no deterioration in their amplitude or latency was ob- leakage. Bony fusion was obtained 6 months postopera-
served during the surgery. Estimated blood loss was 50 ml, tively, and no local recurrence was observed at the two-year
and the operative time was 5 hours 23 minutes. follow-up (Fig. 4).
The postoperative course was uneventful, without CSF
leakage, and the preoperative symptoms disappeared. Bony Discussion
fusion was obtained six months postoperatively, and there
has been no local recurrence two years after the surgery. Although a few studies have reported using the anterior

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Figure 3. Preoperative T2-weighted MRI at sagittal (left) and axial (right) sections show an intra-
medullary heterogeneous lesion surrounded by a hypointense area at the ventral side of the C6 level
(arrowheads).

Figure 4. Postoperative MRI (left) and an X-ray image (right) show that the CH was resected and
bony fusion has been achieved.

approach for CH resection at the cervical spinal cord, infor- A posterior approach is generally selected to access intra-
mation is lacking about the detailed surgical technique or medullary sites. If the tumor or malformation exists on the
clinical outcomes at long-term follow-up3-6). Here, we suc- ventral side, however, deep myelotomy is required, increas-
cessfully resected intramedullary CHs on the cervical ventral ing the risk for postoperative neurological deterioration.
side, as shown in our video images, and demonstrated stable Moreover, indirect access from the dorsal side to the ventral
outcomes without perioperative complications or recurrence side can make it challenging to visualize the whole lesion,
at least two years after surgery. This approach makes it eas- resulting in incomplete resection. Fontaine et al. advocated
ier to directly resect a vascular malformation that exists at an anterolateral approach for ventral lesions7), but this
the ventral part of the spinal cord. Given the nature of a method carries a risk for vertebral artery injury.
case report, however, further study is needed to validate the The anterior approach has several disadvantages. Resec-
usefulness of this approach, by increasing the number of pa- tion of the vertebral bodies with intervertebral discs and an-
tients and observing them for a longer follow-up period. terior and posterior longitudinal ligaments causes spinal in-

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stability, necessitating anterior fusion. In addition, the work- References

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