Professor of Neurosurgery, Director of Spinal Oncology Roswell Park Comprehensive Cancer Center Buffalo, New York, United States
Introduction: Merging of preoperative MRI with intraoperative3D X-ray imaging for spinal neuronavigation is a recently described technique which has primarily been used for intradural spinal tumors. No reports describe its utilization for recurrent extradural tumors in the setting of prior instrumented fusion.Here were present a 60-year-old female with recurrent chondrosarcoma and previous decompression and fusion who underwent this technique.We aim to demonstrate the utility of merging MRI and intraoperative 3D X-rays for resection of recurrent thoracic chondrosarcoma with prior instrumented decompression and fusion
Methods: Patient was placed under general anesthesia and positioned prone on the spinal surgery table. Incision was planned based on AP and lateral X-rays with use of the previous hardware as reference. Reference arc was attached at the inferior level(T7) spinous process after minimal soft tissue dissection,followed by3D X-ray imaging for bony imaging. Combination of semi-automated and manual merge of pre-operative volumetric MRI and CT with intra-operative 3D X-rays was completed on the neuronavigation workstation. Acceptable registration accuracy was confirmedwith direct comparison of navigation probe position to anatomic landmarks.Real time guidance allowed safe maximal resection and clear delineation recurrent tumor from scar tissue
Results: Merging of preoperative MRI with intraoperative3D X-rays and use of neuronavigation was completed with minimal workflow disruption and acceptable accuracy between imaging modalities. Neuronavigation allowed for maximal resection of recurrent chondrosarcoma despite significant scar tissue and distorted anatomy from prior surgery and radiation and avoidance of CSF leak or neurological injury.
Conclusion : Merging of preoperative MRI with intraoperative 3D X-rays in patients with previous spinal instrumentation and recurrent malignant extradural tumor is technically feasible and beneficial for achieving maximal safe extent of resection and avoiding operative complications without dramatically altering operative work flow or complexity.
How to Improve Patient Care: Improved navigation abilities during complex spinal tumor surgeries allows for maximal safe resection, avoidance of neurological deficits and can be easily incorporated into current practice with minimal workflow disruptions.
