Elsevier

World Neurosurgery

Volume 114, June 2018, Pages 344-347
World Neurosurgery

Case Report
Awake Intradural Spinal Tumor Resection; Case Report and Literature Review

https://doi.org/10.1016/j.wneu.2018.03.200Get rights and content

Highlights

  • Intradural spinal meningioma with cord compression in an ASA class IV patient.

  • Excision of intradural spinal meningioma under adequate local anesthesia and sedation.

  • The patient was assessable neurologically during the surgery.

  • The patient tolerated the operation well with subsequent resolution of symptoms and signs.

Background

Meningioma is a common slow-growing spinal tumor with a predilection for intradural occurrence. Patients usually present with pain followed by ataxia and sensory and sphincter problems. The gold standard treatment in these cases is gross total microsurgical resection under general anesthesia. However, there exist high-anesthetic-risk patients unsuitable for general anesthesia. Performing spinal surgeries under local anesthesia and sedation has been reported, albeit rarely for mostly minimally invasive procedures but not for open intradural pathologies.

Case Description

We report a 63-year-old woman with critical aortic stenosis, coronary artery disease, and severe chronic obstructive airways disease who presented with 10 months' history of worsening back pain and bilateral leg pain, ataxia, hyperreflexia in lower limbs, as well as altered lower limb sensation. Magnetic resonance imaging revealed a contrast-enhancing intradural lesion at T6/7 with severe spinal cord compression. However, the patient was American Society of Anesthesiologists class IV and her cardiac disease was not amenable to intervention. She underwent thoracic laminectomy and excision of the tumor under local anesthesia and sedation with no significant complications and clinical improvement.

Conclusion

Our illustrative case and literature review suggest that using local anesthesia and sedation to perform spinal surgeries including intradural tumors is possible even in high-risk patients with good outcome. Our American Society of Anesthesiologists class IV patient tolerated the surgery well with gross total tumor resection and subsequent resolution of the symptoms.

Introduction

Spinal tumors represent 2%–4% of central nervous system tumors and can be intramedullary, intradural extramedullary, or extradural.1 Approximately 40%–50% of spinal tumors are intradural lesions, and the vast majority are extramedullary.2 About 25%–46% of the intradural spinal tumors are meningiomas.3, 4 The peak incidence is in the fifth and sixth decade age group with female predominance.5, 6 Patients most commonly present with pain followed by gait disturbances, sensory changes, and sphincter problems.5 Meningiomas are slowly growing benign lesions, and therefore the gold-standard treatment is complete resection. To achieve this goal, surgical approach has been addressed thoroughly in literature ranging from more than 1-level laminectomies to minimally invasive endoscopic procedures.7 However, all these procedures are carried out under general anesthesia. Although minimally invasive spinal surgeries have been reported under local anesthesia and sedation,8, 9, 10 the literature is scarce regarding resection of intradural tumors under local anesthetic and sedation.

Herein, we report a case of thoracic intradural meningioma in a patient who presented with back and leg pain and gait disturbance and was found to have critical aortic stenosis, coronary artery disease, and severe chronic obstructive airway disease. She had her operation successfully under local anesthesia and sedation with significant improvement. We discuss the clinical presentation, imaging, and operative and anesthetic procedures.

Section snippets

Case Report

A 63-year-old female ex-smoker presented with 10 months' history of back pain and worsening bilateral leg pains. She had unremitting, progressively worsening pain that did not respond to maximal analgesic therapy. She reported reduced mobility over that period but no sphincter disturbances. Despite unsteadiness and ataxic gait on examination, she had normal power throughout her legs but altered light touch sensation and reduced joint position sense in her lower limbs, exaggerated patellar and

Discussion

Complete excision is the surgical aim of intradural spinal meningioma that causes spinal cord compression. The surgery is usually performed under general anesthesia on an urgent or semielective basis depending on the presenting symptoms and signs. However, rare patients may copresent with multiple comorbidities that may make general anesthesia high risk or even contraindicated. Performing the surgery under local anesthesia and sedation is an alternative option. Literature is lacking studies

References (17)

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Conflict of interest statement: Dr. Shtaya is a clinical lecturer for the National Institute for Health Research. This paper was completed with no dedicated funding.

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