PMC5054645_01
(a) Preoperative sagittal T2-weighted magnetic resonance (MR) image showing extensive syringobulbia and syringomyelia and a small mass (arrow) in the spinal cord at C6. (b and c) Preoperative sagittal and axial gadolinium (Gd)-enhanced MR images of the cervical spine showing a small enhanced mass in the spinal cord at C6 (b) and in the right anterior quadrant of the spinal cord (c). (d) Gd-enhanced MR angiogram of the upper parts of the body showing tumor staining in the cervical spine
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F1
Magnetic resonance (MR) imaging of the cervical spine demonstrated an anterolateral enhanced lesion opposite the C6 vertebral body accompanied by a multilevel proximal/distal syrinx extending from the medulla to the T4 level [Figures 1a-c]. MR angiography with gadolinium-diethylenet riaminepenta-acetic acid of the upper body demonstrated the C6 intramedullary anterolateral spinal cord tumor, but no other lesions [Figure 1d].
(a) Left subclavian artery angiogram showing the thyrocervical artery (arrow) as a feeder of the tumor (arrowhead). (b) Selective angiogram of the thyrocervical trunk showing the radicular artery entering (arrow) the spinal canal with the C8 root, branching of the anterior spinal artery (rostral and caudal) (arrowhead) and the feeding artery at C6, tumor staining, and the draining vein. (c) Three-dimensional rotational selective angiogram of the thyrocervical trunk showing the tumor location and surrounding vessels
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F2
Angiography showed that the main feeding vessel was the left anterior C8 radicular artery, which originated from the thyrocervical artery, and then penetrated the dura mater and branched both rostrally and caudally into the ASA [Figure 2].
(a) Three-dimensional (3D) computed tomography angiogram showing C6 and surrounding structures. (b) 3D computer graphic image showing the anatomical relationships of the spinal tumor (purple) and feeding artery (pink), and the cervical vertebral bodies (white), trachea (yellow), esophagus (purple), common carotid artery (red), and jugular vein (blue). (c) Planned corpectomy of C6 and simulated surgical view showing the anterior radicular artery (pink and arrow), anterior spinal artery (pink and arrowheads), tumor (purple), and drainer (blue)
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Surgical microscopic images. (a) After total corpectomy of C6 and partial corpectomies of C5 and C7. (b) Indocyanine green (ICG) injection showing the tumor stain (star), the anterior spinal artery, and surrounding venous drainage. (c) Opening of the dura mater exposed these structures. (d) ICG injection clearly showing the anterior radicular artery (arrow), anterior spinal artery (arrowheads), and the tumor (star). (e) Temporary clip was applied to the feeding artery of the tumor. (f) ICG injection showing reduced blood supply. (g) Dissection of the tumor. (h) ICG injection showing no residual tumor and the intact anterior spinal cord artery
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F4
A left-side skin incision exposed C4 to C7, allowing for completion of a total corpectomy of C6 and partial corpectomies of C5 and C7 [Figure 4a]. Intravenous injection of ICG showed staining corresponding to the tumor, ASA, and surrounding venous drainage through the intact dura mater [Figure 4b]. ASA, tumor, feeder, and draining veins [Figure 4d]. After sharp dissection of the vessels from the arachnoid, a temporary clip with low closing force (Sugita AVM Microclip, Mizuho Medical Co., Ltd., Tokyo, Japan) was applied to the feeding artery of the tumor [Figure 4e]. ICG injection showed reduced blood flow in the feeding artery but intact flow in the ASA [Figure 4f]. The feeding arteries were coagulated and the tumor was totally removed [Figure 4g]. The last ICG injection confirmed complete tumor excision and preservation of the ASA [Figure 4h].
Follow-up MR images 1.5 years after the surgery. (a) Sagittal T2-weighted MR image showing disappearance of the tumor and collapse of the syrinx. (b and c) Sagittal (b) and axial (c) Gd-enhanced MR images revealing total removal of the tumor. (d and e) Postoperative cervical radiographs, anteroposterior (d) and lateral (e) views, showing good graft bone fusion
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F5
Follow-up MR imaging at 1.5 years confirmed total removal of the tumor and shrinkage of the associated syrinx with accompanying atrophy of the spinal cord [Figures 5a-c] and cervical radiographs showed the grafted fibula bone fused to both the caudal and rostral vertebral bones [Figure 5d and e].