Medical Case Study – Neurosurgery

By Kelly Gardner

A 58-year-old female patient presented to the Neurosurgery Spine Clinic at the Jackson T. Stephens Spine & Neurosciences Institute at UAMS with severe progressive pain in her buttock, hip and left leg in a radicular distribution. As a result, she was progressively less able to perform her usual activities of daily living and enjoy her hobbies, including interacting with her grandchildren. The initial assessment with an MRI scan of her spine had revealed a spine tumor with possible nerve impingement.

Assessment

She was referred to Noojan Kazemi, M.D., F.A.C.S. Kazemi is a fellowship-trained neurosurgeon specializing in all aspects of surgical treatment for spine and peripheral nerve conditions. His focus is performing surgery through the latest minimally invasive surgical techniques, and he is often able to treat conditions such as spine tumors and nerve compression through these approaches.

At clinic, her MRI was reviewed and was found to reveal a peripheral nerve sheath tumor, arising from the left T12 neural foramen with clear nerve root compression. The lesion extended into the paraspinal muscles immediately adjacent to the psoas muscle on the left side.

Traditional surgical approaches to spine tumors are invasive and can involve significant blood loss, increased length of stay and carry the usual risks of complications, including infection, nerve injury and potential neurological deficits. The greatest postoperative issue, however, is usually pain from significant muscle dissection often required to access the tumor. Kazemi discussed these issues together with traditional “open” surgery with the patient. However, he proposed a minimally invasive approach to resecting the tumor and felt that a total resection could be achieved this way, with less risk of complications and faster healing with shorter recovery times, including length of stay in hospital.

The patient opted for the minimally invasive surgery.

Procedures

During the operation with the patient positioned prone, fluoroscopy was used to identify internal landmarks, including the rib head, adjacent facet joint and transverse process. These allowed the surgeons to fashion the location of a 3-cm vertical incision on the back.

Assisted by residents now trained in minimally invasive spine techniques, Kazemi made an incision through the fascia and found a plane of cleavage in the layers of the paraspinal muscles, avoiding any division of these muscles. They passed a series of increasingly sized tubular dilators through this plane and inserted and fixed an expandable retractor. Once deployed, the retractor gave the surgeons excellent access to the site of the tumor and the adjacent nerve from which the tumor had arisen.

They performed a partial facetectomy and removed the adjacent rib and transverse process through the tube. Using an intraoperative microscope, they dissected around the mass and ultimately freed it from the surrounding tissue.

During the dissection, the T12 nerve root and its dorsal root ganglion was identified, carefully preserved and freely dissected off the mass. The mass had several satellite nodules and the largest nodule was resected to give access to the remainder of the lesion. This allowed Kazemi to completely remove the mass. The T12 nerve root was decompressed and preserved.

The neurosurgery team needed to ensure that the tumor was noncancerous, as this would influence her subsequent treatment.

UAMS neuropathologist Murat Gokden, M.D., is one of the few neuropathologists in the state. In clinical neuro-oncology, there are more than 100 different types of tumors, most requiring additional testing and molecular markers for accurate diagnosis, prognosis and management. This process requires close coordination and communication between neuropathology, neuro-oncology and neurosurgery. Tumor cases are often discussed at both a neuro-oncology and neuropathology conference pre- and postoperatively.

Gokden confirmed the benign diagnosis with an intraoperative consultation during the initial stages of the procedure.

Once the tumor had been completely resected, the expandable retractor was closed and removed. The paraspinal muscles closed over the surgical site.

This expandable technology and accompanying minimally invasive techniques has opened a wider range of other conditions to safe and practical surgical treatment options, including treatment of spine deformity conditions, spine trauma and degenerative conditions as well as peripheral nerve and other types of tumors.

Follow-ups

The patient had almost complete resolution of their preoperative pain immediately following surgery and left the hospital the following day. At her six-week follow-up, she was pain free and had returned to her full activities.

A video of the surgery is available at Youtu.be/89OY5wdMB_k or by searching YouTube.com for “Minimally invasive approach to resection of paraspinal schwannoma,” which is hosted on the Journal of Neurosurgery’s channel, “AANSNeurosurgery.”

To make a referral, call
501-526-7249.


Noojan Kazemi, M.D., F.A.C.S.Noojan Kazemi, M.D., F.A.C.S.
Assistant Professor
Department of Neurosurgery
UAMS College of Medicine

Education

Medical degree, University of Sydney School of Medicine

Residency

Neurosurgery, Royal Melbourne Hospital and Royal North Shore Hospital, Royal Australasian College of Surgeons, Australia

Fellowships

Neurosurgery Research Fellowship,
Mayo Clinic, Minnesota

Complex Spine Surgery, Department of Orthopedics and Neurosurgery, University of Washington, Seattle

Minimally invasive Complex Spine and Tumor Surgery, Swedish Neuroscience Institute, Seattle

Murat Gokden, M.D.Murat Gokden, M.D.
Professor
Department of Pathology
UAMS College of Medicine

Education

Medical degree, Dokuz Eylul Medical School, Izmir, Turkey

Residency

Anatomic pathology, Washington University, St. Louis

Fellowships

Neuropathology, Washington University, St. Louis

Surgical pathology, University of Texas, M.D. Anderson Cancer Center, Houston

Cytopathology, UAMS