a b cd Figure 4. Surgical treatment of a neurinoma Intraoperative views of a neurinoma at the thoracic region (see Case S tudy 1). a After the dural opening in the midline, dissection of the rostral pole of the tumor is shown. b After intracapsular gutting of the tumor, the spinal cord, the roots and the ligamentum dentatum become visible. c View just at the time of opening of the arachnoidea at the rostral pole of the tumor. One recognizes a dorsal root crossing the tumor on its dorsal surface. d View at the end of the tumor removal. The neurinoma was carefully dissected and removed from the spinal cord preserving the posterior spinal veins. A part of the dorsal root with tumor attachment was removed together with the tumor. around 7–15%. There is no clear correlation between the results and the extent of resection of the dural attachment. The surgical approach is usually via a lami- nectomy for midline dorsal tumors. A hemilaminectomy can sometimes be per- formed in small tumors more laterally located. For tumors in a lateroventral loca- tion a lateral approach has to be performed [7, 9, 23–25, 33, 35]. Intrinsic Spinal Cord Tumor Resection The surgical approach is mostly via a laminectomy with the patient in the prone position or sitting position. The opening should be large enough to expose the 1012 Section Tumors and Inflammation cranial and caudal poles of solid tumor. Intraoperative ultrasound echography can therefore be helpful for this purpose. After thelaminectomy, thedura and the arachnoidea are opened in the midline and the opened dural edge is secured by traction sutures. Longitudinal posterior median myelotomy through the sulcus medianus is the standard approach forremovalof intramedullary tumors Most intramedullary spinal cord tumors are approached through an incision between the posterior column, i.e., spreading the sulcus medianus,whichcanbe difficult but is mostly possible by searching out small emerging veins in the sul- cus ( Case Study 3). Occasionally (for hemangioblastomas or astrocytomas) the access might be through the dorsal root entry zone. Once the tumor is encoun- tered, spread pial edges are sutured using 6-0 Prolene to the opened edge of the dura on both sides, so that the tumor comes into view more extensively between the spread posterior columns. The myelotomy must expose and open the rostral and caudal cysts or the poles of the solid tumor. A frozen section biopsy is obtained for immediate histopatho- a b c d Case Study 3 This 32-year-old male noticed weakness of the right lower extremity associated with paresthesia at its lateral side, which appeared only episodically. The paresthesia was noticed in the fourth and fifth toes also on the right side since about 6 months previously. Weakness and fine motor skills of the left hand had been noted recently. Neurological findings on admission were: no gait disturbance, difficulty standing on one foot, no noticeable weakness in the extremities except for the right iliopsoas muscle (M4), difficulty walking blind straight, tendon reflex symmetric, no abdominal wall reflex, no Babinski signs, hypesthesia below T2/3 level especially on the lateral side of the right leg, position sense intact, and normal sphincter tonus. Preoperative MRI displayed an intramedullary tumor from the level of C6 to T2 with only slight contrast enhancement and with neither syringomyelia nor cyst formation, presenting as a so-called “stift” or “pencil” gli- oma ( a, b). The patient underwent laminectomy from C5 to T2 followed by partial extirpation of intramedullary pilocytic astrocytoma following a longitudinal myelotomy ( c). Demarcation between the tumor and the surrounding tissue was partly not clear so that only about one-third of the tumor was removed and the myelotomy was left open without pial closure. Postoperative neurostatus was almost unchanged, so that the patient was discharged for physiotherapy on the 9th postoperative day. Intradural Tumors Chapter 35 1013 e f g h Case Study 3 (Cont.) The patient was readmitted on the 13th day after the primary surgery due to a pseudomeningocele and neurological deterioration presenting with tetraparesis and respiratory dis- tress. The T2W images revealed a swollen spinal cord at the level of sur- gery and pseudomeningocele ( d, e). At the time of repeat laminectomy 3 weeks after the primary laminec- tomy, a swollen spinal cord was noticed especially at the level of C7– T1 so that additional laminec- tomy of T3 was performed followed by further subtotal removal of tumor. The tumor was lateralized to the right side, At the end of tumor removal, the antero- lateral part of the spinal cord was paper thin at the level of C7–T1. The myelo- tomy was left open and a dural patch with fascia lata was performed for decom- pression, as the spinal cord was still swollen at the level of T2. Postoperatively the patient was unable to walk due to motor paraparesis and also due to loss of position sense. It took him 2 years to be able to walk with a stick and another 2 years without a stick ( f). At the time of follow-up 4 years postoperative exami- nation, no bowel or bladder dysfunction was complained of. MRI displayed no tumor but a very thin spinal cord ( g, h). Most annoying for him after these all years is the dysesthesia or burning sensation in the left lower extremity and in the left flank which trouble him occasionally. logical analysis. If a malignant glioma is a possible diagnosis, the information may be crucial in deciding whether tumor removal should be continued, and if so, how aggressive it should be. Ependymomas can be delineated by a red gray color or by a consistency slightlymoresolidthanthespinalcord( Case Introduction, Fig. 5). After having sent a piece of tumor for frozen section, gutting of the tumor is carried out by suction or with low-power CUSA so that several millimeters of tumor “capsule” are left. Blunt dissection of the capsule from the surrounding spinal cord can be done with ease in ependymomas, inwhich sometimes feeding arteries and drain- ing veins have to be coagulated with low-power currents and cut. This procedure should be done with great care at the most anterior part of the tumor, as the site might be very close to the anterior sulcal artery or even to the anterior spinal artery. Dissection of ependymomas at the cranial pole or caudal pole can be easy in cases where cyst or syrinx is present. Otherwise the tumor tapers into the spi- nal cord, so that its removal should be performed with great care. 1014 Section Tumors and Inflammation a bc def Figure 5. Surgical treatment of an ependymoma A case of an ependymoma of the thoracic spinal cord (see Case Introduction). Intraoperative views: a After dural open- ing followed by a longitudinal myelotomy in the midline, the tumor tissue can be clearly distinguished as pathologic tis- sue. b Dissection of the associated cyst enables identification of the most caudal end of the tumor. c Searching out a clear cleavage plane is crucial for successful tumor removal. d The clear cleavage plane at the rostral tumor end is visible. e The most critical part of the surgical removal of the tumor is its relation to the anterior spinal artery and the branches. f Part of the tumor tissue adhered strongly to the anterior spinal artery so that the part with hemostatic sponges is coagulated and left in order to preserve the artery. The spread margin of the pia mater is approximated and closed with continuous sutures prior to watertight dural closure. After the removal the spread pial ends are closed with 6-0 continuous suture fol- lowed by dural closure. The closure of arachnoidea as much as possible to prevent CSF leakage or adhesive arachnoidopathy should be kept in mind at the time of dural closure [22]. In the case of astrocytoma which is diagnosed on frozen section at the early stage of tumor removal, part of the dissection might not become possible since the delineation between thetumor and normal tissue is not cleareven in the pres- ence of cysts or syrinx, although a considerable part of the tumor is revealed to be well delineated up to that stage. Tumor extirpation should be stopped at this Intradural Tumors Chapter 35 1015 site to prevent postoperative new neurological deficits. The dangers of tumor extirpation are at the anterior and lateral margins. Anterior resection may cause vascular damage to the anterior spinal artery, and lateral resection may directly damage the corticospinal tracts. Hemostasis is obtained by warm saline irriga- tion and microfibrillar collagen. It is rarely necessary to coagulate major vessels outside the tumor bed [5, 12–14, 20, 22, 36]. Intramedullary ependymo- mas have good delineation, while astrocytomas usually donothaveanimpacton tumor removal Spread pial edges do not need to be closed by suture to accomplish decompres- sion. Even a dural patch is needed for decompression in the case of spinal cord swelling at the end of partial tumor removal. One additional laminectomy (below and above tumor extension) might be necessary or recommendable for effective decompression. Hemangioblastomas are located usually at the dorsum of the spinal cord, so that this can be detected just after the dural opening. This orange-dark red colored tumor is usually attached to the pia at the margin and is strongly vascularized, so that its gutting is not recommended due to profuse bleeding. This tumor is usually associated with cyst or syrinx formation, so that the delineation is clearand dissec- tion is not difficult. Tumor capsule coagulation and coagulation of feeding arteries followed by their cutting are the method of removal. The main feeding arteries might be branches of the anterior spinal artery or a radicular artery [39]. Pial closure at the end of tumor removal is to be recommended to prevent col- lapse of the spinal cord [22]. For a large hemangioblastoma, its preoperative embolization by a trained interventional neuroradiologist might reduce intrao- perative blood loss and even reduce the extent of the laminectomy levels and of myelotomy. Cavernous angiomas aretoberemovedinthesubacutestageofbleeding.In this subacute stage, detection of cavernous angioma can occasionally be prob- lematic, as one hardly sees any changes on the dorsal surface of the spinal cord such as swelling or discoloration, so that ultrasound echography can be helpful for its detection. With midline access, one encounters the hematoma cavity and the typical cavernous angioma with blackberry-like appearance. Less than 10% of cavernous angiomas are located eccentrically,so that access through the poste- rior root entry zone is necessary. When the cavernous angioma is located at the conus, a strong posterior longitudinal vein might cover the sulcus medianus, so that its microsurgical dislocation for preservation is recommended by some authors in order to accomplish the midline access [22]. A decompressive laminectomy and duraplasty are the minimal surgical proce- dure in the surgery of “inoperable” intramedullary tumors, since patients with high-grade lesions on biopsy have rapid progression in neurological dysfunction even with aggressive resections. Acknowledgements. The authors are indebted to Mr. P. Roth, Ms. R. Frick and Ms. H. Job for their secretarial and technical assistance. Recapitulation Epidemiology. Intradural tumors represent about 10%ofprimaryCNStumors.Abouttwo-thirds of these tumors are found in an extramedullary loca- tion. The incidence of intramedullary tumors is be- low 1 per 100000. Most extra- and intramedullary tumors are slow-growing neoplasms and can be operated on with a low morbidity. Etiology and pathogenesis. There is considerable evidence that some neoplasms are the result of ge- netic disease. Genetic systemic diseases associated with intradural tumors are neurofibromatosis and vonHippel-Lindaudisease.Thereisanenormous functional adaptive capacity of the spinal cord to slow-growing tumor compression. 1016 Section Tumors and Inflammation Classification. Meningiomas and nerve sheath tumors represent 80% of extramedullary tumors and most of them can be surgically removed with a low recurrence rate. The most frequent intramedul- lary tumors are ependymomas and astrocytomas. About one-third of patients with hemangiobla- stoma, one of the infrequent intramedullary tumors, have von Hippel-Lindau disease. Clinical presentation. Onset is usually very insidious, but an abrupt onset can take place. Cardinal symp- toms are progressive local pain, nocturnal pain of a radicular or medullary nature, non-painful sensory disturbances, motor weakness, ataxia and sphinc- ter disturbances. In intramedullary tumors, sensory disturbance tends to be of the dissociated type and motor disturbance may present with the type of Brown-S´equard’s syndrome. Sensory disturbance of thesacralsegmentcanbepreserved(sacral sparing) until a far advanced stage of intramedullary tumors. Scoliosis or torticollis is often observed. Diagnostic work-up. MRI is the diagnostic modality of choice. At least two different imaging planes must be used in order to locate the tumor properly and to differentiate intra- from extramedullary tumors. The tumor is iso- to hypointense on T1W and hyperintense on T2W images. Almost all spinal cord tumors demonstrate more or less contrast en- hancement. Existence of a “dural tail” and calcifi- cation in meningiomas may differentiate them from neurinomas. Most nerve sheath tumors and ependymomas also demonstrate uniform contrast enhancement but can be inhomogeneous due to intratumoral cyst, hemorrhage or necrosis. Intrame- dullary tumors are frequently associated with cysts or syringomyelia. Operative treatment. Surgery is indicated in any case of intradural tumor. The goal of surgery for any benign tumor is gross total resection.Thegoalfora non-resectable glioma is debulking with preserva- tion of the function. The approach for microsurgical tumor removal is usually via a laminectomy. Extra- medullary tumors can basically be completely removed. Intramedullary tumors are mostly ac- cessed via a dorsal midline myelotomy. Tumors such as ependymomas, hemangioblastomas and cavern- ous angioma with a distinct cleavage plane between tumor and normal spinal cord tissue can be removed totally. An immediate intraoperative biopsy may be crucial in deciding whether tumor removal should be continued, and if so, how aggressive it should be. In non-resectable gliomas a tumor debulking or a decompressive laminectomy and duraplasty are the minimal surgical procedure. Patients with high-grade lesions on biopsy have a rather rapid progression even with aggressive resections. Key Articles Bal´eriaux D (1999) Spinal cord tumors. Eur Radiol 9:1252 – 1258 This paper summarizes the state of the art in MRI diagnostics of intramedullary tumors. Jallo GI, Kothbauer KF, Epstein FJ (2001) Intrinsic spinal cord tumor resection. Neuro- surgery 49:1124 – 1128 This paper shows the present status of preparation of a surgical approach for intramedul- lary astrocytomas, ependymomas and vascular lesions, including neuromonitoring and video demonstration. Brotchi J (2002) Intrinsic spinal cord tumor resection. Neurosurgery 50:1059 – 63 This article describes the surgical method of the author developed during a period of 15years(withGeorgesFischerinLyon)onthebasisofexperiencewithmorethan260 patients and 300 operations. The authors highlight that the standard treatment is com- plete resection whenever possible. For gliomas (ependymomas and astrocytomas), the author favors a midline approach; for most vascular tumors (such as hemangioblastomas and cavernomas), however, he prefers to proceed from the point at which the lesion is observed through the microscope and to dissect the lesion in one piece. Meticulous non- bleeding surgery and experience are regarded as the keys to success. Intradural Tumors Chapter 35 1017 References 1. Al-Mefty O (1998) Operative atlas of meningiomas. Lippincott-Raven, New York, pp 249–382 2. Bal´eriaux D, Brotchi J (1992) Spinal cord tumors: Neuroradiological and surgical consider- ations. Riv Neuroradiol 5:29–41 3. Bal´eriaux D (1999) Spinal cord tumors. Eur Radiol 9:1252–1258 4. Birch BD, McCormick PC, Resnick DK (2005) Intradural extramedullary spinal lesions. In: Benzel EC (ed) Spine surgery: Techniques, complication avoidance, and management, 2nd edn. Livingstone, New York, pp 948–960 5. Brotchi J (2002) Intrinsic spinal cord tumor resection. Neurosurgery 50:1059–1063 6. Constantini S, Miller DC, Allans JC, Rorke LB, Fred D, Epstein FJ (2000) Radical excision of intramedullary spinal cord tumors: surgical morbidity and long-term follow-up evaluation in 164 children and young adults. J Neurosurg (Spine 2) 93:183–193 7. Conti P, Pansini G, Mouchaty H, Capuano C, Conti R (2004) Spinal neurinomas: retrospec- tive analysis and long-term outcome of 179 consecutively operated cases and review of the literature.SurgNeurol61:34–43 8. Cooper P, Epstein F (1985) Radical resection of intramedullary spinal tumors in adult. Recent experience in 29 patients. Neurosurgery 63:492–499 9. El-Mahdy W, Kane PJ, Powell MP, Crockard HA (1999) Spinal intradural tumours: Part I – extramedullary. Br J Neurosurg 13:550–557 10. Elsberg C, Beer E (1911) The operability of intramedullary tumors of the spinal cord. A report of two operations, with remarks upon the extrusion of intraspinal tumors. Am J Med Sci 142:636–647 11. Elsberg CA (1925) Tumors of the spinal cord and the symptoms of irritation and compres- sion of the spinal cord and nerve roots. Hoeber, New York, pp 206–239 12. Epstein FJ, Farmer JP (1990) Pediatric spinal cord tumor surgery. Neurosurg Clin North Am 1:569–590 13. Epstein FJ, Farmer JP, Freed D (1992) Adult intramedullary astrocytomas of the spinal cord. J Neurosurg 77:355–359 14. Fischer G, Brotchi J (1996) Intramedullary spinal cord tumors. Thieme, Stuttgart 15. Gowers W, Horsely V (1888) A case of tumour of the spinal cord: removal, recovery. Med Chir Trans 71:377–428 16. Greenwood J Jr (1954) Total removal of intramedullary tumors. J Neurosurg 11:616–621 17. Guidetti B (1967) Intramedullary tumors of the spinal cord. Acta Neurochir 17:7–23 18. Hoshimaru M, Koyama T, Hashimoto N, Kikuchi H (1999) Results of microsurgical treat- ment for intramedullary spinal cord ependymomas: Analysis of 36 cases. Neurosurgery 44:264–269 19. Jallo GI, Kothbauer KF, Epstein FJ (2001) Intrinsic spinal cord tumor resection. Neurosur- gery 49:1124–1128 20. Kane PJ, El-Mahdy W, Sing A, Powell MP, Crockard HA (1999) Spinal intradural tumours: Part II. Intramedullary. Br J Neurosurg 13:558–63 21. Kurze T(1964) Microtechniques in neurological surgery. Clin Neurosurg 11:128–137 22. Koyama T, Kikuchi H (2000) Microsurgery of spinal cord and nerve roots, chapter 6. Sur- gery of spinal cord tumors andintramedullary hemangiomas. Nankodo, Tokyo, pp 198–258 23. Levy WJ, Bay J, Dohn DF (1982) Spinal cord meningeoma. J Neurosurg 57:804–812 24. Levy WJ, Latchaw J, Hahn JF (1986) Spinal neurofibromas: A report of 66 cases and a com- parison with meningiomas. Neurosurgery 18:331–334 25. MautnerVF,TatagibaM,LindenauM,FunstererC,PulstSM,BaserME,KluweL,ZanellaFE (1995) Spinal tumors in patients with neurofibromatosis type 2: MRI imaging study of fre- quency, multiplicity, and variety. AJR 165(4):951–955 26. McCormick PC, Anson JA (2005) Intramedullary spinal cord lesions. In: Benzel EC (ed) Spine surgery: Techniques, complication avoidance, and management, 2nd edn. Livings- tone, New York, pp 939–947 27. McCormick PC, Stein BM (1996) Spinal cord tumors in adults. In: Youmans JR (ed) Neuro- logical surgery, 4th edn. Saunders, Philadelphia, pp 3102–3122 28. Nishio S, Morioka T, Fujii K, Inamura T, Fukui M (2000) Spinal cord gliomas: management and outcome with reference to adjuvant therapy. J Clin Neurosci 7:20–23 29. Nittner K (1972) Raumbengende Prozesse im Spinalkanal (einschliesslich Angiome und Parasiten) – Stadien der Rückenmarkskompression. In: Olivecrona H, Tönnis W, Krenkel W (eds) Handbuch der Neurochirurgie, vol VII 2. Springer, Berlin, pp 186–197 30. Norstrom CW, Kernohan JW, Love G (1961) One hundred primary caudal tumors. JAMA 178:1071– 1077 31. Osborn AG (1994) Diagnostic neuroradiology, Chap 21: Tumors, cysts, and tumorlike lesionsofthespineandspinalcord.Mosby,Boston,pp876–918 32. Samii M, Klekamp J (1994) Surgical results of 100 intramedullary tumors in relation to accompanying syringomyelia. Neurosurgery 35:865–73 1018 Section Tumors and Inflammation 33. Schick U, Marquardt G, Lorenz R (2001) Recurrence of benign spinal neoplasms. Neurosurg Rev 24:20–25 34. Schweitzer JS, Batzdorf U (1992) Ependymoma of the cauda equina region: diagnosis, treat- ment and outcome in 15 patients. Neurosurgery 30:202–207 35. Solero CL, Fornari M, Giombini S, Lasio G, Oliveri G, Cimino C, Pluchino F (1989) Spinal meningiomas: Review of 174 operated cases. Neurosurgery 25:153–160 36. Stein BM (1990) Surgery of intramedullary lesions and escapable pitfalls. In: deVilliers JC (ed) Some pitfalls and problems in neurosurgery. Karger, Basel, pp 131–153 37. Strommer KN, Brandner S, Sarioglu AC, Sure U, Yonekawa Y (1995) Symptomatic cerebellar metastasis and late local recurrence of a cauda equina paraganglioma. Case report. J Neuro- surg 83:166–169 38. Thakkar SD, Feigen U, Mautner VF (1999) Spinal tumors in neurofibromatosis type 1: An MRI study of frequency, multiplicity and variety. Neuroradiology 41:625–629 39. Yasargil MG, Antic J, Laciga R, de Preux J, Fideler RW, Boone SC (1976) The microsurgical removal of intramedullary spinal hemangioblastomas: Report of twelve cases and a review of the literature. Surg Neurol 6:141–148 40. Yonekawa Y, Khan N, Yoshimura K, Yoshimura S, Imhof HG, Roth P (2003) Posterior fossa tumors – surgical strategies and tactics. In: Sakai N (ed) Brain tumor surgery. Management strategies and Navigator/Neuroendoscope. Med Pub, Osaka, pp 2–14 Intradural Tumors Chapter 35 1019 36 Infections of the Spine Norbert Boos Core Messages ✔ Spinal infections remain a potentially life- threatening disease ✔ Diagnosis is very often delayed ✔ MRI is the imaging modality of choice in spinal infections ✔ In the absence of neurologic deficit, spinal de- formity and instability or incapacitating pain not responsive to pain medication, spinal infec- tions are treated by chemotherapy ✔ Radical debridement and bone grafting accel- erates healing of the infection ✔ Spinal instrumentation does not prevent heal- ing of the spinal infection. Instead, the addi- tional stability promotes clinical resolution of the infection and related symptoms Epidemiology AlthoughevidenceforspinalinfectionsinhumanscanbefoundintheEdwin Smith Surgical Papyrus [6],an ancient Egyptian medical document written about 2000 b.c., Sir Percival Pott is credited with the first description of spinal tuber- culosis in 1779 [37]. In 1897, Lannelongue was the first to describe a pyogenic infection of the spine [27]. At the end of the nineteenth century, Makins and Abbotreportedmortalityratesinchildrenandyoungadultsofashighas70% [31]. Spinal infections occur pre- dominantly in the elderly and immunocompromised patient Spinal infections remain a potentially life-threatening disease Based on the results of a Swedish and a Danish study, the incidence of verte- bral osteomyelitis was 0.5 and 2.2/100000 inhabitants/year, respectively [4, 26]. In particular, if a spinal epidural abscess is present, the morbidity and mortality remainhigh[9,22,29,40].Spinalinfectionstodayoccurpredominantlyintheel- derly [44]. In young adults, the disease appears to have increased in recent decades because of immunodeficiency syndromes and intravenous drug abuse [24]. While in Western industrialized societies spinal tuberculosis has become rare, the incidence seems to be increasing again because of immigrants, extensive tourism into Third World countries, and HIV infections [1, 5, 20, 36, 38]. Despite the fact that treatment of spinal infections has been improved dramat- ically by the advent of chemotherapy and sophisticated surgical techniques for advanced stages, this medical condition remains a potentially life-threatening disease. Today, this fact is sometimes neglected in an era of very powerful antibi- otics. Early diagnosis and aggressive conservative or surgical treatment remain mandatory for a satisfactory outcome. Tumors and Inflammation Section 1021 a b cd ef g Case Introduction A 70-year-old patient presented with increasing low-back pain that was worse with movement. Initial therapy consisted of analgesics and physiotherapy. The clinical history of the patient was otherwise normal. There was no evidence of a general illness and no clinical signs of infection. Despite intensive non-operative treatment, 3 months after onset of symptoms, the patient continued to have back pain, now radiating into the legs and worse during the night. Walking became difficult because of general weakness. Standard radiographs were taken showing a collapsed disc space at the level of L2/3 with segmental kyphosis ( a, b). The key finding was a blurred endplate indicating putative spinal infections. Subsequent MRI demonstrated classical signs of spinal infection with decreased signal intensity of the endplates on T1- weighted images ( c) and partial signal increase on T2-weighted images (d). Blood samples revealed an elevated blood sedimentation rate and C-reactive protein without any leukocytosis. The patient was treated with a broad spectrum of antibiotics for 2 months. Despite antibiotic treatment the patient continued to have severe pain with movement and during the night. At referral, the patient was in poor general health. In a first diagnostic approach, CT-guided biopsy was performed, but remained negative ( e). Surgery was indicated because of deteriorating general health, incapacitating back pain, and inability to ambulate because of pain. In the first stage, pedicle screws were inserted in the spine from the back at L2 and 3. The kyphotic deformity was corrected using indirect reduction (see Fig. 6). In a second stage during the same operation, the spine was approached by a left-sided lumbotomy. Radical debridement was carried out with recon- struction of the anterior spinal column using a tricortical bone graft and additional cancellous bone graft. No causative organism could be isolated most likely due to the previous, antibiotic treatment. Double chemotherapy was adminis- tered postoperatively for 3 months. The patient completely recovered from the spinal infection and became completely asymptomatic at 4 months follow-up. The follow-up radiographs demonstrate an anatomic monosegmental reconstruc- tion of the anterior column with solid interbody fusion ( f, g). 1022 Section Tumors and Inflammation . The most critical part of the surgical removal of the tumor is its relation to the anterior spinal artery and the branches. f Part of the tumor tissue adhered strongly to the anterior spinal artery. operability of intramedullary tumors of the spinal cord. A report of two operations, with remarks upon the extrusion of intraspinal tumors. Am J Med Sci 142:636–647 11. Elsberg CA (1925) Tumors of the spinal. of the spinal cord and the symptoms of irritation and compres- sion of the spinal cord and nerve roots. Hoeber, New York, pp 206–239 12. Epstein FJ, Farmer JP (1990) Pediatric spinal cord tumor