Annie Carter is a very pleasant, spry 84-year-old woman who had been quite healthy all her life. So she was a little surprised when her doctor, Dr. Thomas sent her to the Emergency Room because she thought Annie was having a heart attack. For several days she had been experiencing some pain in her upper back, across her shoulder blades. She didn’t have chest pain or left arm pain radiating up into her jaw, the typical signs of a heart attack. And she certainly didn’t have the sensation that an elephant was sitting on her chest! If anything it felt like a horse kicked her in the back. She had an EKG performed, blood drawn for tests and was admitted to the intensive care unit. The cardiologist examined her and reviewed the results of all her tests and concluded she did not have a heart attack. In fact her heart was healthier than someone half her age! Of course none of that surprised Annie. She was then discharged home.
Nevertheless, she continued to have these pains and in fact they worsened in severity becoming burning in quality as well. She also developed some tingling in her right arm, oh and by the way she had been experiencing some numbness in her right foot as well, which she had forgotten to tell her doctor initially. Because of this Dr. Thomas ordered an MRI of her cervical spine, thinking Annie had to have a pinched nerve or two in her neck. Well she had more than a pinched nerve. When Dr. Thomas called with the results of her scan, Annie was more than a bit surprised when she was told she would need to see a neurosurgeon…she had a spinal cord tumor that could paralyze her at any time!
When I saw Annie in my office she was accompanied by her daughter Jill, who was a carbon copy of Annie, just younger. They both appeared young and vibrant, and Annie certainly seemed much younger than her 84 years. When I examined her it was clear to me she had something compressing her spinal cord, as there were early signs of spinal cord damage.
I then brought up the images of her cervical spine MRI on the computer in the examination room and began to review the findings with Annie and Jill.
The cervical spine is made up of 7 roughly block shaped bones (or vertebrae) that sit on top of one another. (The first and second vertebra, however, have a slightly different shape, but nonetheless sit in line with the others.) Separating these blocks are the discs, or spongy-like shock absorbers that also allow the spine to bend forward, backward, side to side and also twist or rotate. Each spinal block has two small bones that protrude backward from each side, kind of like the walls of a house. Every house, of course needs a roof, so on the back side of these small bones is a gable-like roof that encloses the space called the spinal canal. It is here that the spinal cord is protected, enclosed within a sheath of tissue called the dura, which is shaped like a tube. Within this tube is also the cerebro-spinal fluid which bathes and cushions the spinal cord. Within this spinal canal the spinal cord travels from the brain down to the rest of the body.
The bony spinal canal in Annie’s neck was approximately 1 inch in its widest diameter. The spinal cord occupied about half of this space. The tumor was located at the level between the fifth and sixth vertebrae within the dural tube, on the right side, and was twice the size of the spinal cord. Because of it size it deformed her spinal cord and pushed it to the left. In spite of her age I had to do something to lessen this pressure before the tumor caused significant paralysis of her arms and legs.
Fortunately, based on its appearance on the MRI scan the tumor was benign and not cancer.
I spoke with Annie and Jill about the surgical procedure and the risks involved, and though I told them the risk of paralysis was small, it was always a possibility. They understood and wished to proceed with the operation.
At the time of surgery, I cut away the roof of the house of the spinal canal at the fifth and sixth level. Having peeled away the tissue layer enclosing Annie’s spinal cord, the spinal fluid flooded my surgical field. After I suctioned this fluid away, I could easily see the tumor squashing Annie’s spinal cord. At this point I moved the operating microscope into position in order to be as precise as I could be removing the tumor. Protecting the spinal cord with tiny cotton sponges, I biopsied the tumor. Shortly afterward, the pathologist confirmed the diagnosis; it was a benign tumor, a meningioma.
On the surface of the tumor were the small nerves coming from the spinal cord, which supplied sensation to Annie’s right arm. On the bottom side of the tumor, I knew had to be the nerves supplying the electrical signal to the muscles in Annie’s right arm that would allow her to grasp her coffee cup in the morning and bring it to her mouth so she could drink it. Damage to these nerves would have devastating consequences, especially since Annie was right-handed.
I then proceeded to remove the tumor using an ultrasonic probe, similar to what a dentist uses to clean your teeth, but this one not only disrupts the tumor tissue, it sucks up the tumor cells essentially shrinking the tumor from the inside. In this way the walls of the tumor can be collapsed and thereby dissected, or moved away, from the spinal cord and its nerves.
Some spinal tumors which arise from the nerves of the spinal cord invade and encompass these nerves, which prevents removal of the tumor without cutting or sacrificing them. Meningiomas, in general push away the spinal cord and its nerves and while it may be difficult to dissect those nerves away, using the surgical microscope, it is possible.
When I had removed a majority of the tumor and could push the wall of the tumor away from the spinal cord I was able to see on the other side of the tumor, expecting to see the motor or muscle nerves passing along the back side of the tumor and out through their opening in the spinal canal traveling to Annie’s right arm. When I did so, however, I was quite literally shocked at what I saw….
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