Laminectomy at T4 and T5 for Resection of Symptomatic Cavernous Malformation

Although rare, intramedullary spinal cavernous malformations have a 1.4%-6.8% annual hemorrhage risk and can cause significant morbidity.1 Prior hemorrhage and size >1 cm are risk factors for future hemorrhage that, in addition to notable or progressive symptoms, may justify early surgical intervention.1,2 In this video, we present key steps in surgical management of a large, symptomatic thoracic cavernous malformation. A 56-year-old woman presented with worsening lower extremity weakness, imbalance, and difficulty ambulating. Strength was 3/5 in her right lower extremity and 4/5 in her left lower extremity. She had an incomplete T4 sensory level and hyperreflexia. Magnetic resonance imaging demonstrated a heterogeneous popcorn-appearing expansile intradural intramedullary 2.2- 3 1.2-cm lesion at T4-5, consistent with a cavernous malformation. Angiography was deferred given the characteristic magnetic resonance imaging appearance. Given her progressive symptoms (including weakness), lesion size, and good health, resection was recommended. Using neurological monitoring, a T4-5 laminectomy, midline myelotomy, and piecemeal microsurgical resection of the lesion was performed, clearly identifying the cavernoma-spinal cord interface and avoiding spinal cord retraction. Histopathology confirmed a cavernoma. Postoperatively, the patient had improved left lower extremity strength and stable right lower extremity strength but worsened dorsiflexion (1/5), which improved with rehabilitation. At 1-year follow-up, she had full strength in her left lower extremity and 4/5 in her right lower extremity, with mild paresthesias below T10. Consistent with prior series demonstrating low complication rates and good long-term neurological outcomes,2 microsurgical resection of selected symptomatic intramedullary spinal cavernous malformations can halt neurological decline and potentially improve neurological function.

Automated summary

Intramedullary spinal cavernous malformations are rare but have a risk of hemorrhage that can cause significant morbidity. Prior hemorrhage and size greater than 1 cm are risk factors for future hemorrhage, and notable or progressive symptoms may justify early surgical intervention.