Neurological outcome following resection of benign presacral neurogenic tumors using a nerve-sparing technique

Surgical Management of Lumbosacral Plexus Tumors

BACKGROUND

Lumbosacral plexus tumors are uncommon, and because of their deep location and proximity to critical nerves subserving lower extremity function, understanding surgical approaches and short-term outcomes is important.

METHODS

In a retrospective case series of lumbosacral plexus tumor surgeries performed from May 2000 to July 2021 by a single neurosurgeon, demographic information, clinical presentation, imaging studies, and operative outcomes were analyzed.

RESULTS

A total of 42 patients with mean age of 48.3 years (range, 16-84 years) underwent surgery for a lumbosacral plexus tumor. Patients presented with leg pain (n = 25; 59.5%), followed by back/flank pain (n = 5; 11.9%), abdominal/pelvic pain (n = 5; 11.9%), leg weakness (n = 5; 11.9%), and leg numbness (n = 3; 7.1%). The most common tumor pathology was schwannoma (n = 20; 50.0%) followed by neurofibroma (n = 9; 22.5%). A retroperitoneal approach was used in all cases. Gross total resection was achieved in 23 (54.8%) patients, and only 1 (2.4%) patient exhibited symptomatic tumor recurrence after subtotal resection of a malignant tumor. Mean follow-up was 33.1 months (range, 1-96 months). Postoperatively, patient neurological status remained unchanged or improved (n = 37; 88.1%). Complications were infrequent, with 4 (9.5%) patients experiencing new sensory symptoms and 1 patient (2.4%) experiencing new anticipated motor weakness after en bloc resection of a malignant tumor.

CONCLUSIONS

Indications for surgery include pain and/or neurological symptoms attributable to the lesion or large size if asymptomatic. Careful study of preoperative imaging is necessary to determine the best approach. Intraoperative nerve stimulation is essential to preserve function and guide extent of resection in benign tumors.

Surgical management of sacral schwannomas: a 21-year mayo clinic experience and comparative literature analysis

INTRODUCTION

Sacral and presacral schwannomas are rare, accounting for a minority of spinal schwannomas. We present our institution's experience surgically treating spinal schwannomas and compare it to the literature.

METHODS

Data were collected for 27 patients treated surgically for sacral or presacral schwannoma between 1997 and 2018 at all Mayo Clinic locations and 93 patients in the literature. Kaplan-Meier disease-free survival analysis was conducted. Unpaired two-sample t tests and Fisher's exact tests assessed statistical significance between groups.

RESULTS

Our patients and those in the literature experienced a similar age at diagnosis (49.9 y/o. vs 43.4 y/o., respectively). Most of our patients (59.3%) reported full recovery from symptoms, while a minority reported partial recovery (33.3%) and no recovery (11.1%). A smaller percentage in the literature experienced full recovery (31.9%) and partial recovery (29.8%) but also no recovery (1.1%). Our patients experienced fewer complications (14.8% versus 25.5%). Disease-free survival curves for all patients showed no significant variation in progression by extent of resection of schwannoma (log-rank P = 0.26). No lesion progression was associated with full or partial symptom improvement (p = 0.044), and female patients were more likely to undergo resection via a posterior approach (p = 0.042).

CONCLUSION

Outcomes of patients with sacral or presacral schwannomas vary based on patient demographics, tumor characteristics, symptoms, and surgical treatment. Among the range of symptoms experienced by these patients, the most common is pain. Prognosis improves and overall survival is high when the surgical approach towards sacral schwannomas is prepared and executed appropriately.

Surgical Management of Symptomatic Lumbar, Sacral, and Lumbosacral Plexus Tumors: a Peripheral Nerve Unit Experience

OBJECTIVE

Data concerning the surgical treatment of lumbosacral plexus tumors (LSPTs) is scarce. This study aims to present our experience with a series of 19 patients surgically treated for symptomatic LSPTs at our institution.

METHODS

This is a retrospective study of 19 patients surgically treated for symptomatic LSPTs from 2011 to 2019. Clinical data were retrieved from medical records and consisted of age, gender, clinical presentation, location of the lesion, surgical approach, final histopathologic diagnosis, follow-up time, outcomes, and complications.

RESULTS

Nineteen surgical procedures were conducted. Thirteen patients were female and six, male. The median age of patients was 45 years (range 20 to 63 years). No patients harbored genetic syndromes. Surgical treatment appears to be correlated to the reduction of pain in patients with peripheral nerve sheath tumors (PNSTs), as assessed by visual analog scale (VAS). Sixteen patients did not present with new-onset deficits during follow-up (84.2%), two of whom recovered from their preoperative deficit. Four patients presented with postoperative weakness. The histopathological diagnoses were 11 schwannomas, four neurofibromas, three metastases, and one lymphoma.

CONCLUSIONS

LSPTs are rare. When surgical treatment is indicated, it usually requires multidisciplinary management. Surgery appears to be effective concerning the reduction of pain in PNSTs and may also recover neurological deficits. Iatrogenic neurological deficits are an evident risk, such that intraoperative multimodal monitoring should always be performed if available. In lesions involving the sacral plexus, we found it to be indispensable.

A black esophagus as a result of treatment of inferior vena cava occlusion by a massive pelvic schwannoma

This case presentation involves a 57-year-old-male who suffered multiple adverse sequels from the delayed diagnosis of a large presacral mass. He initially presented with lower extremity deep vein thrombosis (DVT). Several months later, he had developed a pulmonary embolus. Imaging demonstrated a 13 × 14 cm presacral pelvic mass that occluded the right-sided venous return from the leg and caused the DVT and pulmonary embolism. An inferior vena cava filter was placed and eventually clotted. He then was referred to our institution for surgical consultation. The patient received lytic therapy and unfortunately developed hematemesis and a significant hemoglobin drop. An esophagogastroduodenoscopy (EGD) showed a black esophagus. A transthoracic echocardiogram showed a patent foramen ovale. The patient eventually stabilized and a repeat EGD a week later showed resolution of the ischemic esophagus. The patient later underwent a resection of the pelvic mass. The surgical approach and the surgical decision-making will be discussed.

Single Stage Posterior Approach for Total Resection of Presacral Giant Schwannoma: A Technical Case Report

The neurogenic tumor of frequent occurrence in the presacral area is a schwannoma. Giant presacral schwannoma has a risk for anterior surgical approach because of its massive size and proximity to abundant vascularity of presacral region. We report a single stage posterior approach for total resection of a giant presacral schwannoma. A 40-year-old female patient experienced left buttock pain and tingling sensation at left S1 dermatome. Magnetic resonance imaging showed that the presacral huge mass at S1–3 level with osseous extension and structural remodeling in left sacral ala. The presacral mass was ranging in maximum diameter from 8.0 to 8.6 cm. S2 foramen laminectomy was performed to expose the mass. The tumor capsule and the root were carefully dissected away. The tumor was removed while preserving the capsule by dissecting the plane between the inner wall of the capsule and the tumor. The single stage posterior approach for presacral giant schwannoma is feasible, and it can be a good surgical alternative to prevent pelvic organ or vascular damage and anterior approach related dystocia and infertility.

Management approach and surgical strategies for retrorectal tumours: a systematic review

AIM

The management strategy for retrorectal tumours is complex. Due to their rarity, few surgeons have expertise in management.

METHOD

A systematic literature review was conducted using the PubMed database. English language publications in the years 2011-2015 that assessed preoperative management, surgical strategies and chemoradiotherapy for presacral tumours were included. Two hundred and fifty-one abstracts were screened of which 88 met the inclusion criteria. After review of the full text, this resulted in a final list of 42 studies eligible for review.

RESULTS

In all, 932 patients (63.2% female, 36.8% male; P < 0.01) with a retrorectal tumour were identified. Most were benign (65.9% vs. 33.7%, P < 0.01). Imaging distinguished benign from malignant lesions in 88.1% of cases; preoperative biopsy was superior to imaging in providing an accurate definitive diagnosis (91.3% vs. 61.4%, P < 0.05) with negligible seeding risk. Biopsy should be performed in solid tumours. It is useful in guiding neoadjuvant therapy for gastrointestinal stromal tumours, sarcomas and desmoid type fibromatosis and may alter the management strategy in cases of diffuse large B-cell lymphoma and metastases. Biopsies for cystic lesions are not recommended. The gold standard in imaging is MRI. The posterior Kraske procedure is the most common surgical approach. Overall, the reported recurrence rate was 19.7%.

CONCLUSION

This review evaluated the management strategies for retrorectal tumours. A preoperative biopsy should be performed for solid tumours. MRI is the most useful imaging modality. Surgery is the mainstay of treatment. There is limited information on robotic surgery, single-port surgery, transanal endoscopic microsurgery, chemoradiotherapy and reconstruction.