Cervical Intramedullary Schwannoma: Case Report and Review of the Literature

The Role of MRI in the Diagnosis of Spinal Cord Tumors

Spinal cord tumors are uncommon, and its multiple representatives not always have pathognomonic characteristics, which poses a challenge for both patients and caring physicians. The radiologist performs an important role in recognizing these tumors, as well as in differentiating between neoplastic and non-neoplastic processes, supporting clinical and surgical decision-making in patients with spinal cord injury. Magnetic Resonance Imaging (MRI) assessment, paired with a deep understanding of the various patterns of cord involvement allied to detailed clinical data can provide a diagnosis or significantly limit the differential diagnosis in most cases. In this article, we aim to review the most common and noteworthy intramedullary and extramedullary spinal tumors, as well as some other tumoral mimics, with an emphasis on their MRI morphologic characteristics.

Upper cervical intramedullary schwannoma of the spinal cord presenting with myelopathy: illustrative case

BACKGROUND

Intramedullary schwannomas account for 1.1% of all spinal schwannomas. Preoperative diagnosis is best accomplished by thoroughly evaluating clinical and radiological characteristics, accompanied by a high index of suspicion. The authors report a case of C2-3 intramedullary schwannoma in a young male who presented with neck pain and vertigo. The current literature is also reviewed.

OBSERVATIONS

The authors reviewed the data of a young male with a 2-month history of neck pain and vertigo. Magnetic resonance imaging of the brain and cervical spine showed an intramedullary mass at C2-3 with a syrinx extending into the cervicomedullary junction. Laminectomy, myelotomy, and microsurgical excision of the mass under intraoperative neurological monitoring (IONM) were done. Postoperative pathology reported the specimen as a schwannoma.

LESSONS

Gross-total resection of a schwannoma using IONM is the treatment of choice because of the lesion's benign nature, a better prognosis, and defined cleavage plane. Schwannomas should be included in the differential diagnosis of intramedullary spinal tumors. Because of its progressive nature, early surgery is recommended in symptomatic patients.

Intramedullary schwannoma – A case report

Background:

Schwannomas are benign but clinically progressive tumors. Mostly, they present as intradural extramedullary lesions. They are quite rare in the intramedullary (IM) region. We report a case of IM schwannoma.

Case Description:

A 52-year-old gentleman presented with a history of gait instability and numbness in bilateral lower limbs. He had clinical signs of myelopathy. His magnetic resonance imaging (MRI) dorsal spine was done that showed an intradural IM lesion at the level of D11, with one differential of ependymoma. Near total resection of lesion was done and histopathology reported it schwannoma.

Conclusion:

Preoperative radiologic assessment for IM spinal lesions is difficult and high degree of suspicion should be present when approaching a patient with somatic pain and IM lesion on MRI, keeping in mind one differential of IM schwannoma.

Clinical Effect of Laminectomy with Lateral Mass Screw Fixation in Treating Cervical Schwannoma: A Retrospective Study

Background

The objective of this study was to evaluate the clinical effectiveness and safety of laminectomy combined with lateral mass screw fixation in treating cervical intradural extramedullary schwannoma.

Methods

We retrospectively collected and analyzed medical records of 38 patients who underwent resection of cervical intraspinal schwannoma between January 2012 and April 2019. Based on different surgical procedures, two groups were divided among all participants: laminectomy-only (n = 21) and laminectomy with instrumented fixation (n = 17); the minimum follow-up time was 1 year. The visual analogue scale (VAS) score and neck disability index (NDI) were utilized for pain assessment; the Japanese Orthopedic Association (JOA) score was carried out for the assessment of neurological impairment. Radiographic changes of Cobb angle were compared before and after the surgery.

Results

Consequently, demographics were well matched in both groups, without any statistical difference (P > 0.05). Compared with preoperation, both surgical procedures significantly improved VAS, NDI, and JOA scores (P < 0.001), but no differences between them (P > 0.05). In terms of postoperative spinal instability/deformity, laminectomy-only caused more events than instrumented fixation, which is statistically significant (P < 0.001).

Conclusions

In summary, laminectomy with lateral mass screw fixation is an effective and safe approach to treat cervical intraspinal schwannoma, which is likely to be a better choice than the laminectomy-only approach.

Spinal intramedullary schwannomas-report of a case and extensive review of the literature

Intramedullary schwannomas (IMS) represent exceptional rare pathologies. They commonly present as solitary lesions; only five cases of multiple IMS have been described so far. Here, we report the sixth case of a woman with multiple IMS. Additionally, we performed the first complete systematic review of the literature for all cases reporting IMS. We performed a systematic review of the literature in PubMed, EMBASE and Cochrane Central Register of Controlled (CENTRAL) to retrieve all relevant studies and case reports on IMS. In a second step, we analysed all reported studies with respect to additional cases, which were not identified through the database search. Studies published in other languages than English were included. One hundred nineteen studies including 165 reported cases were included. In only five cases, the patients harboured more than one IMS. Gender ratio showed a ratio of nearly 3:2 (male:female); mean age of disease presentation was 40.2 years; 11 patients suffered from neurofibromatosis (NF) type 1 or 2 (6.6%). IMS are rare. Our first systematic review on this pathology revealed 166 cases, including the here reported case of multiple IMS. Our review offers a basis for further investigation on this disease.

Rare Case of Multiple Intradural Extramedullary Spinal Schwannomas With Intramedullary Extension

Spinal schwannomas are benign WHO grade I nerve sheath tumors that account for nearly 30% of all spinal neoplasm. Typically, these lesions are intradural extramedullary in location and are composed entirely of well-differentiated eosinophilic Schwann cells. Intramedullary schwannomas, however, are extremely rare due to the lack of Schwan cells in the normal spinal cord and represent 1% of all the spinal schwannoma population. The presence of such an intramedullary component makes diagnosis challenging as imaging features may resemble other intramedullary neoplastic entities.

Here, we describe a case of a 56-year-old male patient who presented with an 18-month history of intermittent right-sided mid-thoracic pain secondary to multiple intradural extramedullary spinal schwannoma with intramedullary extensions. We also review the literature pertaining to the condition.

Intradural Extramedullary Spinal Neoplasms: Radiologic-Pathologic Correlation

While intradural extramedullary spinal disease varies widely, identification of tumors in this location and their radiologic manifestations greatly facilitates narrowing of the diagnostic considerations. Meningioma and schwannoma are the two most common intradural extramedullary tumors, and both are associated with neurofibromatosis. Meningiomas are most common in the thoracic spine and show a strong female predilection and a clinical manifestation related to compression of the spinal cord or nerve roots. Schwannomas typically are associated with radicular pain and other sensory symptoms. Melanotic schwannoma frequently shows T1 hyperintensity at MRI related to the presence of paramagnetic free radicals in melanin. Neurofibroma, known for its T2 hyperintensity, frequently involves the cervical spine, where it may make surgical resection challenging. Less commonly, malignant peripheral nerve sheath tumor commonly mimics the imaging appearance of a schwannoma but has decidedly more aggressive biologic behavior. In the cauda equina, myxopapillary ependymoma and paraganglioma are believed to arise from the filum terminale and have characteristic imaging manifestations based on their underlying pathologic features. Recent identification of a common genetic marker has led to reclassification of what had previously been regarded as separate tumors and are now known as solitary fibrous tumor/hemangiopericytoma. In the proper clinical setting, the presence of nodular intradural enhancement strongly suggests the presence of leptomeningeal metastatic disease, even when results of cerebrospinal fluid analysis are negative. This article highlights the characteristic neuroimaging manifestations of these neoplasms, with emphasis on radiologic-pathologic correlation. See Illumination by Frazier .