Schwannomas of the hand and wrist: long-term results and review of the literature

Rare multiple schwannomas of the left upper extremity: A case report

Schwannomas are rare benign neoplasms originating from Schwann cells of peripheral nerve sheaths. The current study presents a distinctive case involving multiple schwannomas along the peripheral nerves of the left upper extremity. The patient exhibited multiple gradually enlarging subcutaneous masses distributed along the nerves of the left upper limb, without pain, neurological deficits or a positive Tinel's sign upon physical examination. Preoperative diagnostic imaging, including high-resolution ultrasonography and magnetic resonance imaging, revealed well-circumscribed, homogeneous soft-tissue masses with characteristic features. Despite these findings, imaging modalities demonstrated limited specificity in conclusively differentiating the upper extremity tumors from other soft-tissue neoplasms. Surgical exploration conducted under general anesthesia identified three encapsulated masses with focal capsular discontinuities, adherent to surrounding skeletal muscle and the median nerve. The masses measured 6×5×3, 5×4×3.5 and 5×3.5×3 cm from proximal to distal, respectively. Complete surgical excision was performed with meticulous preservation of adjacent neurovascular structures. Histopathological analysis confirmed the diagnosis of schwannomas. This report also provides an extensive review of the literature addressing the etiology, clinical presentation, diagnostic techniques and treatment strategies for peripheral nerve schwannomas, contributing to a deeper understanding of this rare neurogenic tumor and aiding in its effective clinical management.

Recurrent Ulnar Nerve Schwannoma in the Cubital Tunnel Elbow: A Rare Presentation and Surgical Management

Schwannoma is a benign tumor arising from Schwann cells of peripheral nerves. Although recurrence is rare, this case report highlights a unique instance of recurrent ulnar nerve schwannoma in a 76-year-old construction worker, emphasizing the complexities of surgical management. The patient presented to our orthopedic clinic with persistent pain and tingling in the medial aspect of his left forearm and hand for the past two years. His medical history included bilateral ulnar nerve schwannoma excision at the cubital tunnel level 20 years prior. Examination revealed a firm, non-tender swelling measuring 5 × 5 cm on the medial side of the left distal arm, with neurological assessment indicating reduced sensation in the little finger and medial half of the ring finger, as well as intrinsic hand muscle weakness. His preoperative Disabilities of the Arm, Shoulder, and Hand (DASH) score was 65, reflecting substantial functional limitations. Preoperative nerve conduction studies confirmed ulnar nerve damage, and MRI indicated a tumor originating from the left ulnar nerve. Given the tumor's increasing size, surgical excision was done. The procedure involved careful dissection around the elbow to isolate the ulnar nerve, significantly affected by fibrosis from prior surgeries. We performed macro neurolysis, which decompresses larger segments of the nerve, and micro neurolysis, which allows for precise intervention on specific segments, to effectively address the challenges presented by the scar tissue. Anterior transposition of the ulnar nerve was conducted to place it in an unscarred area, reducing compression and promoting nerve function. The postoperative biopsy confirmed a benign schwannoma characterized by localized Antoni A and Antoni B areas. Six months post surgery, the patient reported complete resolution of symptoms, with grip strength improving to approximately 95% of normal and a postoperative DASH score of 25. Follow-up assessments showed enhanced nerve function, with no signs of tumor recurrence over two years. This case underscores the challenges of managing recurrent ulnar nerve schwannoma and emphasizes the critical role of surgical intervention in preserving nerve function and improving patient outcomes. The successful management of this recurrence highlights the importance of meticulous surgical technique and thorough follow-up in ensuring long-term patient well-being.

Schwannomas of the upper limb: Clinical presentation, preoperative management and outcomes of surgical treatment

INRODUCTION

Schwannomas are the most common tumors of the peripheral nervous system. Surgical eradication with excision or enucleation is the treatment for symptomatic and large schwannomas.

Extracranial Head and Neck Schwannomas: A Single Centre Retrospective Experience of 97 Cases

Introduction

Schwannomas are rare benign neurogenic tumours. About 25-45% of extracranial schwannomas are found in the head and neck region. In the head and neck, they can arise from various cranial, peripheral and autonomic nerves. Due to this, they have varied clinical presentations.

Material and Methods

This retrospective cohort includes 97 patients diagnosed with extra cranial head and neck schwannoma, and operated in the Otolaryngology and Head & Neck Surgery department, from 2013 to 2022. The parameters observed were the age and gender distribution, location, nerve of origin, size, pressure symptoms, cranial palsies, post-operative symptoms, recurrence and complications. The data were collected from the institute's electronic records.

Results

The median age of the study population was 36 years; among them, 51 were men and 46 were women. The most common tumour location was parapharynx. The patients had varied head and neck symptoms, of which 23.7% had nerve paresis at presentation. Transcervical surgical approaches was most used. New onset cranial nerve paresis immediately post-surgery was noted in 22.7%. Recurrence was noted in 2% of cases.

Conclusions

Extra cranial schwannomas are uncommon neoplasms and have varied presentations. Comprehensive evaluation with appropriate imaging should be done in all cases. Though benign, patients can present with nerve paresis. Recurrence is uncommon after complete resection.

Peripheral Nerve Sheath Tumor: A Diagnostic and Therapeutic Challenge

INTRODUCTION

Peripheral nerve tumors are a group of rare soft tissue tumors of neuro-ectodermal origin. Although the majority of them are benign in nature, up to 10% can be malignant. The symptoms depend on the site, size, and structures compressed by the tumor.

AIM

To highlight the heterogeneity of signs and symptoms and their presentations, which has often made it difficult for the attending physician to accurately diagnose and direct the patient toward appropriate treatment.

METHODS

Eight patients treated at our tertiary care hospital between 2015 and 2022 were included in this study. They were evaluated in detail. Treatment was surgical. The patients underwent complete excision of the tumor under magnification to help preserve the adjacent neurovascular bundle. All patients were followed up post-operatively to document the status of their symptoms.

RESULTS

The average duration prior to referral to our hospital was 13 months. Seven subjects had pain at presentation, one had neurological deficit. Seven also complained of swelling. Five of the eight lesions were schwannoma, two neurofibroma and one showed malignant histology. Post-operatively, Hoffman Tinel signs improved in all six subjects. five of the seven subjects were completely pain-free, and the other two had a reduction in symptoms.

CONCLUSIONS

Early diagnosis and referral to a specialist center are needed to achieve satisfactory outcomes while treating peripheral nerve tumors. Proliferative lesions should be treated surgically in specialist centers by experienced doctors with appropriate skills and equipment for microsurgical procedures to ensure full recovery.

Surgery of Schwannoma in the upper limb - sensitivity and specificity of preoperative magnetic resonance imaging and relation between tumour size and symptoms

BACKGROUND

Benign peripheral nerve tumours consist of different types, most commonly Schwannomas. Preoperative Magnetic Resonance Imaging (MRI) is commonly performed before surgery and Pathoanatomical Diagnosis (PAD) confirms the diagnosis. Our aims were to study the utility of MRI and the relation between tumour size and symptoms.

METHODS

Retrospectively, patients, surgically treated for benign nerve tumours between 2008 and 2019, were identified and preoperative MRI, with measurement of tumour size, PAD, symptoms, peroperative details, and symptomatic outcomes of surgery, were analysed.

RESULTS

The sensitivity and specificity to correctly identify Schwannomas with preoperative MRI were 85% and 50%, respectively, based on 30 Schwannomas and nine neurofibromas that were identified. Tumour size did not affect the presence of preoperative symptoms, but patients with sensory dysfunction at last follow-up had larger Schwannomas (p < 0.05). Symptoms as a palpable tumour, paraesthesia and pain improved by surgical excision (p < 0.001, p < 0.001 and p < 0.012, respectively), but sensory and motor dysfunction were common postoperatively. No malignant peripheral nerve sheath tumours (MPNST) were found. Using a surgical microscope, instead of only loop magnification, lowered the risk of perioperative nerve injuries (p < 0.05), but did not further diminish postoperative symptoms.

CONCLUSIONS

Early and accurate diagnosis of Schwannomas is valuable for adequate presurgical preparation and prompt surgical intervention. Preoperative examination with MRI has a high sensitivity, but low specificity; although recent advancement in MRI technology indicates improvement in diagnostic precision. Surgical excision is preferably performed early in conjunction with symptomatic debut to improve outcome.

Benign nerve tumours in the upper limb: a registry-based study of symptoms and surgical outcome

Surgery for benign nerve tumours is performed for pathoanatomical diagnosis and symptomatic relief, but might cause residual problems. We aimed to assess patient-reported symptoms and disability before and after surgery at a national level. In total, 206 cases surgically treated for a benign peripheral nerve tumour 2010-2019 registered in the Swedish Quality Registry for Hand Surgery (HAKIR; response rates 22-34%) were analysed. Surgery reduced overall disability in the affected limb (QuickDASH 18/100 [IQR 5-36] preoperatively and 5/100 [IQR 0-22] 12 months postoperatively), improved ability to perform daily activities (HQ-8; 11/100 [IQR 0-50] preoperatively and 0/100 [IQR 0-20] 12 months postoperatively) and decreased three evaluated pain modalities: pain at rest (HQ-8; 20/100 [IQR 0-40] preoperatively and 0/100 [IQR 0-10] 12 months postoperatively), pain on motion without load (HQ-8; 20/100 [IQR 0-40] preoperatively and 0/100 [IQR 0-10] 12 months postoperatively), and pain on load (HQ-8; 24/100 [IQR 1-69] preoperatively and 1/100 [IQR 0-30] 12 months postoperatively). Cold sensitivity was a minor problem both before and after surgery (HQ-8; 0/100 [IQR 0-30] preoperatively and 1/100 [IQR 0-40] 12 months postoperatively). We conclude that surgery for benign peripheral nerve tumours provides good symptomatic relief with low risk for residual problems.

Clinical results after surgical resection of benign solitary schwannomas: A review of 150 cases

INTRODUCTION

Peripheral nerve schwannomas are the most common nerve tumors. While they are efficiently treated with surgery, the risk of neurological complications, especially sensory deficits, remains debated.

HYPOTHESIS

We postulate that rates of post-operative sensory deficits in peripheral schwannoma surgery are low and are not increased in schwannomas of the hand, in which preservation of discriminative tact is of prime functional importance.

MATERIALS AND METHODS

A retrospective multicenter study was carried out on 150 patients with an isolated peripheral schwannoma operated between 2002 and 2018, including 11 patients with schwannomas of the hand. All cases were reviewed preoperatively and postoperatively with a detailed exam of the neurological status.

RESULTS

Most schwannomas were located in the lower limbs (58%). The two main affected trunks were the posterior tibial nerve in the lower limb and the median nerve in the upper limb. The average preoperative tumor volume measured on MRI was 2.93 cm³ [0.11 cm³-25 cm³]. The most common preoperative symptoms were paresthesia (77.1%) and pseudo-Tinel sign (55.7%). Less frequently, pain (50.3%) and hypoesthesia (18.1%) were observed. On the other hand, preoperative neurological motor manifestations remained exceptional (3.3%). The rates of new post-operative motor deficits, paresthesias, and sensory deficits were 4.6%, 10.9% and 8% respectively and were not increased in schwannomas of the collateral nerves of the hand.

CONCLUSION

Surgical resection is a safe procedure for peripheral nerve schwannoma treatment with satisfying functional results and an acceptable risk of nerve injury, especially for sensory function.

LEVEL OF PROOF

D; Multicenter retrospective study.

Schwannoma of the Upper Limb: Retrospective Study of a Rare Tumor with Uncommon Locations

Background: Although schwannoma (neurilemmoma) is the most common tumor of the peripheral nerve, its low incidence, slow growth and vague symptoms often lead to misdiagnosis or delayed diagnosis. The aim of the study is to present a series with a large number of schwannomas in the upper limbs, some with very rare occurrence. Methods: We report 17 patients with a mean age of 58.5 years and upper limb schwannomas, located on the median, ulnar and radial nerves, but also on the posterior interosseous nerve and digital collateral nerves. The diagnosis was made by clinical examination and imaging tests, and in no case was a preoperative biopsy performed. Surgical treatment was established based on symptoms or aesthetic concerns. In all cases, a diagnosis of schwannoma was confirmed through histopathological and immunohistochemical examinations. Results: For all patients, a complete tumor enucleation was performed under a surgical microscope. No recurrence was recorded at 2 years after surgery. Patient satisfaction was good, with complete socio-professional integration in all cases. Conclusions: Although more frequently present on the main nerve trunks, schwannoma may be present on the collateral digital nerves in rare cases. A correct technique with complete tumor excision offers excellent postoperative outcomes and avoids recurrences.

Schwannoma in the extremity: clinical features and microscopic intra-capsular enucleation

Objective: Schwannomas are the most common type of neoplasm of the peripheral nerves. Enucleation is a standard surgical procedure; however, it occasionally results in iatrogenic nerve injury, even with atraumatic procedures. Herein, we present the clinical characteristics of schwannoma arising in the extremities and discuss the clinical outcomes of extra- and intra-capsular enucleation.

Patients and Methods: We reviewed 122 schwannomas treated at our institute. Schwannomas arising from the minor nerve (n=30) or intramuscularly (n=15) were operated using the extra-capsular technique. Of the 77 major nerve schwannomas, 62 schwannomas were treated using the intra-capsular technique and 15 schwannomas using the extra-capsular technique.

Results: Neurological deficits following enucleation were significantly lower using the intra-capsular technique than with the extra-capsular technique. The patient age, duration of symptoms, maximum tumor diameter, and site of occurrence were not associated with subsequent neurological deficits. With both techniques, no tumor recurrence was observed at the final follow-up.

Conclusion: These results support the use of intra-capsular micro-enucleation as a safe and reliable treatment for every type of schwannoma. To minimize the risk of nerve injury, en bloc resection should not be used because the main purpose of schwannoma surgery is the relief of symptoms, not tumor resection.

Multiple Schwannomas in Sciatic Nerve: A Rare Case Report

Schwannomas are the most common nerve sheath tumors which are usually solitary enucleated lesions. Multiple schwannomas are a rare circumstance which may occur with or without other manifestations of neurofibromatosis. In this study, we report the case of a 45-year-old man presenting with pain and swelling in the thigh and popliteal space without any manifestation of neurofibromatosis or neurologic problems. Surgery was performed and revealed four separated tumors in the sciatic nerve which was characteristic of schwannoma and confirmed by pathologic findings. Although multiple schwannomas are frequently associated with neurofibromatosis, the current case demonstrated a patient with multiple schwannomas without any manifestation of neurofibromatosis.

Surgical Excision of a Giant Schwannoma of the Hand: A Case Report

CASE

We report a 78-year-old man who underwent excision of a 13-year-old benign schwannoma originating from the terminal motor branch of the ulnar nerve. The mass measured 13 cm in diameter on presentation and was successfully excised, preserving a functional hand. At 4-year follow-up, the patient was asymptomatic with intact motor and sensory function and no signs of recurrence. To the best of our knowledge, this is the largest schwannoma of the hand to be reported in the literature.

CONCLUSIONS

Large schwannomas of the hand can successfully be excised with no postoperative complications.

Schwannoma of the posterior branch of the great auricular nerve

Schwannoma, also known as neurilemmoma, is a tumor of the nerve sheath, which most often occurs in the peripheral nerves of the extremities. Schwannoma can be accompanied by symptoms such as pain, paresthesia, and Tinel sign; however, patients can also be asymptomatic. Here, we present the case of a 17-year-old woman who presented with a slowly growing, asymptomatic, postauricular mass that appeared 10 years prior. Ultrasonography was performed, and the mass was thought to be an epidermal inclusion cyst. However, the clinical manifestation during surgery was not correlated to an epidermal inclusion cyst, leading to the suspicion of schwannoma from the posterior branch of the great auricular nerve. After a meticulous dissection, schwannoma was diagnosed based on a permanent section biopsy. Postoperative complications and recurrence were not observed. Schwannoma in the peripheral nerve area of the face is rare. Therefore, an investigation of tumors that occur where the nerve passes using imaging and clinical features is necessary to confirm the diagnosis of schwannoma and to establish suitable treatment methods.

Tibial Nerve Schwannoma: An Unexplained Cause of Lateral Foot Pain - A Rare Case Report and Review

Introduction:

Schwannoma is a benign tumor that arises from the peripheral nerve sheath. It presents as a discrete, often tender, and palpable nodule associated with neurogenic pain or paresthesia when compressed or traumatized. The growth rate is usually slow, and these lesions seldom exceed 2 cm in diameter.

Case Report:

We report the case of a schwannoma arising from the tibial nerve located in the left popliteal fossa. The patient presented with the left foot pain in the lateral plantar region without any motor deficit. The pre-operative diagnosis was made with magnetic resonance imaging (MRI) scan. He was subjected for neurolysis and excision biopsy of the lesion. The surgical specimen consisted of encapsulated white-yellow mass with irregular contours, measuring 2 × 3 cm. The cut section revealed cystic degenerations with areas of hemorrhage and necrosis. The patient reported symptom free in the post-operative period and during follow-up. Marginal excision appears to be recommended therapy for this tumorous lesion, without any evidence of recurrence during follow-up.

Conclusion:

A benign nerve sheath tumor of a peripheral nerve could be a possibility for long-standing neuropathic pain in the foot, ankle, and leg, wherein all other possibilities have been ruled out. The meticulous examination of the entire length of the tibial nerve including sciatic nerve by palpation and percussion was helpful in diagnosis which should be confirmed by MRI scan. The excision biopsy remains the gold standard treatment of choice for schwannoma of the peripheral nerve.

Deep palmar tumorous conditions of the hand

PURPOSE

Deep palmar tumors of the hand are very rare, and reported cases are usually benign. The most important issue is frequent anatomical variations with challenging surgical exposure and excision of these lesions. Some case reports or a small series of patients have been reported in the literature. The aim of this study was to present our experience with the deep palmar tumors of the hand.

PATIENTS AND METHODS

In the study, retrospective analyses of 43 patients treated with deep palmar tumors of the hand between January 1998 and June 2015 were evaluated. Tumors and tumor-like pathologies of the deep palmar space of the hand were retrospectively evaluated according to age, gender, localization, preoperative symptoms, size, site, treatment methods, histopathology, and early and late complications. Statistics and data analyses were also performed.

RESULTS

All 43 pathologies were benign, and histopathologic diagnoses were 10 lipomas, 8 ganglions, 5 giant cell tumor of the tendon sheath, 4 schwannomas, 3 hemangiomas, 3 palmar fibromatosis, 2 epidermal cysts, 2 neurofibroma, 1 angiolymphoid hyperplasia with eosinophilia, 1 granuloma, 1 calcifying aponeurotic fibroma, 1 digital fibroma, 1 foreign body granuloma, and 1 lipofibromatous hamartoma. The most common complication was temporary numbness and paresthesias of the digits. Marginal excision was performed in 40 patients, excision with nerve grafting in 2 patients (with neurofibroma) and carpal tunnel release in one patient with lipofibromatous hamartoma.

CONCLUSION

In the deep palmar space of the hand, pathologies are closely associated with tendons, muscles, and neurovascular structures. Preoperative magnetic resonance imaging is helpful for the preoperative diagnosis, evaluating tumor extension, and successful surgical planning. Level of Evidence: IV Therapautic.

Long-term Follow-up of Intracapsular Schwannoma Excision

INTRODUCTION

The current criterion-standard treatment for schwannomas is intracapsular excision. This study was designed as a long-term follow-up to investigate postoperative symptoms, nervous impairment, and recurrence rate.

METHODS

We performed a long-term follow-up of 18 subjects who underwent intracapsular schwannoma excision. We evaluated preoperative versus postoperative 2-point discrimination (2-PD) in the affected dermatome, pain (visual analog scale [VAS] from 0-10), Hoffmann-Tinel sign, and thermoreceptor response. For reasons of comparison, all examinations were done on both the healthy and affected extremity.

RESULTS

Last postoperative follow-up was done on average after approximately 50.4 months. Comparison between preoperative and postoperative sensibility testing (2-PD) in the affected dermatome showed a significant improvement of 22.7% after surgery (5-mm 2-PD; P = 0.02). Compared with the healthy nonoperated extremity preoperatively, subjects showed a significant sensory deficit of 40.9% (9-mm 2-PD; P < 0.000). Postoperatively, 12 of 18 subjects still showed a deficit in 2-PD. However, deficiency was decreased to 23.5% (mean, 4-mm 2-PD; P = 0.003). Through intracapsular schwannoma excision, subjects could drastically improve their pain (from VAS 6.7 to VAS 4.0).During our examination, we clinically suspected recurrence in 3 subjects, which were sent to magnetic resonance imaging to rule out or confirm a recurrent tumor.

DISCUSSION

Many subjects reported ongoing pain and sensory deficits after intracapsular excision of schwannomas. Symptoms right after surgery may be due to iatrogenic nerve injury or residual deficits from compression damage of the tumor mass. As schwannomas are usually growing at a slow rate, early symptoms after a symptom-free period might possibly indicate scarring of soft tissue, which may cause signs of recurrent neurological deficits or pain. Patients with a late onset of symptoms are at the highest risk of having a true recurrence of schwannoma. None of the 3 suspected subjects showed radiological evidence for a recurrent schwannoma, but rather scarring and soft tissue adhesions to the nerve, which could explain the clinical findings.Intracapsular removal of schwannomas is relatively easy to perform, does not cause any additional damage to the nerve in most cases, and is therefore an excellent method for treatment of symptomatic schwannoma patients.

Retrospective Analysis of 20 Patients Affected by Schwannomas in the Upper and Lower Limbs

Objective  To analyze the epidemiological profile and evolution of 20 patients diagnosed with upper- and lower-limb schwannomas.

Methods  A group of patients was defined for a retrospective evaluation comprising the period between February 2002 and June 2018, in which we studied and evaluated 20 medical records of patients undergoing surgery due to schwannoma; the diagnosis was confirmed by an anatomopathological examination.

Results  Male and female patients were equally affected. The average age was 50.85 years, ranging from 12 to 77 years. There was a predominance of the upper limb and of the flexor face. The most affected nerve was the ulnar nerve. In total, 6 (30%) patients had transient postoperative complications. No cases of tumor recurrence were identified.

Conclusion  Schwannoma is a rare and difficult-to-diagnose lesion. It should always be considered as a hypothesis when facing a soft-tissue tumor affecting the limbs. The Tinel sign should be regarded, given its higher correlation with complications. The patients should be informed of the possible postoperative complications, which are frequent but usually transient.

Median Nerve Schwannoma of the Hand and Wrist: 3 Cases

Tumors of the median nerve are difficult to diagnose and median nerve schwannomas are rare. During a ten-year period, we treated eleven median nerve schwannomas found on the hand (nine) and wrist (two). All the tumors were treated by enucleation under loupe magnification and tourniquet application. All had a favorable result at a mean follow up of five years. We present three of our most typical cases, with schwannomas found on the wrist, palm and thumb. We also review the literature offering a wider view on the pathology, diagnosis and treatment of schwannomas in general.

Schwannoma of the long thoracic nerve in the left axilla: a case report

Schwannoma, which is also known as neurilemmoma, is a type of tumor that arises from the peripheral nerve sheaths. Cases of schwannomas located in different regions have been reported. Some schwannomas present as asymptomatic masses, while others cause discomfort, such as pain and numbness. Magnetic resonance imaging (MRI) is a valuable diagnostic tool. A 23-year-old woman presented to our hospital with a mass in the left axilla that was misdiagnosed as mammae erraticae. The patient also considered the condition to be mammae erraticae for approximately 14 months because of a lack of symptoms. MRI was recommended by a surgeon from the galactophore department. A giant schwannoma was found. The mass was surgically excised, while preserving the continuity of the long thoracic nerve. Routine histopathological analysis confirmed the presence of a benign schwannoma. Schwannomas located in the axilla are rare and may be easily misdiagnosed as mammae erraticae or enlarged lymph nodes. Early investigation is necessary to make the diagnosis, and surgical excision is usually curative.

Nerve Tumors of the Upper Extremity

Nerve sheath tumors of the upper extremity are among the common neoplastic pathologies encountered by hand surgeons. A majority of these tumors are benign schwannomas or neurofibromas and may be associated with neurofibromatosis. Clinical signs of malignant transformation include new onset of pain and rapid growth. Imaging characteristics, such as standardized uptake value greater than 4.0 on PET scan, may aid in the diagnosis of a malignant tumor. Surgical excision, often with intrafascicular dissection with nerve preservation, is recommended treatment of benign lesions. Wide surgical excision is recommended for malignant lesions.

Multiple schwannomas of the digital nerves and common palmar digital nerves: An unusual case report of multiple schwannomas in one hand

RATIONALE

Benign schwannoma is the most common tumor of peripheral nerves while plexiform multiple schwannomas are rare conditions. This manuscript reported a case of multiple Schwannomas characterized by unusual location.

PATIENT CONCERNS

We report a 34-year-old workman presented with multiple nodules in his forefinger, middle finger and palm respectively for 5 years. He felt pain combined with paraesthesias in fingers and palm. The symptoms could be eased through rest and drugs medication.

DIAGNOSIS

Three Schwannomas were found in surgery respectively. Histologic findings confirmed the diagnosis of schwannomas.

INTERVENTIONS

We removed all of the 3 schwannomas completely without damaging the continuity of the nerve.

OUTCOMES

Six months after the surgery, the patient had had not experienced any symptom recurrence.

LESSONS

Successful treatment of multiple schwannomas depends upon accurate diagnosis. Early surgery can improve the treatment outcome of multiple schwannomas.

Ancient Schwannoma of Radial Nerve: A Report of Two Cases

Ancient schwannoma is a rare variant of schwannoma associated with a longstanding course. They differ from classical schwannomas in the long duration for this subtype of schwannoma to develop and also by demonstrating haemorrhagic and degenerative changes with nuclear atypia. It is because of these histologic hallmarks that they are frequently misdiagnosed as malignant tumours. They usually involve the major nerves of flexor surfaces in upper extremity such as the ulnar and median nerve but schwannomas of the radial nerve are a rare entity. We report two cases of ancient schwannoma involving the radial nerve at mid arm and dorsum of the hand. The differential diagnoses included atypical soft tissue sarcomas and tumours of neural origin. Imaging and histopathology are crucial in diagnoses of these tumours.

Axillary Nerve Schwannoma: A Rare Case Report

Primary tumors of the brachial plexus are a rare cause of an axillary swelling. Schwannomas are benign tumors arising from Schwann cells. Most of the schwannomas occur in the head and neck region and in the flexor aspect of the limbs. We present a case of a 60-year-old female who presented with pain in the left axilla radiating to the left upper limb since 2 years and a painful swelling in her left axilla for 3 months. The diagnosis is made by fine needle aspiration cytology and magnetic resonance imaging, and confirmed by histopathological examination as schwannoma.

Retrospective Analysis of 20 Patients With Schwannomas: Magnetic Resonance Imaging Characteristics, Pain, and Outcomes Following Excision

A Tinel's sign, a percussion-induced, painful sensation, has been reported as the most useful sign for diagnosing a schwannoma. On magnetic resonance imaging, schwannomas often exhibit a split fat sign and a target sign. The typical treatment for schwannomas is surgical excision; however, excision often results in high rates of neurological deficit. The authors retrospectively reviewed 20 patients who underwent excision of a schwannoma from 2007 to 2015. Twenty patients presented with a split fat sign and 12 patients presented with a Tinel's sign on magnetic resonance imaging. Only 3 patients presented with a target sign on magnetic resonance imaging. The operative approach involved removing the schwannoma, preserving the nearby nerve fascicles, and leaving the epineurium open. Follow-up ranged from 3 to 91 months (average, 29 months). At final follow-up, all patients were pain free. Nineteen patients had normal sensation and full function of their affected limb. One patient developed postoperative posterior interosseous nerve palsy. A Tinel's sign, preoperative pain, and a split fat sign on preoperative magnetic resonance imaging are the clinical symptoms most useful for diagnosing a schwannoma. Schwannomas can be safely removed via intracapsular surgical excision with minimal complications, yielding eradication of preoperative pain, normal sensation, and full function. [Orthopedics. 2017; 40(6):e1036-e1043.].

Neurilemmomas of the Hand—A Review of the Clinical Presentation, Surgical Outcome, and Potential Risk Factors

Introduction

Neurilemmoma of the hand may not usually present with the classic triad (mass, differential mobility, Tinel's sign). Failure to recognize a neurilemmoma may result in the inadvertent injury of nerves. Preoperative diagnosis is very important and challenging.

Materials and Methods

A retrospective study of patients who underwent surgery for neurilemmoma of the hand between 2001 and 2013 was conducted. Their clinical presentation, surgical outcome and potential risk factors were reviewed.

Results

Twenty-eight cases of neurilemmoma arising from digits and hands in 28 patients were retrieved for study. Seventeen were male and 11 were female; the mean age at surgery was 57.1 years old and mean follow-up was 15.4 months. Nineteen lesions were on the volar side and the others were on the dorsal side. Volar digital nerve was the most common site of involvement. All patients presented with a mass, with an average duration of symptoms of 41.1 months; 35.7% had local tenderness. Differential mobility and Tinel's sign could be elicited in 39.3% and 21.4%, respectively. Correct preoperative diagnosis was made only in 25% of cases. At final follow-up, 82.1% of patients was symptom-free. Numbness, local tenderness and hypertrophic scar were reported in 7.1%, 7.1% and 3.6% of patients, respectively. No recurrence and no wound complications were noted. No reoperation was necessary. Multiple lesions and a positive Tinel's sign were associated with less satisfactory outcome and increased risk of postoperative complications as shown by the statistical analysis.

Conclusion

Neurilemmoma should be one of the differential diagnoses when dealing with hand masses. Tinel's sign should be done routinely on examination to facilitate correct preoperative diagnosis. Loupe magnification should be used during operation for optimal surgical outcome.

Magnetic Resonance Imaging of the Digital Nerves of the Hand: Anatomy and Spectrum of Pathology

Digital nerves are intrinsic to the sensory and motor function of the hand. These nerves represent the terminal ramifications of the ulnar, median, and radial nerves and are located distal to the carpal tunnel and Guyon canal. With magnetic resonance imaging, traumatic and nontraumatic abnormalities of the digital nerves can be shown with high contrast as well as high spatial resolution. Digital nerve abnormalities are most commonly posttraumatic in nature; however, infection, inflammatory, vascular malformations, and neoplasms can rarely occur. Magnetic resonance imaging is playing an increasing role in the assessment of peripheral nerve injury throughout the body, and in the hand, which can accurately identify the extent and character of digital nerve abnormalities before operative intervention.

Giant Schwannoma of ulnar nerve: case report

Schwannomas are the most common benign neoplasms of the peripheral nerves in the upper limbs.

Although many are asymptomatic, they can produce a mass effect, thus impinging against soft tissues or interfering with joint function.

The authors present a case report and a review of a giant Schwannoma in the ulnar nerve.

High-Resolution Ultrasound of Schwannomas of the Limbs: Analysis of 72 Cases

Schwannomas are common benign tumors that develop in peripheral nerves. High-resolution ultrasound (HRUS) is an effective imaging modality in clinics. The aim of this study was to define the value of HRUS in diagnosing schwannomas that originate from different nerves in limbs. We reviewed the ultrasound and surgical records of 72 pathologically confirmed schwannomas in the limbs of 60 patients. Results revealed that 44 (61.1%) of 72 cases, 44 (75.9%) of 58 cases and 0 (0%) of 14 cases received an overall correct pre-operative diagnosis, a correct pre-operative diagnosis in nerve trunks and a correct pre-operative diagnosis in small branches, respectively. Identification of the nerve of origin of schwannomas through HRUS likely increased confidence in diagnosing these benign tumors.

Post-traumatic Median Nerve Neuroma in Wrist. A Case Report and brief review of Literature

Introduction:

Distal median nerve masses may be developed post-traumatic or non-traumatic. In this paper, we aim to present a 52 year old female case with a postraumatic neuroma of the median nerve in the left wrist.

Case Series:

A 52-year-old female patient had accidental incised wound over her left wrist which was primarily sutured. She presented 6 months later with unrelieved pain and growing swelling at the wrist. USG showed solid mass of size 2x3 cms. Intraoperatively the mass was seen to arise from medial nerve and careful excision was done protecting the nerve. At one year follow up the patient is relived of her symptoms with no sensorimotor deficit.

Conclusion:

Post traumatic neuroma present as unrelieved pain and progressive swelling. A high index of suspicion should be kept in cases of wound that are primarily sutured over an area with superficial nerves. Careful excision of the lesion is very effective in relieving patients symptoms

Benign nerve tumours of the hand (excluding wrist)

INTRODUCTION

Hand tumours of neural origin are rare in clinical practice. The aim of this work is to present our experience in operative treatment of benign nerve tumours located in the hand. Special emphasis has been put on determining the occurrence rates of particular tumour types characterized by their unique histopathological patterns and describing detailed location of the lesions. The obtained results of treatment were assessed.

MATERIALS AND METHODS

The study comprised of 26 patients, both female (19) and male (7). The mean age and age range of the female and male patients were 44.8 years (range, 21-73 years) and 39.6 years (range, 21-74 years), respectively. The patients underwent operative treatment for tumours of neurogenic origin located in the hand between the years 1990 and 2013. In total, 31 tumours in 26 patients were removed. The most common site of tumour origin was small cutaneous branches and only exceptionally the tumours arose from common digital nerves (2 patients). No patient was lost to postoperative follow-up. The shortest period of postoperative follow-up covered 1 year.

RESULTS

No tumour recurrence was detected during postoperative follow-up examinations. The patients reported neither pain nor presence of paraesthesias. Neurofibromas (17 tumours) predominated in the gathered clinical material, while the second most common group of tumours were schwannomas (12 tumours).

CONCLUSIONS

(1) Benign nerve tumours of the hand are rare. Neurofibromas and schwannomas predominate among them. Tumours having other histopathological patterns are extremely uncommon. (2) The prognosis after resection of benign nerve tumours located in the hand is good and the risk of postoperative complications and recurrence is low.

Median nerve schwannoma: A case and review of literature

We report a case of a median nerve schwannoma, a rare type of a benign tumor of Schwann cells that presents as a palpable and painful mass on the flexor aspect of the forearm. Schwannomas of the median nerve make up 0.1–0.3% of all hand tumors. Symptoms are caused by an entrapment syndrome resulting from the growing tumor. Pain is the most common complaint of schwannomas. Imaging studies include computed tomography and magnetic resonance imaging and ultrasound. It is difficult to differentiate schwanommas from neurofibromas solely on the basis of a radiological investigation. Tumors of the median nerve are diagnostically challenging and median nerve schwannomas are rare. Diagnostic pearls are described to facilitate a more accurate and timely diagnosis. These characteristics include mobility, Tinel's sign, S-100 histological staining, and Antoni patterns. With a correct diagnosis, the tumor can be extirpated with preservation of nerve function and a low risk of recurrence.

Results of surgical treatment of schwannomas arising from extremities

Schwannomas are benign neoplasms derived from Schwann cells. In this work, we present our experience in operative management of schwannomas and analyse results of treatment. Clinical material consisted of 34 patients, in whom 44 schwannomas located in extremities were excised between 1985 and 2013. Thirty-five tumours originated from major peripheral nerves and 9 from small nerve branches. Postoperatively, in the first group of tumours, pain resolved in 100%, paresthesias in 83.3%, and Hoffmann-Tinel sign in 91.6% of the patients. Improvement in motor function was noted in 28.5% of the cases, in sensory function: complete in 70%, and partial in 15%. The most frequently affected major peripheral nerves were the ulnar (11 tumours) and median (5 tumours) nerves. Schwannomas originating from small nerve branches were removed without identification of the site of origin. After their resection, definitive healing was achieved. Conclusions. (1) Schwannomas located in extremities arise predominantly from major peripheral nerves, most commonly the ulnar and median nerves. (2) Gradual tumour growth causes exacerbation of compression neuropathy, creating an indication for surgery. (3) In most cases, improvement in peripheral nerve function after excision of schwannoma is achieved. (4) The risk of new permanent postoperative neurological deficits is low.

Results of surgical treatment of schwannomas arising from extremities

Schwannomas are benign neoplasms derived from Schwann cells. In this work, we present our experience in operative management of schwannomas and analyse results of treatment. Clinical material consisted of 34 patients, in whom 44 schwannomas located in extremities were excised between 1985 and 2013. Thirty-five tumours originated from major peripheral nerves and 9 from small nerve branches. Postoperatively, in the first group of tumours, pain resolved in 100%, paresthesias in 83.3%, and Hoffmann-Tinel sign in 91.6% of the patients. Improvement in motor function was noted in 28.5% of the cases, in sensory function: complete in 70%, and partial in 15%. The most frequently affected major peripheral nerves were the ulnar (11 tumours) and median (5 tumours) nerves. Schwannomas originating from small nerve branches were removed without identification of the site of origin. After their resection, definitive healing was achieved. Conclusions. (1) Schwannomas located in extremities arise predominantly from major peripheral nerves, most commonly the ulnar and median nerves. (2) Gradual tumour growth causes exacerbation of compression neuropathy, creating an indication for surgery. (3) In most cases, improvement in peripheral nerve function after excision of schwannoma is achieved. (4) The risk of new permanent postoperative neurological deficits is low.

Schwannomas of the upper extremity: analysis of 34 cases

BACKGROUND

Schwannomas are the most common benign tumours developing in peripheral nerves. They usually present as a slow-growing mass, sometimes associated with pain and paraesthesia. The aim of this study is to define the correct preoperative diagnosis, to review the surgical treatment employed and to evaluate short- and long-term neurological deficits.

METHODS

Thirty-four patients affected by schwannoma in the upper limbs were treated in the period 1995-2011. In 15 patients the tumour was located on the ulnar nerve, in 8 on the median nerve, in 2 on the radial nerve, in 1 on the anterior interosseous nerve, in 1 on the muscle-cutaneous nerve, and in the remaining 7 on the digital nerves. All patients were surgically treated using a microsurgical approach.

RESULTS

The enucleation of the mass was possible without fascicle lesion in 12 cases. In 22 cases resection of the indissociable fascicles was performed. Postoperative paraesthesia was present in 28 out of 34 treated patients; this clinical sign regressed in a mean period of 12 months in 27 patients.

CONCLUSIONS

When approaching a palpable mass in the upper limbs, the possibility of a peripheral nerve tumour should always be considered. It is important to look for typical signs of schwannomas, such as a positive Tinel sign and peripheral paraesthesia. Imaging assessment with magnetic resonance imaging (MRI) and ultrasonography enables the determination of where the tumour takes its origin and from which nerve. Microsurgical techniques and know-how are recommended in approaching the resection in order to respect as many nerve fibres as possible.

Multiple plexiform schwannomas in the plantar aspect of the foot: case report and literature review

Background

Plexiform schwannoma (PS) is a rare, peripheral nerve sheath tumor arranged in a plexiform pattern.

Case presentation

We report an unusual case of a 19-year-old woman, who complained of pain in the plantar aspect of the left foot. Magnetic resonance image (MRI) demonstrates three solitary nodules of varying sizes in the deep soft tissue of the plantar aspect of the foot that are homogeneously isointense to skeletal muscle on T1-weighted images and hyperintense on T2-weighted fat-suppressed images, especially the rim of the lesion. Subsequent pathological examination confirmed the diagnosis of PS.

Conclusion

MRI characteristic plays an important role in detecting this rare lesion. A review of the literature on PS is also presented.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-342) contains supplementary material, which is available to authorized users.

Management of extremity neurilemmomas: clinical series and literature review

BACKGROUND

Delicate enucleation of neurilemmoma preserves most of nerve fascicles and causes minimal nerve function impairment. Accurate preoperative diagnosis of neurilemmoma is based on clinical findings and image studies.

MATERIALS AND METHODS

Between November 2003 and February 2013, operations for the treatment of neurilemmoma were performed on 14 patients (12 men and 2 women) at our institution. The image studies in this series were collected. The tumor mass was approached by splitting the epineurium. In a few cases, enucleation of the neurilemmoma caused some fascicles loss, but reconstruction with sural nerve grafts preserved nerve function.

RESULTS

Before surgery, 7 patients received computed tomographic scan, 4 patients underwent magnetic resonance imaging, and 3 patients received sonography. Six patients presented with motor or sensory deficits immediately after tumor enucleation. Three patients recovered completely from the neurological defects with or without nerve reconstruction.

CONCLUSIONS

Our results indicate that neurilemmoma can be removed by delicate enucleation with an acceptable risk of injury to the nerve trunk.

Imaging and surgical approach for a schwannoma of the hand

Schwannomas are benign encapsulated neoplasms of the peripheral nerve sheath. Clinical diagnosis is often difficult, and final diagnosis is usually based on histopathological findings. Imaging techniques, such as magnetic resonance imaging and ultrasonography, can be optimized to improve assessment prior to surgical treatment. The present case demonstrates that high-resolution sonography can be useful in assessing the underlying cause of median nerve pathology.

Neurilemmoma of median nerve

Neurilemmomas constitute one of the most common tumors of peripheral nerves. Rarer amongst them is their occurrence in median nerve in the region of arm. A sixteen-year-old female presented with painless mass in right arm which was non-tender on palpation with positive Tinel's sign and no motor or sensory deficit in the affected arm. Ultrasound examination revealed an eccentrically arising mass of size 19 × 11 mm along median nerve. MRI study revealed a mass homogenously isointense on T1 weighted images and hyperintense in T2 weighted images placed eccentrically in relation to median nerve in arm. Excisional biopsy under loupe magnification was carried out which revealed the mass to be neurilemmoma. This slowly growing benign tumor of peripheral nerves with an incidence of 5% with 14% involvement of Median nerve can be enucleated from the nerve with little or no damage. In spite of advanced imaging studies the mass cannot be differentiated preoperatively from another peripheral nerve sheath tumor neurofibroma. Both these tumors although bearing some clinical and imaging resemblance carry different intraoperative findings, histopathological features and post-operative results.

Schwannoma of the median nerve at the wrist and palmar regions of the hand: a rare case report

Schwannomas are also known as neurolemmas that are usually originated from Schwann cells located in the peripheric nerve sheaths. They are the most common tumours of the hand (0.8-2%). They usually present solitary swelling along the course of the nerve however multiple lesions may be present in cases of NF type 1, familial neurofibromatosis, and sporadic schwannomatosis. Schwannomas are generally represented as an asymptomatic mass; however pain, numbness and fatigue may take place with the increasing size of the tumour. EMG (electromyelography), MRI (magnetic resonance imagination), and USG (ultrasound) are helpful in the diagnosis. Surgical removal is usually curative. In this paper, we present a 24-year-old male referred to our clinic for a lump located at the volar side of the left wrist and a lump located in his left palm and numbness at his 3rd and 4th fingers. Total excision was performed for both lesions. Histopathological examination of the masses revealed typical features of schwannoma. At the 6th-month followup the patient was symptom-free except for slight paresthesia of the 3rd and the 4th fingers. For our knowledge, this is the second case in the literature presenting wrist and palm involvement of the median nerve schwannoma.

Schwannoma in the upper limbs

Schwannomas are the commonest tumours of peripheral nerves. Despite the classical description that schwannomas are well encapsulated and can be completely enucleated during excision, a portion of them have fascicular involvement and could not be completely shelled out. A retrospective review for 8 patients was carried out over 10 years. 75% of schwannoma occurred over the distal region of upper limb (at elbow or distal to it). It occurs more in the mixed nerve instead of pure sensory or motor nerve. 50% of patients had mixed nerve involvement. Fascicular involvement was very common in schwannoma (75% of patients). Removal of the tumour with fascicles can cause functional deficit. At present, there is no method (including preoperative MRI) which can predict the occurrence of fascicular involvement; the authors therefore proposed a new system to stratify patients who may benefit from interfascicular nerve grafts. In this group of patients, the authors strongly recommend that the possibility and option of nerve graft should be discussed with patients prior to schwannoma excision, so that nerve grafting could be directly proceeded with patient consent in case there is fascicular involvement of tumour found intraoperatively.