Surgery of spinal nerve schwannoma. Risk of neurological deficit after resection of involved root

Functional outcomes in intradural extramedullary spinal tumors

Background

Intradural extramedullary (IDEM) spinal cord tumors account for approximately two-thirds of benign intraspinal neoplasms. These are amenable to gross total excision but can have variable functional outcomes, which plays a key role in assessing their impact on a patient's quality of life. Understanding the functional outcomes associated with these tumors is crucial for healthcare professionals to devise appropriate treatment plans and provide comprehensive care.

Methods

In this study, we retrospectively reviewed the outcomes of 130 patients with IDEM tumors who underwent surgery in the past six years between January 2017 and December 2022 at a single institution. Patient demographics, symptoms, and tumor characteristics (anatomical and pathological) in all operated spinal IDEM tumors were analyzed. The neurological findings obtained during the preoperative stage and the postoperative follow-up were evaluated according to the Frankel grading. The back pain was assessed using the Denis pain scale (DPS).

Results

The age range, gender distribution, presentation, histopathology, and tumor characteristics were analyzed. The histopathological outcomes of the study were as follows: 56 cases of schwannoma, 37 cases of meningiomas, 16 patients of neurofibroma, six cases of epidermoid cyst, five cases each of ependymoma and dermoid cyst, three cases of arachnoid cyst, two cases of metastasis, and one case of paraganglioma. Pain was the most common symptom (38.5%), followed by weakness in limbs (31.5%), paresthesia/numbness (22.3%), and sphincter disturbance (7.7%). Complete total resection was seen in 93% of cases, with 7% undergoing subtotal excision. The complications encountered were - four cases of surgical site infection and one case each of cerebrospinal fluid leak, pseudomeningocele, and epidural hematoma. In our series, 49.3% of patients had significantly good improvement in functional outcomes as per improvement in Frankel score, and 43% of patients had good functional improvement. Significant functional improvement was noted at immediate postoperative follow-up, 2-week follow-up, and six-month follow-up periods. Reoccurrence was seen in 7 cases (5.4%). The DPS score mean values showed a significant decrease over the follow-up duration as compared to preoperative mean values. Significantly poor outcome was seen in IDEM tumours present anteriorly.

Conclusion

The IDEM tumors are usually benign and are readily detected by contrast-enhanced magnetic resonance imaging scans. These have variable functional outcomes in different centers. Assessing this functional outcome is an essential aspect of managing IDEM spinal tumors. It was observed through our study that the ventral location of the tumor, thoracic tumors, and poor preoperative neurological status of the patient correspond with poorer postoperative functional outcomes. Furthermore, a significant decrease in the pain symptoms with improvement of Frankel score was seen postoperatively, thus this being suggestive of a significant improvement of functional outcome after surgery. This study helps to conclude that the morbidity associated with the resection of IDEM tumors is not as significant as originally thought to be.

Surgical management of spinal schwannomas arising from the first and second cervical roots: Results of a cumulative case series

Objective

Schwannomas of the first and second nerve roots are rare neurosurgical entities, harboring specific surgical features that make surgical resection particularly challenging and deserve specifics dissertations. This study is a retrospectively analysis of 14 patients operated in two different neurosurgical centers: the San Filippo Neri Hospital of Rome and the Federal Centre of Neurosurgery of Tjumen.

Materials and Methods

In the last 6 years, 14 patients underwent neurosurgical resection of high cervical (C1-C2) schwannomas, in two different neurosurgical centers. Patients data regarding clinical presentation, radiological findings, and surgical results were retrospectively analyzed.

Results

The mean age was 50 years (range 13-74), the follow-up mean duration was 30 ± 8.5 (range 24-72 months), and there was no significant differences among different tumor locations (intradural, extradural, and dumbbell). Surgical results were excellent: gross total resection was achieved in all cases and there were no intraoperative complications or postoperative mortality. All patients presented postoperative clinical improvement except one who remained stable. Karnofsky performance status, at the last follow-up, confirmed a global clinical improvement. No vertebral artery (VA) injury neither spinal instability occurred; nerve root sacrifice was reported in one case.

Conclusions

Neurosurgical treatment of C1-C2 schwannomas is associated with good outcomes in terms of extent of resection and neurological function. In particular, dumbbell shape and VA involvement do not represent limitations to achieve complete tumor resection and good clinical outcome. In conclusion, microsurgery represents the treatment of choice for C1-C2 schwannomas.

Sacrifice of Involved Nerve Root during Surgical Resection of Foraminal and/or Dumbbell Spinal Neurinomas

Even if usually needed to achieve the gross total resection (GTR) of spinal benign nerve sheath tumors (NSTs), nerve root sacrifice remains controversial regarding the risk of neurological deficit. For foraminal NSTs, we hypothesize that the involved root is poorly functional and thus can be safely sacrificed. All spinal benign NSTs with foraminal extension that underwent surgery from 2013 to 2021 were reviewed. The impacts of preoperative clinical status and patient and tumor characteristics on long-term outcomes were analyzed. Twenty-six patients were included, with a mean follow-up (FU) of 22.4 months. Functional motor roots (C5-T1, L3-S1) were involved in 14 cases. The involved nerve root was routinely sacrificed during surgery and GTR was obtained in 84.6% of cases. In the functional root subgroup, for patients with a pre-existing deficit (n = 5/14), neurological aggravation persisted in one case at last FU (n = 1/5), whereas for those with no preop deficit (n = 9/14), a postoperative deficit persisted in one patient only (n = 1/9). Preoperative radicular pain was the only characteristic significantly associated with an immediate postoperative motor deficit (p = 0.03). The sacrifice of an involved nerve root in foraminal NSTs seems to represent a reasonable and relevant option to resect these tumors, permitting one to achieve tumor resection in an oncologic fashion with a high rate of GTR.

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.

Percutaneous Transforaminal Full-Endoscopic Removal of Neurinoma of the Fifth Lumbar Nerve Root With Intraoperative Neuromonitoring: A Case Report

Background

Technical achievements and surgical techniques improvement contribute to the expansion of the endoscopic spine surgery possibilities. However, today there are few reports about the use of percutaneous endoscopy in spinal tumor surgery. A case of percutaneous transforaminal endoscopic removal of the lumbar spinal nerve tumor with intraoperative neuromonitoring is presented.

Case Description

A 59-year-old female was complaining of a left shin and foot pain, weakness, and paresthesia. Preoperative magnetic resonance imaging (MRI) revealed a tumor (neurinoma) at the left L5-S1 intervertebral foramen. Transforaminal endoscopic removal of an extramedullary tumor from an 8-mm skin incision with intraoperative neuromonitoring was performed. Postoperative MRI revealed the signs of total resection of the tumor.

Conclusion

The presented case confirms that percutaneous endoscopic removal of lumbar spine intraforaminal neurinomas can be safe and effective.

Monitoring spinal surgery for extramedullary tumors and fractures

Meningiomas are the most common intradural extramedullary tumors, followed by nerve sheath tumors that can also grow extradurally. Metastases are the most frequent extradural tumors and most commonly affect the thoracic vertebrae. Spinal fractures with column dislocation and/or instability require surgical fixation. Spine surgery for an extramedullary tumor or fracture usually involves decompression of neural elements and instrumentation for stabilization. These procedures risk spinal cord and nerve root injury. The incidence of nerve root deficits after resection of nerve sheath tumors is particularly high since the tumor grows from the rootlets. Intraoperative neurophysiologic monitoring and mapping techniques have been introduced to prevent iatrogenic neurologic deficits. These include motor and sensory evoked potentials, electromyography, compound muscle action potentials, and the bulbocavernosus reflex. The combination of techniques chosen for a particular procedure depends on the surgical level and the character of the lesion.

Intraoperative electromyographic techniques for the decision-making of tumor-involved nerve root resection for treating spinal schwannomas

BACKGROUND CONTEXT

Total removal of spinal schwannomas is ideal but it sometimes requires tumor-involved root resection, which increases the risk of postoperative motor deterioration (PMD). Therefore, it is important for clinicians to predict the impact of tumor-involved root resection on motor function in spinal schwannomas.

PURPOSE

To investigate the role of intraoperative electromyographic (EMG) techniques in decision-making of tumor-involved root resection for treating spinal schwannomas.

STUDY DESIGN

A retrospective analysis PATIENT SAMPLE: Sixty-eight patients with spinal schwannomas arising from C5-T1 or L3-S1 roots underwent total resection of schwannoma, including tumoral root.

OUTCOME MEASURES

Nerve root activation threshold, free-running EMG signals, visual analogue scale, and American Spinal Injury Association scale.

METHODS

During evoked EMG, nerve root activation threshold for tumoral root stimulation was recorded from muscles anatomically corresponding to tumoral root. During free-running EMG, abnormal EMG signals were identified as irregularly recurrent, monomorphic signals, low frequency (<5 Hz) or absent discharges recorded from muscles innervated by tumoral root. Clinical assessments were performed before, 3 to 5 day's and six months' after operation.

RESULTS

Sixteen (16 of 68, 23.5%) patients showed PMD, and muscle strength improved or was not affected in the other 52 patients. Absent myogenic responses were observed in 19 patients with non-PMD, and nerve root activation threshold in non-PMD group was higher than that in PMD group (p<.05). Receiver operating characteristic curve revealed that cut-off value of nerve root activation threshold for distinguishing functional and nonfunctional roots was 11.8 mA. A larger number of patients without PMD than with PMD showed abnormal free-running EMG signals (p<.05). At postoperative 6-months' follow-up, ten patients with muscle weakness after tumor-involved root resection showed functional recovery (full vs. partial recovery: 5 vs. 5), and intraoperative nerve root activation threshold in these patients was higher than that in the other patients without functional recovery (p<.05). Furthermore, there is negative relationship between the duration for full recovery and nerve root activation threshold (p<.05).

CONCLUSIONS

Both evoked and free-running EMG can be used as supplementary tests for differentiating functional and nonfunctional tumoral roots in spinal schwannomas, and nerve root activation threshold may be also related to prognosis of patients with muscle weakness caused by tumor-involved root resection. Therefore, intraoperative EMG techniques may provide additional references in decision-making of tumor-involved root resection.

A significant association between C5 nerve sheath tumors and new postoperative weakness

OBJECTIVE

The objective of this study was to determine if patients with nerve sheath tumors affecting the C5 spinal nerve are at greater risk for postoperative weakness than those with similar tumors affecting other spinal nerves contributing to the brachial plexus.

METHODS

A retrospective chart review (1998-2020)identified patients with pathologically confirmed schwannomas or neurofibromas from the C5 to T1 nerves. Patients with plexiform nerve sheath tumors, tumors involving more than 1 nerve, and malignant peripheral nerve sheath tumors were excluded. Collected variables included basic demographics, tumor dimensions, its location relative to the dura, involved nerve level, surgical approach, extent of resection, presenting symptoms, postoperative neurological deficits, and recurrence rate.

RESULTS

Forty-six patients (23 men, 23 women) were identified for inclusion in the study with an average age of 47 ± 17 years, BMI of 28 ± 5 kg/m2, and follow-up of 32 ± 45 months. Thirty-nine patients (85%) had schwannomas and 7 (15%) had neurofibromas. Tumors involved the C5 (n = 12), C6 (n = 11), C7 (n = 14), C8 (n = 6), and T1 (n = 3) nerves. Multivariable logistic regression analysis with an area under the curve of 0.85 demonstrated C5 tumor level as an independent predictor of new postoperative weakness (odds ratio 7.4, p = 0.028). Of those patients with new postoperative weakness, 75% improved and 50% experienced complete resolution of their motor deficits.

CONCLUSIONS

Patients with C5 nerve sheath tumor resections are at higher odds of new postoperative weakness. This may be due to the predominant single innervation of shoulder muscle targets in contrast to other upper extremity muscles that receive input from 2 or more spinal nerves. These findings are important for clinical decision-making and preoperative patient counseling.

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.

A Case Series of Surgically Treated Spinal Dumbbell Tumors of Critical Parent Nerve Roots: To Cut or Not to Cut?

BACKGROUND

Dumbbell tumors present challenging cases, with either an incomplete tumor resection or a need to sacrifice nerve roots. Published literature suggests encouraging neurological outcomes after nerve root amputation.

OBJECTIVE

To determine the incidence of postoperative neurological deficits after amputating the parent nerve root.

METHODS

A retrospective consecutive analysis of all patients treated for dumbbell nerve sheet tumors with a reported amputation of the functional relevant parent nerve roots C5-Th1 and L3-S1.

RESULTS

Among 21 evaluated patients, minor postoperative neurological motor function deterioration occurred in 4 patients (19%). Most patients recovered to the preoperative level at the follow-up examination, and only one patient retained a new Medical Research Council (MRC) scale of 4/5 for deltoid weakness. The majority of tumors were resected at the lumbar level (nerve root L3: 28.6%, L5: 19%). Gross total resection was achieved in 90.5% of patients. Neuropathic pain was reported in one third of the patients during the long-term follow-up.

CONCLUSION

Amputating critical parent nerve roots during the dumbbell tumor resections seems to result in a low incidence of postoperative motor deficits and may offer an acceptable sacrifice in otherwise only incompletely resectable dumbbell tumors. The cross-innervation of neighboring nerve roots and its, probably, per-se-reduced functionality may be a possible mechanism for maintaining motor function.

Myelopathies from Neoplasms

Benign and malignant tumors can be an important cause of myelopathy. Patients may present with a wide range of neurologic symptoms including back and neck pain, weakness, sensory abnormalities, and bowel and bladder dysfunction. Management can be challenging depending on the location and underlying biology of the tumor. Neuroimaging of the spine is an important component of diagnostic evaluation and patient management both during initial evaluation and when monitoring after treatment. This article provides a systematic and practical review of neoplasms that can cause myelopathy. Unique imaging and biological features of distinct tumors are discussed, and their management strategies are reviewed.

Surgical outcomes and factors related to postoperative motor and sensory deficits in resection for 244 cases of spinal schwannoma

In a large cohort the clinical presentation, management and outcomes of spinal schwannoma and factors related to postoperative motor and sensory deficits were invesgtigated. In 244 patients (males: 126, females: 118, average age 51.8 y) at one center, significant factors related to postoperative motor and sensory deficits were identified. Tumors were in the cervical (n = 79, 32.4%), lumbar (n = 66), thoracolumbar (T11-L1) (n = 55), and thoracic (n = 39) regions, and 5 patients had sacrum tumors. The rates of postoperative motor and sensory deterioration were 13.1% and 20.5%, respectively. The risk factors for motor deterioration were preoperative motor weakness, preoperative gait disturbance, dumbbell Eden type II, subtotal resection, and operative time, and those for postoperative sensory deficit were preoperative gait disturbance and subtotal resection. Of 12 patients with significant TcMEP changes, 11 had a new motor deficit after surgery; and of 216 patients with stable TcMEP data, 196 were neurologically intact after surgery (true negative) and 20 (11.0%) had deficits in the immediate postoperative stage (false negative). These deficits resolved during hospitalization for most patients. Of 15 patients with TcMEP deterioration and recovery, 11 (93.3%) had no motor deficits after surgery (p < 0.01).

A Rare Presentation of Spinal Schwannoma Causing Conus Medullaris Syndrome: A Case Series on Surgical Outcome

Introduction

Spinal schwannoma can occur anywhere along the spinal cord but is predominantly seen in the cervical and thoracic region.It composes mainly of well-differentiated schwann cell and is benign in nature. It is typically seen in the peripheral nerves and is commonly associated with neurofibromatosis. Up to 80% of cases, spinal schwannoma is reported to be intradural in location and 15% of cases have both intradural and extradural components. Spinal schwannoma rarely causes conus medullaris syndrome.

Case Report

In this case series, all three female patients in their 4th and 5th decades of life presented with conus medullaris syndrome. Lower back pain, radiculopathy, lower limb weakness, and urinary incontinence are their main clinical presentation. Magnetic resonance imaging shows a well-defined intradural, extramedullary mass compressing onto the conus medullary region. These patients undergone microscopic assisted excision of the tumor and had remarkably good early outcome despite the advanced presentation of neurological deficit.

Conclusion

Despite the late presentation with significant neurological deficit, surgical excision of spinal schwannomas carries a good prognosis postoperatively due to their benign nature and extramedullary location.

Minimally invasive resection of a lumbar extradural schwannoma: how I do it

BACKGROUND

Complete surgical resection of a foraminal lumbar schwannoma may require an extended surgical exposure and facetectomy and thus secondary instrumentation. The minimally invasive technique through the use of tubular retractors may represent a valid surgical alternative.

METHOD

We describe the resection of a foraminal lumbar schwannoma through the use of tubular retractors, along with its advantages and limitations. A limited medial facetectomy was performed and no stabilization was needed.

CONCLUSION

Minimally invasive surgery is suitable for an efficient and safe resection of foraminal schwannomas and may help in avoiding stabilization when a limited facetectomy is performed.

Giant spinal nerve sheath tumours - Surgical challenges: case series and literature review

Background: Giant nerve sheath tumours (GNST) are rare and literature on their management is scant. Spinal GNST present as a surgical challenge due to the involvement of anatomical regions often outside the "comfort zone" of a spinal surgeon. This case series aims to identify challenges in the surgical management of GNSTs. Methods: Retrospective case note review of all spinal GNST cases from 2010 to 2016 managed in Sheffield Teaching Hospitals identified 8 patients, 3 of whom were incidental findings (kept under surveillance) and were excluded. 5 cases were treated surgically. Data collected included patient demographic, presenting symptom(s), radiological data, surgical approach to the tumour and challenges encountered, histopathology report and follow up. Results: Our cohort consisted entirely of females (N = 5) with a mean age of 56.4 years (range 45-70). Imaging studies and histopathological diagnoses confirmed 5 GNSTs (four benign schwannomas and one ganglioneuroma). A Single-stage anterior approach was adopted for three patients while a combined anterior-posterior approach was adopted for the remaining two. In one patient, a posterior approach was initially planned, but this was abandoned and converted to an anterior approach following onset of acute superior vena cava (SVC) syndrome secondary to SVC compression by the giant tumour on prone positioning of the patient. PET imaging of case 3 showed intense tracer uptake consistent with malignancy, however histology confirmed WHO grade 1 Schwannoma. The other three non-operated GNSTs are kept under yearly radiological and clinical surveillance. Conclusions: GNSTs are surgically challenging as they often invade territories that are beyond the comfort zone of one single specialty. A multidisciplinary approach with careful pre-operative surgical planning is recommended. Patients in whom a posterior approach is planned should have a trial of prone positioning pre-operatively. Careful interpretation of FDG-PET imaging is recommended due to the possibility of false positive result.

Intraosseous schwannoma of the mobile spine: a report of twenty cases

PURPOSE

To clarify the clinical features, surgical strategies, and outcomes of intraosseous schwannoma (IOS) of the mobile spine.

METHODS

We retrospectively reviewed patients with primary benign spinal schwannoma who underwent surgery in our orthopedic department.

RESULTS

A total of 101 patients with primary benign schwannoma located in the mobile spine underwent surgery in our orthopedic department from 2005 to 2015. Twenty-five patients presented with aggressive features. Twenty patients were regularly followed up, twelve with lesions in the cervical spine, six with lesions in the thoracic region, and two with lesions in the lumbar spine. Preoperative CT-guided biopsy was performed in fourteen cases; the accuracy of diagnosis was 100%, and IOS is not histologically different from conventional schwannoma. The computed tomography (CT) scan revealed expansile and osteolytic bone destruction in all these cases, with six patients having pathological fracture. On T2-weighted magnetic resonance imaging, the lobulated schwannomas showed heterogeneous signal intensity and significant heterogeneous enhancement on post-contrast images. Gross total resection was performed in seventeen patients and subtotal resection in three. Tumor-involved nerve roots resection were documented to decrease local recurrence in fourteen cases. The visual analog scale score decreased from 5.66 ± 1.79 preoperatively to 1.16 ± 1.77 at the final follow-up. No local recurrence was noticed at the final follow-up.

CONCLUSION

CT-guided biopsy is effective for the preoperative diagnosis of spinal IOS. Total resection is the optimal treatment for IOS, whereas subtotal resection could be an alternative choice for high-risk cases. These slides can be retrieved under electronic supplementary material.

MR imaging features of benign retroperitoneal paragangliomas and schwannomas

Background

To determine whether MRI feature analysis can differentiate benign retroperitoneal extra-adrenal paragangliomas and schwannomas.

Methods

The MRI features of 50 patients with confirmed benign retroperitoneal extra-adrenal paragangliomas and schwannomas were retrospectively reviewed by two radiologists blinded to the histopathologic diagnosis. These features were compared between two types of tumours by use of the Mann-Whitney test and binary logistic regression. The patients’ clinical characteristics were reviewed.

Results

Analysis of MRI images from 50 patients revealed no significant differences in the quantitative MRI features of lesion size, ratio of diameter and apparent diffusion coefficient. There were significant differences in the qualitative MRI features of location, necrosis, cysts and degree of tumour enhancement for two readers, with no significant differences in the other qualitative MRI features between these tumours. The combination of necrosis with degree of tumour enhancement during the arterial phase increased the probability that a retroperitoneal mass would represent retroperitoneal extra-adrenal paraganglioma as opposed to schwannoma.

Conclusion

We have presented the largest series of MRI features of both benign retroperitoneal extra-adrenal paragangliomas and schwannomas. Some MRI features assist in the differentiation between these tumours, with imaging features consisting of necrosis and avid enhancement during the arterial phase, suggestive of retroperitoneal extra-adrenal paragangliomas.

Spinal Nerves Schwannomas: Experience on 367 Cases-Historic Overview on How Clinical, Radiological, and Surgical Practices Have Changed over a Course of 60 Years

Background

Spinal schwannomas are common benign spinal tumors. Their treatment has significantly evolved over the years, and preserving neurological functions has become one of the main treatment goals together with tumor resection.

Study Design and Aims

Retrospective review focused on clinical assessment, treatment techniques, and outcomes.

Methods

A retrospective study on our surgical series was performed. Clinical and operative data were analyzed. In regard to neurophysiologic monitoring, patients were retrospectively divided into two groups comparing the outcomes before and after introduction of routine intraoperative neurophysiology tests.

Results

From 1951 to 2010, 367 patients overall were treated. Diagnosis was obtained using angiography and/or myelography (pre-CT era), MRI, or CT scan. A posterior spinal approach was used for most patients; complex approaches were adopted for treatment of giant/dumbbell tumors. A trend of neurophysiology monitoring decreasing the rate of post-op neurological deficits was observed but was not statistically significant enough to draft evidence-based conclusions.

Conclusions

Clinical and radiological assessment of spinal schwannomas has markedly changed over the course of 50 years. Diagnostic tools have improved, and detection of recurrence has become way more sensitive. Neurophysiologic monitoring has become a useful intraoperative tool to guide resection and prevent post-op neurological impairment.

Non-Syndromic Spinal Schwannomas: A Novel Classification

Schwannomas are the most frequent primary tumors of the spine with an incidence of 0.3-0.5/100,000 person per year. Current treatment for non-syndromic spinal schwannomas is total resection of the tumor with preservation of neurovascular structures. This study aims to report neurologic and radiologic outcome following treatment of non-syndromic spinal schwannomas along with a novel tumor classification used in our clinic. A retrospective case series was carried out with a patient sample of 82 male and female patients with non-syndromic spinal schwannomas. All patient data were retrospectively collected from the hospital records. As a routine procedure, after admittance and primary evaluation, patients' tumors were classified using CT or MRI in accordance with our proposed classification method, which employs a dual designation method with tree groups (A, B, and C) for tumor volume and four types (I, II, III, and IV) for tumor localization. Subsequent resection surgery was followed by neurological assessments and follow up at 45th, 180th, and 360th postoperative day. Along with Karnofsky performance status scale, pain, sensory deficits, and motor weakness were scored to assess neurologic recovery. Our finding indicates that patients with different tumor types significantly differ in their neurological scores and show consistent but differential neurological recovery at early and late time points postsurgery. Complications during and postsurgery were minimal, occurring only in two patients. Our findings further reinforce the established safety of total resection operations and indicate that our proposed classification is a simple, effective tool that has proven helpful in preoperative planning and avoiding unnecessary surgical approaches.

Discrimination of a nerve fiber that is the origin of a cauda equina tumor using acetylcholinesterase staining

Spinal nerve sheath tumors are well known to typically originate from dorsal sensory nerve roots. However, it is difficult to anatomically identify the origin in the case of cauda equina tumors. In this study, we aimed to ascertain whether a cauda equina nerve root removed with a nerve sheath tumor was a motor nerve using acetylcholinesterase (AchE) staining. Nerve rootlet sections removed with tumors were stained for AchE using the AchE Rapid Staining Kit. Additionally, we performed intraoperative motor-evoked potential (MEP) monitoring following either transcranial electrical stimulation (TES) or electrical stimulation of nerve rootlets. The muscular strength of the lower extremities was assessed bilaterally before and after surgery using manual muscle testing. An AchE-positive motor nerve rootlet that was the origin of a cauda equina tumor was observed in one of the 12 patients. In this patient, a MEP in the right quadriceps evoked by electrical stimulation of this rootlet was detected. TES-MEP showed a 30% decrease in the amplitude in the right quadriceps evoked after tumor resection with this nerve rootlet. However, the motor strength in both lower extremities did not change after surgery. AchE staining and intraoperative MEP monitoring could detect the motor nerve rootlet that was the origin of a cauda equina tumor. Nerve sheath tumors originating from the motor nerve might be rare even in cauda equina.

Neurological outcomes and surgical complications in 221 spinal nerve sheath tumors

OBJECTIVE

Among all primary spinal neoplasms, approximately two-thirds are intradural extramedullary lesions; nerve sheath tumors, mainly neurofibromas and schwannomas, comprise approximately half of them. Given the rarity of these lesions, reports of surgical complications are limited. The aim of this study was to identify the rates of new or worsening neurological deficits and surgical complications associated with the resection of spinal nerve sheath tumors and the potential factors related to these outcomes.

METHODS

Patients were identified through a search of an institutional neuropathology database and a separate review of current procedural terminology (CPT) codes. Age, sex, clinical presentation, presence of neurofibromatosis (NF), tumor type, tumor location, extent of resection characterized as gross total or subtotal, use of intraoperative neuromonitoring, surgical complications, presence of neurological deficit, and clinical follow-up were recorded.

RESULTS

Two hundred twenty-one tumors in 199 patients with a mean age of 45 years were identified. Fifty-three tumors were neurofibromas; 163, schwannomas; and 5, malignant peripheral nerve sheath tumors (MPNSTs). There were 70 complications in 221 cases, a rate of 32%, which included 34 new or worsening sensory symptoms (15%), 12 new or worsening motor deficits (5%), 10 CSF leaks or pseudomeningoceles (4%), 11 wound infections (5%), 5 cases of spinal deformity (2%), and 6 others (2 spinal epidural hematomas, 1 nonoperative cranial subdural hematoma, 1 deep venous thrombosis, 1 case of urinary retention, and 1 recurrent laryngeal nerve injury). Complications were more common in cervical (36%) and lumbosacral (38%) tumors than in thoracic (18%) lesions (p = 0.021). Intradural and dumbbell lesions were associated with higher rates of CSF leakage, pseudomeningocele, and wound infection. Complications were present in 18 neurofibromas (34%), 50 schwannomas (31%), and 2 MPNSTs (40%); the differences in frequency were not significant (p = 0.834). Higher complication rates were observed in patients with NF than in patients without (38% vs 30%, p = 0.189), although rates were higher in NF Type 2 than in Type 1 (64% vs 31%). There was no difference in the use of intraoperative neuromonitoring when comparing cases with surgical complications and those without (67% vs 69%, p = 0.797). However, the use of neuromonitoring was associated with a significantly higher rate of gross-total resection (79% vs 66%, p = 0.022).

CONCLUSIONS

Resection is a safe and effective treatment for spinal nerve sheath tumors. Approximately 30% of patients developed a postoperative complication, most commonly new or worsening sensory deficits. This rate probably represents an inevitable complication of nerve sheath tumor surgery given the intimacy of these lesions with functional neural elements.

Factors Affecting Postoperative Neurological Deficits After Nerve Root Resection for the Treatment of Spinal Intradural Schwannomas

STUDY DESIGN

A retrospective clinical data analysis.

OBJECTIVE

To investigate the factors related to postoperative neurological deficits after nerve root resection in the treatment of spinal intradural schwannoma.

SUMMARY OF BACKGROUND DATA

Neurological deficits could be observed after resection of tumor-involved nerve roots in spinal intradural schwannoma. Thus, it is important to find the factors related to postoperative neurological deficits.

METHODS

Clinical and pathological data were selected from patients underwent total resection of the solitary spinal intradural schwannoma from T11 to S. Patients were divided into the postoperative neurological deficits positive group (PND group, n = 12) and negative group (non-PND group, n = 52). Clinical features including age, sex, duration of disorders, diabetes, preoperative visual analogue scale (VAS) and SF-36 score, preoperative symptoms, tumor size, tumor location, and immunostaining results were analyzed.

RESULTS

Age, sex, duration of disorders, diabetes, preoperative VAS and SF-36 score, tumor length, and tumor-occupied ratio were not significantly different between the two groups (P > 0.05). Lower extremity pain, sensory disturbance, and motor disturbance were found in 25.0%, 50.0%, and 75.0% of patients in the PND group and 76.9%, 17.3%, and 7.7% of patients in the non-PND group, respectively, and the results were significantly different (P < 0.05). The rate of postoperative neurological deficits was higher when the tumor was located in the thoracolumbar junction (T11-L2) than other segments (L2-S; P = 0.009). For immunostaining study, CD34-positive rate was significantly different between the two groups (P = 0.013).

CONCLUSION

The absence of preoperative lower extremity pain, presence of sensory and motor disturbances, and tumor location in the thoracolumbar junction (T11-L2) are the predictors of postoperative neurological deficits. Age, sex, duration of the disorders, diabetes, preoperative VAS score, preoperative SF-36 score, tumor length, and tumor-occupied ratio are not related to postoperative neurological deficits. On immunostaining of tumors, CD34-negative results are related to the development of postoperative neurological deficits.

LEVEL OF EVIDENCE

4.

Astounding recovery after resection of an intradural nerve sheath tumor in an adult male from Vietnam

Background:

Spinal cord tumors can be classified as intramedullary, intradural extramedullary, or extradural. The differential diagnosis of spinal cord tumors includes meningiomas, astrocytomas, ependymomas, metastasis, nerve sheath tumors such as schwannomas or neurofibromas, and multiple sclerosis plaques. Radiology can provide clues to the type of tumor, but a pathology evaluation of a specimen is necessary to provide an accurate diagnosis. These tumors can cause a variety of neurological symptoms from spinal cord compression including pain, weakness, and paresthesia. They are treated by surgical resection, with a variety of outcomes possible depending on the severity of the preoperative symptoms, location and extent of the tumor, and efficacy of the surgery performed.

Case Description:

A 59-year-old male from Vietnam came to the Atlanta Medical Center for evaluation of severe ride sided hemiparesis and paresthesias. He first noticed alterations in his handwriting and quickly deteriorated to the point of being unable to walk or move his right arm. A cervical spinal mass was identified and analyzed on magnetic resonance imaging. Surgical resection was performed under a microscope in a joint operation between an orthopedic surgeon and neurosurgeon. A specimen of the tumor was sent to pathology for further evaluation.

Conclusion:

The mass was determined to be an intradural extramedullary schwannoma. The severity of the patient's symptoms and the location and size of the tumor made full recovery unlikely and postoperative quadriplegia a real possibility. The tumor was surgically resected, which led surprisingly, however, to a full and prompt resolution of the patient's symptoms. Less than 2 weeks after surgery, the patient was able to walk and had almost fully regained use of his hands.

The Long-term Outcome After Resection of Intraspinal Nerve Sheath Tumors

BACKGROUND:

The existing literature on recurrence rates and long-term clinical outcome after resection of intraspinal nerve sheath tumors is limited.

OBJECTIVE:

To evaluate progression-free survival, overall survival, and long-term clinical outcome in a consecutive series of 131 patients with symptomatic intraspinal nerve sheath tumors.

METHODS:

Medical charts were retrospectively reviewed. Surviving patients voluntarily participated in a clinical history and physical examination that focused on neurological function and current tumor status.

RESULTS:

Follow-up data are 100% complete; median follow-up time was 6.1 years. All patients (100%) had surgery as the first line of treatment; gross total resection was performed in 112 patients (85.5%) and subtotal resection in 19 patients (14.5%). Five-year progression-free survival was 89%. The following risk factors for recurrence were identified: neurofibroma, malignant peripheral nerve sheath tumor, subtotal resection, neurofibromatoses/schwannomatosis, and advancing age at diagnosis. More than 95% of patients had neurological function compatible with an independent life at follow-up. The rate of tumor recurrence in nonneurofibromatosis patients undergoing total resection of a single schwannoma was 3% (3/93), in comparison with a recurrence rate of 32% (12/38) in the remaining patients.

CONCLUSION:

Gross total resection is the gold standard treatment for patients with intraspinal nerve sheath tumors. In a time of limited health care resources, we recommend that follow-up be focused on the subgroup of patients with a high risk of recurrence. The benefit of long-term, yearly magnetic resonance imaging follow-up with respect to recurrence in nonneurofibromatosis patients undergoing gross total resection of a single schwannoma is, in our opinion, questionable.

Hemidiaphragmatic palsy following excision of cervical dumbbell neurofibroma in a patient with neurofibromatosis: Importance of assessing functional status of "non-limb" roots

A 27-year-old male patient with neurofibromatosis type 1 who was operated on for a dumbbell neurofibroma of the cervical spine developed transient respiratory difficulty due to postoperative unilateral diaphragmatic palsy. This report emphasizes the need for preoperative assessment of residual function in involved non-limb roots, the role of intraoperative monitoring to take a decision on root sacrifice, and the need for optimizing respiratory function preoperatively, and describes a complication rarely reported in literature.

Surgical Strategies for Cervical Spinal Neurinomas

Cervical spinal neurinomas are benign tumors that arise from nerve roots. Based on their location, these tumors can also take the form of a dumbbell-shaped mass. Treatment strategies for these tumors have raised several controversial issues such as appropriate surgical indications and selection of surgical approaches for cervical dumbbell-shaped spinal neurinomas. In this report, we review previous literature and retrospectively analyze cervical spinal neurinoma cases that have been treated at our hospital. Surgical indications and approaches based on tumor location and severity are discussed in detail. Thus, with advances in neuroimaging and neurophysiological monitoring, we conclude that appropriate surgical approaches and intraoperative surgical manipulations should be chosen on a case-by-case basis.

Differences between Cervical Schwannomas of the Anterior and Posterior Nerve Roots in Relation to the Incidence of Postoperative Radicular Dysfunction

Study Design

A retrospective study.

Purpose

To assess the case files of patients who underwent surgery for cervical dumbbell schwannoma for determining the differences between schwannomas of the anterior and posterior nerve roots with respect to the incidence of postoperative radicular dysfunction.

Overview of Literature

The spinal roots giving origin to schwannoma are frequently nonfunctional, but there is a risk of postoperative neurological deficit once these roots are resected during surgery.

Methods

Fifteen patients with cervical dumbbell schwannomas were treated surgically. Ten men and 5 women, who were 35-79 years old (mean age, 61.5 years), presented with neck pain (n=6), radiculopathy (n=10), and myelopathy (n=11).

Results

Fourteen patients underwent gross total resection and exhibited no recurrence. Follow-ups were performed for a period of 6-66 months (mean, 28 months). Preoperative symptoms resolved in 11 patients (73.3%) but they persisted partially in 4 patients (26.7%). Six patients had tumors of anterior nerve root origin, and 9 patients had tumors of posterior nerve root origin. Two patients who underwent total resection of anterior nerve root tumors (33.3%) displayed minor postoperative motor weakness. One patient who underwent total resection of a posterior nerve root tumor (11.1%) showed postoperative numbness.

Conclusions

Appropriate tumor removal improved the neurological symptoms. In this study, the incidence of radicular dysfunction was higher in patients who underwent resection of anterior nerve root tumors than in patients who underwent resection of posterior nerve root tumors.

Surgical Excition of Spinal Intradural Meningiomas through a Single-Sided Minimally Invasive Approach: Key-Hole Laminotomy

Study Design

Eight patients who underwent surgery through a single-sided keyhole laminotomy due to intradural extramedullary (IDEM) meningiomas were retrospectively investigated.

Purpose

To present the surgical outcomes of single-sided keyhole laminotomies aimed to excise large ventral IDEM spinal cord menengiomas.

Overview of Literature

Less invasive procedures, such as laminotomies and osteoplastic laminotomies, have been previously described in the literature, but an approach that interferes with spinal stability to an even lesser extent would be more desirable.

Methods

Tumors were removed through a slit-like space between the dura and spinal cord without retraction of the spinal cord. The neurological conditions of patients were evaluated pre- and postoperatively with the Nurick grading system. Pathologic subtypes, preoperative symptom duration, tumor location on the sagittal and axial planes, and the percentage of tumor occupying the intradural space were investigated. On follow-up, magnetic resonance imaging was conducted to evaluate whether the tumor had recurred.

Results

All tumors were localized either ventrally or ventrolaterally. Of the spinal menengiomas, four were cervical and four were thoracic. All lesions were completely excised, and the neurological condition improved in six patients. The remaining two patients already had preoperative Nurick grades of 0, and this score was maintained postoperatively. Neither kyphotic changes nor instability developed in any patient during the follow-up period.

Conclusions

Total resection of anterior and anterolateral IDEM menengiomas, without introducing new neurological deficits, can be performed by an isolated posterior approach through a single-sided keyhole laminotomy. However, this approach should be applied cautiously and with a thorough understanding of its limitations.

Surgical management of solitary nerve sheath tumors of the cervical spine: a retrospective case analysis based on tumor location and extension

Complete resection of spinal nerve sheath tumors (NSTs) does not always result in significant neurological deficit. The purpose of this retrospective case analysis was to discuss the optimal surgical strategy for spinal NST of the cervical spine. Twenty-four patients who underwent surgery for solitary cervical NST over the past decade were included in this retrospective study. Patients with neurofibromatosis or schwannomatosis were excluded. Seventeen of the 24 cases (70.8%) showed extradural dumbbell extension, most frequently at the C1 or C2 vertebral level. Neurological condition was assessed using the modified McCormick functional schema and sensory pain scale. Total removal of the tumor was achieved in 20 of 24 cases (83.3%). Staged surgery using combined anterior and posterior approaches was applied for 2 of 17 cases with extradural dumbbell extension. Tumor involvement with nerve root fibers critical for upper extremity function (C5–C8) was recognized in 6 of 24 cases (25.0%), with complete resection in all 6 cases. Final assessment of neurological function revealed satisfactory or acceptable recovery in all 6 patients. Spinal NSTs with extradural dumbbell extension are a common condition in the cervical spine. Complete removal of spinal NST of the cervical spine may carry a risk of permanent neurological deficit, but such sequelae appeared to be the exception in the present case analysis. A radical and safe surgical strategy, including staged surgery combining anterior and posterior approaches, should be tailored to the individual case.

Minimally invasive resection of an extradural far lateral lumbar schwannoma with zygapophyseal joint sparing: surgical nuances and literature review

Introduction. Spinal schwannomas are benign nerve sheath tumors. Completely extradural schwannomas of the lumbar spine are extremely rare lesions, accounting for only 0,7–4,2% of all spinal NSTs. Standard open approaches have been used to treat these tumors, requiring extensive muscle dissection, laminectomy, radical foraminotomy, and facetectomy. In this paper the authors present the case of a minimally invasive resection of a completely extradural schwannoma. Operative technique literature review is presented. Material & Methods. A 50-year-old woman presented with progressive complains of chronic right leg pain and paresthesia. The magnetic resonance imaging revealed a giant well-encapsulated dumbbell-shaped extradural lesion at the L3-L4 level. The patient underwent a minimally invasive gross total resection of the tumor using a tubular expandable retractor system. Results. The patient had complete resolution of radiculopathy in the immediate postoperative period and she was discharged home, neurologically intact, on the second postoperative day. Postoperative MRI demonstrated no evidence of residual tumor. At latest follow-up (18 months) the patient remains asymptomatic. Conclusion. Although challenging, this minimally invasive procedure is safe and effective, being an appropriate alternative, with many potential advantages, to the open approach.

Complete removal of the spinal nerve sheath tumors. Surgical technics and results from a series of 30 patients

OBJECTIVE

Observe whether a microsurgical gross total removal (GTR) of a spinal nerve sheath tumors (SNSTs) is safe and decreases the tumor recurrence.

METHOD

We identify 30 patients with 44 SNSTs.

RESULTS

We operated upon 15 males and 15 females patients; mean age 40 years. GTR was achieved in 29 (96.6%) instances. Surgical mortality was 3.3% and the recurrence rate was 3.3%. The median follow-up time was 6.2 years.

CONCLUSION

The surgical approach used in this group of patients afford that the great majority of tumors could be totally removed with low mortality and low recurrence rates, proving to be safe and effective.

Normal pressure hydrocephalus caused by a spinal neurinoma at the cauda equina level: a case report

Neurinomas are common space-occupying lesions located in the spinal canal. Many reports concerning their clinical characteristics, diagnoses, treatments, and operative results have been published. Some case reports have discussed spinal neurinomas located at the cauda equina level. However, there is little information on their natural history. Here, we report a case of spinal neurinoma located at the cauda equina level, which caused normal pressure hydrocephalus (NPH). All symptoms resulting from the NPH were resolved by tumor removal. These findings suggested that if a spinal neurinoma located at the cauda equina level causes symptoms due to NPH, then removal of the tumor should be considered, when appropriate removal procedures are possible.

Charcot-Marie-Tooth syndrome and neurofibromatosis type 1 with multiple neurofibromas of the entire spinal nerve roots

The coexistence of polyneuropathy which has the definite clinical and electromyographical findings consistent with Charcot-Marie-Tooth (CMT) syndrome and neurofibromatosis type 1 (NF1) has infrequently been reported. We describe a patient with both CMT and NF1, who had multiple neurofibromas involving the entire spinal neural axis. In addition, he had multiple neurofibromas distributed within the ileopsoas and gluteus muscles and subcutaneous tissues. These lesions were detected readily by MRI and the patient underwent successful surgical resection of the largest tumours compressing bilateral C2 nerve roots. To our knowledge, this is the first reported case of CMT syndrome coexisting with NF1 in which multiple neurofibromas involved the entire spinal nerve roots. We discuss the diagnostic and therapeutic challenges, emphasising the role of MRI and electrophysiology in such cases and provide a literature review.

Totally cystic schwannoma of the lumbar spine

A schwannoma is a benign tumor arising from a schwann cell and occurs mainly in the nerve sheath in the intradural extramedullary region. Schwannomas have been well described as occurring in the lumbar spine, but total cystic degeneration of schwannomas is rarely reported. The authors describe the clinical and radiographic evaluations and treatment of a rare case of an intraextradural totally cystic schwannoma on the lumbar spine.Two patients reported a history of 6 to 12 months of pain accompanied by weakness in the lower extremities. On examination, 1 patient had bilateral lower-extremity muscle strength graded at 4/5, and magnetic resonance imaging revealed a cystic schwannoma (1.5 × 2.0 cm in the sagittal dimension) at L2-L3. The other patient had a right lower-extremity muscle strength graded at 3/5, and magnetic resonance imaging revealed a cystic schwannoma (2.0 × 3.0 cm in the sagittal dimension) at L4-L5. The patients underwent operative treatment, and the tumors were completely removed, as were the filum terminale adhered to the tumor. Pedicle screws were used to maintain stability of the lumbar spine. Gross examination of the tumors showed yellowish-white soft contents. Histologic examination confirmed that they were benign totally cystic schwannomas. Postoperatively, the patients' neurologic symptoms completely resolved.Cystic schwannomas can be diagnosed using preoperative magnetic resonance imaging. The filum terminale cut off the tumor walls did not cause the clinical symptoms in the 2 patients.

C2 root nerve sheath tumors management

BACKGROUND

Upper cervical nerve sheath tumors (NST) arising mainly from C2 root and to lesser extent from C1 root are not uncommon, they constitute approximately 5-12% of spinal nerve sheath tumors and 18-30% of all cervical nerve sheath tumors, unique in presentation and their relationship to neighbouring structures owing to the discrete anatomy at the upper cervical-craniovertebral region, and have atendency for growth reaching large-sized tumors before manifesting clinically due to the capacious spinal canal at this region; accordingly the surgical approaches to such tumors are modified. The aim of this paper is to discuss the surgical strategies for upper cervical nerve sheath tumors.

METHODS

Eleven patients (8 male and 3 females), age range 28-63 years, with C2 root nerve sheath tumors were operated upon based on their anatomical relations to the spinal cord. The magnetic resonance imaging findings were utilized to determine the surgical approach. The tumors had extra- and intradural components in 10 patients, while in one the tumor was purely intradural. The operative approaches included varied from extreme lateral transcondylar approach(n = 1) to laminectomy, whether complete(n = 3) a or hemilaminectomy(n = 7), with partial facetectomy(n = 7), and with suboccipital craniectomy(n = 2).

RESULTS

The clinical picture ranged from spasticity (n = 8, 72,72 %), tingling and numbness below neck (n = 6, 54,54 %), weakness (n = 6, 54,54 %), posterior column involvement (n = 4, 26,36 %), and neck pain (n = 4, 36,36 %). The duration of symptoms ranged from 1 to 54 months, total excision was performed in 7 patients; while in 3 patients an extraspinal component, and in 1 patient a small intradural component, were left in situ. Eight patients showed improvement of myelopathy; 2 patients maintained their grades. One poor-grade patient was deteriorated.

CONCLUSION

The surgical approaches for the C2 root nerve sheath tumors should be tailored according to the relationship to the spinal cord, determined by magnetic resonance imaging.

Clinical analysis of 73 cases of intraspinal nerve sheath tumor

Seventy-three patients with spinal nerve sheath tumor who were surgically treated in our hospital during the years 2004-2010 were retrospectively reviewed with respect to recovery of neurological function, recurrence of the tumor and occurrence of kyphotic deformities. Preoperative clinical manifestations, imaging data, surgical records and follow-up results were comprehensively analyzed. The follow-up duration was 12-60 months with an average of 32.0 months. Out of the 73 cases enrolled, 69 had gradual recovery of sensation, motor and sphincter functions 1 week to 3 months after operation. Forty-six cases had incomplete paralysis, whose American Spinal Injury Association (ASIA) grades, however, were gradually increased during the follow-up period, 4 cases had no significant improvement of the clinical symptoms and no change in ASIA grades during the follow-up period. Two cases had postoperative recurrence of the tumor. There were no deaths, no spinal instability, and no kyphotic malformations found in any cases. Our study indicated that complete removal of the tumor is important for good recovery, and an ideal surgical method may reduce the recurrence of the tumor or the occurrence of complications.

Giant lumbosacral schwannoma in a child

Small spinal intradural extramedullary schwannoma are a common occurrence in the middle aged. However, giant schwannoma in pediatric age group is rare. We report one such case of giant extradural lumbosacral schwannoma in an 8-year-old child. Clinical features, histopathology and management of giant schwannoma is discussed and the present literature reviewed.

Sacrococcygeal neurofibroma: rare cause for chronic pelvic pain

Pelvic pain is a common gynecologic complaint. Retroperitoneal pelvic tumors are rarely a cause of pelvic pain. Neurofibroma is an uncommon pelvic retroperitoneal tumor, and only 17 cases are reported to date. A 38-year-old woman with chronic pelvic pain had a soft fixed mass that was the size of an orange in the right posterolateral fornix, with a normal uterus on pelvic examination, and a mass of 6.3 × 5.2 cm with mixed echotexture on the right side separate from both ovaries on transvaginal ultrasonography. A provisional diagnosis of retroperitoneal mass probably a retroperitoneal teratoma was made. Laparoscopy was performed; an ill-defined retroperitoneal soft tissue mass of about 6 cm was seen on the right pararectal and presacral area, displacing the rectum toward the left side. The mass was soft and jellylike without a cyst wall. Histopathologic study and immunohistochemistry results were consistent with neurofibroma of the sacrococcygeal regions. To our knowledge this is the third case of sacrococcygeal neurofibroma treated by complete laparoscopic excision. Gynecologists should keep sacrococcygeal neurofibroma as a differential diagnosis of pelvic pain with atypical location of a pelvic mass. A high index of suspicion and an appropriate imaging technique are needed for accurate diagnosis. Laparoscopy seems to be a safe and effective method of managing retroperitoneal presacral neurofibromas.

Postpartum paraparesis from spinal neurofibroma

BACKGROUND CONTEXT

One hallmark of neurofibromatosis Type 1 (NF1) is the presence of multiple neurofibromas, which are hormonally responsive and may undergo rapid growth during periods of hormonal surge. Although spinal neurofibromas occur in up to 40% of patients with NF1, they rarely cause neurologic sequelae, especially in the young.

PURPOSE

To document a unique case of acute postpartum paraparesis in a young woman because of an extradural neurofibroma compressing the conus medullaris and discuss the possible hormonal influences related to rapid growth of this otherwise "benign" nerve sheath tumor. This case demonstrates the importance of closely monitoring patients with known NF1 for neurologic symptoms, especially during pregnancy and the postpartum period. We also seek to describe the management of this patient, which resulted in an excellent outcome.

STUDY DESIGN

Case report and literature review.

METHODS

Detailed history was obtained from the patient and her family members. All medical records, imaging studies, histopathological findings, and pertinent literature were reviewed.

RESULTS

After evaluating a 26-year-old postpartum woman with NF1 for paraparesis, magnetic resonance imaging of the lumbar spine revealed a large heterogeneously enhancing mass at the conus medullaris. She subsequently underwent resection of the mass via laminectomy. Postoperatively, the patient exhibited marked improvement in weakness and was able to ambulate with assistance 2 days later. Histopathological examination of the mass revealed a neurofibroma with strong expression of estrogen and progesterone receptors.

CONCLUSIONS

This patient had a spinal neurofibroma, which likely grew in size within the peripartum period, causing a neurologic emergency. The rapid growth of the neurofibroma may have been the result of hormonal influence of estrogen or progesterone or both. To the best of our knowledge, rapid paraparesis caused by a spinal neurofibroma has never been reported in a peripartum setting. Laminectomy with complete tumor resection is the preferred treatment for spinal neurofibromas causing acute neurologic symptoms.