Combined approach for cervical schwannomas with large extraforaminal extension

Abstract

Background Data: About 75% of spinal schwannoma are intradural, 10% intraextradural, and 15% completely extradural. These tumors are usually slowly growing and reach a large size before becoming symptomatic. The tumors which are totally or partially located in the epidural space (dumbbell tumors) are either intraspinal, foraminal, or extraspinal. These dumbbell tumors represent almost 18% of the total percentage of whole spinal schwannomas, but they are responsible for almost half of the cervical schwannomas. When these tumors have large extraforaminal part, total excision through a single approach might be difficult to achieve. Study design: This is a retrospective clinical case study. Purpose: To evaluate the efficacy and safety of combined approach for excision of these large tumors that are closely related to the vertebral artery. Patients and Methods: This study was conducted in Mansoura University Hospital on six patients suffering from cervical spinal schwannoma with large lateral extraforaminal component. The mean age was 38 (range, 22–50) years. Two patients were males and four were females. All patients were assessed clinically and radiologically using CT and MRI cervical spine and vertebral artery angiography before surgery. Motor power was assessed according to MRC muscle power grading system. Posterior approach through a hemilaminectomy with facet preservation was used for excision of the intraspinal part, followed by the anterolateral approach to remove the extraspinal extension to avoid any manipulation to the vertebral artery. Perioperative data were reported and a routine postoperative MRI of the cervical spine was conducted. Patients were followed up at the outpatient clinic on a regular basis. Results: Complete surgical excision of both tumor components were performed through combined posterior and lateral approach in all patients. Postoperative clinical assessment showed that all patients with radiculopathy improved; however, in two patients with weaknesses, one mildly deteriorated and the other remained the same, but both improved by physiotherapy. One patient developed wound CSF Leak after surgery, responding to frequent dressing and lumbar drain. Conclusion: Cervical spinal schwannomas with large lateral extra foraminal component can be treated safely and effectively with combined posterior and lateral approaches to achieve complete surgical excision. (2019ESJ189)

Keywords

• cervical spine
• dumbbell schwannoma
• combined approach
• surgical excision