Resection of a Large Thoracic Schwannoma: 2-Dimensional Operative Video

2020 ◽  
Author(s):  
Kyle B Mueller ◽  
Jean-Marc Voyadzis
Keyword(s):  
Spinal Cord ◽  
Case Reports ◽  
Intraoperative Ultrasound ◽  
Neurofibromatosis Type ◽  
High Yield ◽  
Peripheral Nerve Sheath Tumors ◽  
Thoracic Level ◽  
Institutional Review ◽  
Patient Consent ◽  
Intradural Extramedullary

Abstract Spinal schwannomas most likely occur at the thoracic level and within the intradural extramedullary compartment. They are benign, typically slow-growing, peripheral nerve sheath tumors that produce symptoms by displacing or compressing the nerve roots and spinal cord. There is an association with patients that have neurofibromatosis type 2. Surgical pearls including the utilization of intraoperative ultrasound for localization, D wave monitoring, and microsurgical dissection are demonstrated. Pertinent high-yield radiographic and histological features of schwannomas are reviewed.1-4  We report the case of a 59-yr-old female who presented with progressively worsening gait instability that was associated with lower extremity numbness progressing to weakness. She had myelopathic findings on examination, which included brisk patellar reflexes and persistent clonus with sensory changes to the umbilicus and mild leg weakness. Full body examination revealed no stigmata of neurofibromatosis. Magnetic resonance imaging of the neuroaxis demonstrated a large, intradural extramedullary mass with peripheral enhancement that spanned the T9 to T11 vertebral levels with severe compression of the spinal cord. There were no intracranial, cervical, or lumbar findings. Surgical intervention was planned with the following objectives: decompression of the neural elements, curative resection, and diagnosis. Patient consent for the procedure was obtained. Institutional Review Board approval for solitary case reports are not needed at our institution.

Resection of 2 Intradural Extramedullary Cervical Spine Tumors in a Patient With Neurofibromatosis Type 2: 3-Dimensional Operative Video

2018 ◽  
Vol 16 (2) ◽  
pp. 274-274
Author(s):  
Simone E Dekker ◽  
Chad A Glenn ◽  
Thomas A Ostergard ◽  
Osmond C Wu ◽  
Fernando Alonso ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Cervical Spine ◽  
Treatment Options ◽  
Tumor Resection ◽  
Neurofibromatosis Type ◽  
Cord Compression ◽  
Neurofibromatosis Type 2 ◽  
3 Dimensional ◽  
Intradural Extramedullary

Abstract This 3-dimensional operative video illustrates resection of 2 cervical spine schwannomas in a 19-yr-old female with neurofibromatosis type 2. The patient presented with lower extremity hyperreflexity and hypertonicity. Magnetic resonance imaging (MRI) demonstrated 2 contrast-enhancing intradural extramedullary cervical spine lesions causing spinal cord compression at C4 and C5. The patient underwent a posterior cervical laminoplasty with a midline dural opening for tumor resection. Curvilinear spine cord compression is demonstrated in the operative video. After meticulous dissection, the tumors were resected without complication. The dural closure was performed in watertight fashion followed by laminoplasty using osteoplastic titanium miniplates and screws. Postoperative MRI demonstrated gross total resection with excellent decompression of the spinal cord. The postoperative course was uneventful. The natural history of this disease, treatment options, and potential complications are discussed.

scholarly journals Cervical 7-Thoracic 3 Laminoplasty for Resection of Arteriovenous Malformation: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (1) ◽  
pp. E3-E4
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Spinal Cord ◽  
Video Recording ◽  
Mass Effect ◽  
Feeding Artery ◽  
Pia Mater ◽  
Institutional Review ◽  
Signal Change ◽  
Spinal Arteriovenous Malformations ◽  
Intradural Extramedullary ◽  
Vascular Steal

Abstract Symptomatic spinal arteriovenous malformations (AVMs) are most frequently associated with hypoperfusion of the spinal cord, either from venous congestion or vascular steal, and are less frequently associated with hemorrhage. This patient had a large cervicothoracic spinal AVM and presented with right hemibody sensory deficit with intact motor function. The AVM had significant preoperative mass effect on the dorsal spinal cord with cord signal change. Preoperative digital subtraction angiography demonstrated a left supreme intercostal feeding artery and left thyrocervical feeding artery, which was embolized preoperatively. A laminoplasty was performed from cervical 7 to thoracic 3 to allow for adequate visualization. The lesion demonstrated an intradural extramedullary presence, which made preservation of the pia mater paramount during the resection. The AVM was disconnected and removed in its entirety as determined by operative visualization and postoperative imaging. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Operative Adjuncts and Technique for En Bloc Removal of Lumbar Intradural-Extramedullary Tumor: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (6) ◽  
pp. E235-E235
Author(s):  
William Clifton ◽  
Alfredo Quinones-Hinojosa ◽  
Selby Chen
Keyword(s):  
Cauda Equina ◽  
Intraoperative Ultrasound ◽  
Leg Pain ◽  
Nerve Roots ◽  
En Bloc ◽  
Tumor Capsule ◽  
Extramedullary Tumor ◽  
Patient Consent ◽  
Intradural Extramedullary ◽  
Dural Opening

Abstract We present a surgical video illustrating the technique for en bloc resection of an intradural-extramedullary lumbar tumor. The patient is a 63-yr-old woman presenting with worsening bilateral leg pain. Imaging of her lumbar spine showed an enhancing, circumscribed intradural-extramedullary tumor compressing her cauda equina at the L2 level. With informed patient consent, an L1-L3 laminectomy was performed, and intraoperative ultrasound provided the tumor location in order to plan the dural opening as well as define the tumor boundaries with respect to the surrounding nerve roots. The nerve roots were found to be dorsal to the tumor on the ultrasound and appeared to be separate from the tumor capsule. After the dura was opened, the nerve roots were dissected from the tumor capsule and the filum was identified at its proximal and distal portions relative to the mass. The tumor appeared to be arising from the filum itself. Intraoperative electromyography monitoring and stimulation identified the motor roots around the filum and were dissected away. The filum was isolated and cut proximally in order to prevent upward displacement of the mass above the dural opening. The distal portion was then cut and the tumor was removed en bloc. The patient had good postoperative relief of her leg pain and no new neurologic or genitourinary complications. This case highlights the preoperative and intraoperative surgical planning as well as detailed technical aspects of en bloc intradural-extramedullary lumbar tumor resection with preservation of the tumor capsule in order to achieve gross total resection.

Resection of a Pediatric Intramedullary Spinal Cord Tumor: 2-Dimensional Operative Video

2018 ◽  
Vol 16 (4) ◽  
pp. 518-518
Author(s):  
Royce W Woodroffe ◽  
Mario Zanaty ◽  
Patricia Kirby ◽  
Brian J Dlouhy ◽  
Arnold H Menezes
Keyword(s):  
Spinal Cord ◽  
Motor Evoked Potentials ◽  
Spinal Cord Tumor ◽  
Intraoperative Ultrasound ◽  
Intramedullary Spinal Cord ◽  
Long Term Outcome ◽  
Good Strength ◽  
Intramedullary Spinal Cord Tumor ◽  
Spinal Reconstruction ◽  
Patient Consent

Abstract This video is a case presentation and demonstration of surgical approach to a pediatric intramedullary spinal cord tumor (IMSCT). IMSCT can be associated with significant morbidity and aggressive resection is associated with more favorable long-term outcome. A 13-yr-old male presented to clinic for evaluation of rapidly progressive scoliosis to the left. A contrasted MRI revealed expansion of the spinal cord with edema from approximately T3 to T9 and an enhancing lesion at T6-7 associated with a small cyst. On neurological exam, the patient had good strength throughout, but decreased sensation in the T7-12 dermatomes and decreased deep tendon reflexes in his lower extremities. The procedure included T5 to T8 osteoplastic laminectomies and IMSCT resection followed by spinal reconstruction. Intraoperative ultrasound was used to verify the tumor's location and somatosensory and motor evoked potentials were monitored throughout the procedure. Intraoperative consultation with neuropathology suggested the mass was likely pilocytic astrocytoma; therefore, it was aggressively debulked using microsurgical techniques including an ultrasonic aspirator. There was a plane between the tumor and spinal cord white matter allowing for a gross total resection. Postoperatively the patient had good strength throughout and sensation was intact except for continued numbness of the anterior thigh bilaterally. Immediate postoperative MRI demonstrated complete resection of the tumor without residual enhancement and the patient was ultimately discharged home on postoperative day 8. Follow-up imaging remained stable at 2 mo and the patient continued to do well neurologically. All patient identifiers were removed from the presented material, thus, patient consent was not obtained.

Contralateral Minimally Invasive Laminectomy for Resection of a Synovial Cyst: 2-Dimensional Operative Video

2019 ◽  
Vol 19 (1) ◽  
pp. E63-E64 ◽  
Author(s):  
Kyle Mueller ◽  
Islam Fayed ◽  
Steven Spitz ◽  
Nathan Nair ◽  
Jean-Marc Voyadzis ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Conservative Management ◽  
Case Reports ◽  
Synovial Cyst ◽  
Leg Pain ◽  
Epidural Steroid Injections ◽  
Institutional Review ◽  
Patient Consent ◽  
Epidural Steroid ◽  
Tissue Trauma

Abstract Synovial cysts of the lumbar spine result from degeneration of the facet capsule, and their prevalence may be as high as 10% in symptomatic patients. Although conservative management is possible, the majority of patients will require resection. Traditional procedures for resection use an ipsilateral approach requiring partial or complete resection of the ipsilateral facet complex, possibly leading to further destabilization. A contralateral technique using minimally invasive tubular retractors for synovial cyst resection avoids facet disruption, minimizes soft-tissue trauma, and limits disruption of the ligamentous and bony structures. Additionally, by approaching contralateral, the cyst/dura interface is better visualized especially at the depths of the lateral recess. Seeing the full extent of this interface from an ipsilateral approach is very difficult without decompressing the cyst, which, in turn, makes dissecting and separating the remaining cyst wall more difficult and increases the risk of durotomies.1,2  We report the case of a 53-yr-old female who presented with persistent left leg pain in an L5 distribution that was associated with some mild lower back pain. She was refractory to conservative management that included physical therapy along with a series of epidural steroid injections. She was noted to have some weakness with dorsiflexion on the left side and as absent a straight leg raise. Given the predominance of her leg over her back symptoms along with the patient's age, a minimally invasive contralateral approach for resection of the synovial cyst was offered as opposed to more traditional decompression and fusion. Institutional Review Board approval and patient consent for solitary case reports are not needed at our institution.

Hybrid peripheral nerve sheath tumor

2012 ◽  
Vol 117 (5) ◽  
pp. 897-901 ◽  
Author(s):  
Shih-Shan Lang ◽  
Eric L. Zager ◽  
Thomas M. Coyne ◽  
Raj Nangunoori ◽  
J. Bruce Kneeland ◽  
...  
Keyword(s):  
Peripheral Nerve ◽  
Case Reports ◽  
Tumor Resection ◽  
Femoral Nerve ◽  
Neurofibromatosis Type ◽  
Nerve Sheath Tumor ◽  
Her Family ◽  
Peripheral Nerve Sheath Tumors ◽  
Nerve Sheath ◽  
Sciatic Nerves

In recent literature, there have been case reports of an extremely rare entity characterized by hybrid peripheral nerve tumors consisting of elements of neurofibroma, schwannoma, and/or perineurioma. The authors present a unique case of a patient with multiple painful hybrid tumors with negative genetic testing for neurofibromatosis Type 1 and no clinical evidence of neurofibromatosis Type 2 or schwannomatosis. A 28-year-old woman presented with tentatively diagnosed schwannomatosis. She had painful bilateral retromastoid scalp tumors as well as multiple other painful tumors in the distribution of the saphenous, femoral, and sciatic nerves. Her family history was significant for a paternal grandfather with a solitary schwannoma. The patient underwent multiple surgical procedures for tumor resection, including tumors in the regions of the retromastoid scalp, bilateral sciatic nerves, left femoral nerve, and left axilla. These tumors were examined and evaluated histologically. Within the tumors, components of both neurofibromas and schwannomas were found, even though these 2 peripheral nerve sheath tumors have been long considered to be distinct entities. This case report suggests a distinct syndrome that has not previously been appreciated.

Lumbar Malignant Peripheral Nerve Sheath Tumor in a Young Dog

2021 ◽  
Vol 49 ◽  
Author(s):  
Ana Caroline da Silva Néto Souza ◽  
Carlos Humberto da Costa Vieira Filho ◽  
Elainne Maria Beanes Da Silva ◽  
Caterina Muramoto ◽  
Icaro Farias Correia ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Peripheral Nerve ◽  
Spinal Nerve ◽  
Lumbar Region ◽  
Presumptive Diagnosis ◽  
Nerve Sheath Tumors ◽  
Peripheral Nerve Sheath Tumors ◽  
Nerve Sheath ◽  
S 100 ◽  
Intradural Extramedullary

Background: The most common location of malignant tumors of the peripheral nerve sheath in the spinal cord is the intradural-extramedullary region, and is rare in the spinal nerve roots in the lumbar region. They mainly affect large female dogs over six years of age. Imaging tests assist in the presumptive diagnosis, but confirmation requires histopathological and immunohistochemical examination. The prognosis is guarded. Diagnostic imaging, anatomopathological and immunohistochemical findings of a malignant tumor of the intradural-extramedullary peripheral nerve sheath with medullary infiltration in the lumbar region in a young dog are reported.Case: A body of a 6-year-old Poodle dog was donated for necropsy and diagnostic clarification. In the history, there was a suspicion of lumbar intramedullary neoplasia, detected by computed tomography (CT), with a 4 years progressive chronic evolution. Additionally, the dog had hidden spina bifida (L7 to S3), as detected by radiography and CT. On post mortem radiographic examination (X-ray), there was an enlargement of the vertebral canal (T10 to S2), intense osteolysis (L1 to S2), spinous processes (L5 to L7), and ankylosis (L3 to L7). Necropsy revealed ankylosis (L3 to L7) and intradural-extramedullary mass (9.5 × 2.6 × 2.3 cm) (L2 to L6). No metastases were identified. On microscopy, there was neoplastic proliferation of cells with intense pleomorphism, arranged in bundles interlaced in palisades and sometimes solid mantles. The mitotic index was high, ranging from 10 to 12 mitoses per field. There was also necrosis, hemorrhage, edema, and focal axonal demyelination of the adjacent white matter in the spinal cord. Masson Trichrome staining highlighted an intense diffuse conjunctive stroma. There was a suspicion of a malignant tumor of the peripheral nerve sheath and an immunohistochemical panel was performed for confirmation. There was strong and diffuse positivity for vimentin and S-100 and partial positivity for neuron-specific enolase (NSE), negative for anti-factor VIII, glial fibrillary acidic protein (GFAP), α-actin for smooth muscle, cytokeratin, neurofilament, and desmin. Thus, the diagnosis of malignant neoplasm of the peripheral nerve sheath was confirmed.Discussion: Peripheral nerve sheath tumors are classified as benign or malignant. In dogs, they are frequent in elderly, females, and large breeds. In this case report, the animal was young, female, and small breed. The location of the spinal nerve roots is uncommon, and is more commonly found in the brachial plexus. In the animal reported, the tumor was observed as lumbar swelling. Clinical signs vary with the affected region, however, neurogenic claudication and muscle atrophy are more frequent, as observed in this report. Imaging examinations such as X-rays and CT assist in the presumptive diagnosis. In this case report, spina bifida was identified on radiography, and CT suggested the presence of intramedullary neoplasia and allowed to monitor tumor growth. Post mortem X-ray imaging revealed intense osteolysis and ankylosis, which were confirmed at necropsy, which also elucidated its intradural-extramedullary location with infiltration into the spinal cord. The confirmation of the neoplasm was made by histopathological and immunohistochemical examination; the latter should be made a panel, not restricted to the use of antibodies S-100 and vimentin only. The prognosis of malignant peripheral nerve sheath tumors (MPNST) of the spinal cord is poor, and although there are palliative methods, there is no curative treatment, as complications can interfere with the quality of life of the animal. MPNST should be included in the differential diagnosis of spinal disorders, even in young dogs and small breeds. CT helps in early diagnosis to make decisions aimed at the animal's well-being.

Posterior Approach for a Ventral Intradural Extramedullary Meningioma: 2-Dimensional Operative Video

2020 ◽  
Vol 20 (1) ◽  
pp. E50-E50
Author(s):  
Elena Solli ◽  
Vincent Dodson ◽  
Fareed Jumah ◽  
Nitesh V Patel ◽  
Simon Hanft
Keyword(s):  
Spinal Cord ◽  
Posterior Approach ◽  
Complete Resection ◽  
Surgical Access ◽  
Patient Consent ◽  
Bilateral Approach ◽  
Intradural Extramedullary ◽  
Multiple Levels ◽  
The Right ◽  
Dentate Ligament

Abstract Ventral thoracic meningiomas are rare entities in which the spinal cord is attenuated and draped over the meningioma symmetrically. This is a challenging surgical entity compared to typical intradural meningiomas, which nearly always eccentrically displace the cord. In these more common meningiomas, surgical access is fairly straightforward as the meningioma is often visualized upon opening the meninges. Resection can be more safely performed with the cord largely shifted. In cases of ventral meningioma, the tumor is hidden ventral to the spinal cord, and techniques to safely mobilize the spinal cord must be utilized. We demonstrate that an entirely posterior approach allows complete resection of a ventrally situated mass. After careful identification and sectioning of the dentate ligament at multiple levels on the right side of the canal, we then suture and rotate the dentate ligament at each site, thereby allowing progressive visualization of the ventral meningioma. A narrow, but viable, working corridor to the tumor allows safe debulking. Once it is felt that the tumor can no longer be safely excised through the created corridor, we then disconnect our dentate sutures and move to the other side of the canal. Similarly, the dentate is sectioned and sutured so that the contralateral aspect of the meningioma can be visualized and debulked. The tumor can then be safely removed. A standard posterior approach and midline durotomy allows this bilateral approach to a ventrally situated meningioma and, therefore, in our mind, represents a safe and also highly effective road to resection.  Patient consent was obtained prior to publication.

Use of Intraoperative CO2 Laser for the Resection of a Ventral Intradural Extramedullary Cervical Spinal Tumor: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (5) ◽  
pp. E161-E161
Author(s):  
Joseph A Osorio ◽  
Guillermo Victorino T Liabres ◽  
Catherine A Miller ◽  
Michael W McDermott ◽  
Praveen V Mummaneni
Keyword(s):  
Spinal Cord ◽  
Co2 Laser ◽  
Tumor Resection ◽  
Spinal Tumor ◽  
Cord Compression ◽  
Spinal Tumors ◽  
Laser Technique ◽  
Who Grade ◽  
Patient Consent ◽  
Intradural Extramedullary

Abstract Ventral spinal tumors are surgically challenging because the tumor resection should minimize spinal cord and nerve root manipulation to minimize morbidity, while providing access to a complete tumor resection. The CO2 laser has been useful in resection of central nervous system tumors, but little is described about the method used to resect spinal tumors.1 This video demonstrates the removal of a ventral cervical spinal meningioma using the CO2 laser. A 62-yr-old man presented with progressive paresthesias, gait instability, and urinary frequency. A 1-cm intradural extramedullary mass at C5 showed severe spinal cord compression. Patient consent was obtained prior to performing the procedure. A posterior lateral approach is shown, with a bone removal corridor created at C5 for accessing the tumor ventrally. A right-sided facetectomy and pediculectomy at C5 were performed being flush with the posterior vertebral body. A dural opening positioned laterally provided a working corridor between C5 and C6 nerve rootlets. Lateral portions of tumor were excised in wedge-shaped slices starting laterally and working medially. These slices created a successive and enlarging space to safely allow piecemeal tumor dissection and removal, while limiting retraction upon the spinal cord. The CO2 laser was used to cauterize the tumor capsule, create wedge resections of tumor, and coagulate the final dural attachment. The pathology was a meningioma WHO Grade I. The patient did well, with resolution of parasthesias and ataxia. The CO2 laser technique allowed for limited spinal cord retraction throughout the tumor resection and gross total resection of the tumor was achieved.

scholarly journals Cranial nerve and intramedullary spinal malignant peripheral nerve sheath tumor associated with neurofibromatosis-1

2021 ◽  
Vol 12 ◽  
pp. 630
Author(s):  
Christopher Newell ◽  
Alan Chalil ◽  
Kristopher D. Langdon ◽  
Vahagn Karapetyan ◽  
Matthew O. Hebb ◽  
...  
Keyword(s):  
Peripheral Nerve ◽  
Cranial Nerve ◽  
Case Reports ◽  
Neurofibromatosis Type ◽  
Optic Glioma ◽  
Type I ◽  
Nerve Sheath Tumor ◽  
Intramedullary Spinal Cord ◽  
Peripheral Nerve Sheath Tumors ◽  
Nerve Sheath

Background: Malignant peripheral nerve sheath tumors (MPNSTs) are uncommon but aggressive neoplasms associated with radiation exposure and neurofibromatosis Type I (NF1). Their incidence is low compared to other nervous system cancers, and intramedullary spinal lesions are exceedingly rare. Only a few case reports have described intramedullary spinal cord MPNST. Case Description: We describe the clinical findings, management, and outcome of a young patient with NF1 who developed aggressive cranial nerve and spinal MPNST tumors. This 35-year-old patient had familial NF1 and a history of optic glioma treated with radiation therapy (RT). She developed a trigeminal MPNST that was resected and treated with RT. Four years later, she developed bilateral lower extremity deficits related to an intramedullary cervical spine tumor, treated surgically, and found to be a second MPNST. Conclusion: To the best of our knowledge, this is the first report of cranial nerve and intramedullary spinal MPNSTs manifesting in a single patient, and only the third report of a confined intramedullary spinal MPNST. This unusual case is discussed in the context of a contemporary literature review.

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