Minimally invasive removal of an extradural intraradicular lumbar schwannoma

Minimally Invasive Lateral Retroperitoneal Approach for Resection of Extraforaminal Lumbar Schwannomas: Results After 1-Year Follow-Up

OBJECTIVE

Extradural spinal nerve sheath tumors with foraminal involvement are rare, and the gold standard for surgical resection is not established yet. Traditionally, lumbar intra-extraforaminal schwannomas have been resected through a posterior midline or paraspinal open approach. The lateral transpsoas approach represents a suitable, minimally invasive approach which can provide direct access to the extraforaminal and lumbar plexus region avoiding bone removal, hence the necessity of lumbar fusion. The aim of this study is to share our experience of extraforaminal lumbar schwannomas approached through a minimally invasive lateral transpsoas technique with intraoperative neurophysiological monitoring.

METHODS

This is a single-center retrospective case series study. Seven adult patients who underwent extraforaminal lumbar schwannoma removal through a lateral retroperitoneal approach were enrolled. A detailed description of the surgical technique is reported. The outcome measures included mean surgical duration, mean blood loss, postoperative mobilization, day of discharge, complication, postoperative symptoms, and extent of removal. All patients had a minimum follow-up of 1 year.

RESULTS

The average age was 51 years. Surgery lasted 225 minutes on average, with minimal blood loss. One patient had a cerebrospinal fluid leak, which was successfully repaired. Most patients were mobilized the day after surgery and 6 were discharged within 2-4 days. At a 12-month follow-up, 6 patients showed symptom improvement and magnetic resonance imagings confirmed complete tumor resection in all cases.

CONCLUSIONS

Retroperitoneal transpsoas approach represents a safe tool in the neurosurgeon's armamentarium, particularly suitable for this subset of tumors representing a short and direct way to approach them. Surgeon confidence of working inside the psoas and close to the lumbar plexus is increased using continuous electromyography monitoring. At the end, the retroperitoneal transpsoas approach for extraforaminal lumbar schwannoma can provide minimal soft tissue damage, better pain control, decreased blood loss, and short hospitalization.

Minimally invasive tubular removal of spinal schwannoma and neurofibroma - a case series of 49 patients and review of the literature

To evaluate the efficacy and safety of minimally invasive tubular removal of spinal schwannoma and neurofibroma. In this single-centre study, we retrospectively analysed 49 consecutive patients who underwent minimally invasive removal of a total of 51 benign spinal nerve sheath tumors using a non-expandable (n = 18) or expandable tubular retractor (n = 33) retractor system between June 2007 and December 2019. The extent of resection, surgical complications, neurological outcome, operative time, and estimated blood loss were recorded. Histopathology revealed 41 schwannomas and 10 neurofibromas. After a mean follow-up of 30.8 months, postoperative MRI showed gross total resection in 93.7%, and subtotal resection in 6.3% of the tumors. Three patients were lost to follow up. Of the subtotal resections, one was a schwannoma (2.4% subtotal resections in schwannomas) and two were neurofibromas (20.0% subtotal resections in neurofibromas). Intraspinal and paraspinal tumor localizations were equally accessible by minimally invasive tubular surgery. Conversion to open surgery was not required in any case. The mean operative time was 167 ± 68 min, and estimated blood loss was 138 ± 145 ml. We observed no major surgical complications. Spinal schwannoma and neurofibroma can be removed effectively and safely using a minimally invasive tubular approach, with satisfying extent of tumor resection comparable to the conventional open surgical technique and no increased risk for neurological deterioration.

Minimally Invasive Surgical Technique for the Management of Giant Dumbbell Spinal Schwannoma

BACKGROUND

 Completely extradural spinal schwannomas have a unique morphology (dumbbell tumors) with an intra- and extraspinal component. When they compromise two contiguous vertebral bodies or have an extraspinal extension >2.5 cm, they are classified as giant spinal schwannomas. The aim of this study is to present our experience in the surgical management of completely extradural giant spinal schwannomas with a minimally invasive approach.

METHODS

 This study is a case series of patients treated at the Neurosurgery Department of the University Clinical and Provincial Hospital of Barcelona, Spain, between January 2016 and December 2019.

RESULTS

 Fifteen patients met the inclusion criteria, with thoracic and lumbar spines being the most frequent locations. All patients underwent surgical treatment, with a mini-open interlaminar and far-lateral technique. Total gross resection was accomplished in all patients and spine instrumentation was not necessary.

CONCLUSIONS

 Microsurgery is the treatment of choice for spinal schwannomas, and gross total resection with low morbidity must be the surgical goal. Mini-open interlaminar and far-lateral access is a valid surgical option, with low morbidity in experienced hands, and there is no need for spinal instrumentation.

Direct Lateral Minimally Invasive Approach for Excision of a L1/L2 Neurofibroma-A Technical Note and Literature Review

A case of resection of a large dumbbell-shaped nerve sheath tumor at L1/L2 via a direct lateral minimally invasive approach is described. The tumor was removed via a lateral, subdiaphragmatic, rib-sparing, retropleural, retroperitoneal approach. The thoracolumbar junction can be challenging via the lateral approach and to the best of our knowledge this is the first report of excision of a paravertebral tumor via this approach. We believe this provided the benefits of direct operative trajectory and exposure, excellent tumor access, and avoided the need for facetectomy and extended spinal instrumentation across the thoracolumbar junction. Complete tumor excision was achieved with preserved motor function and improvement in radicular pain and sensory neurological deficit.

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.

Minimally Invasive Lateral Retroperitoneal Approach for Resection of Extraforaminal Lumbar Plexus Schwannomas: Operative Techniques and Literature Review

BACKGROUND

Traditional approaches for retroperitoneal lumbar plexus schwannomas involve anterior open or laparoscopic resection. For select tumors, the lateral retroperitoneal approach provides a minimally invasive alternative.

OBJECTIVE

To describe a minimally invasive lateral transpsoas approach for the resection of retroperitoneal schwannomas.

METHODS

A lateral retroperitoneal transpsoas approach was used to resect a 3.1 × 2.7 × 4.1 cm schwannoma embedded within the psoas muscle. A minimally invasive retractor system allows for appropriate visualization and complete resection with the aid of the microscope. The patient tolerated the procedure without complication and was discharged on postoperative day 2 in good condition at her neurological baseline.

RESULTS

The lateral retroperitoneal approach provides a minimally invasive alternative for select retroperitoneal schwannomas. In theory, this procedure allows for faster recovery and less blood loss compared to traditional open anterior approaches. For a subset of tumors, anterior laparoscopy may provide better access, but the lateral approach is well known to most neurosurgeons who perform lateral interbody fusions and can be easily tailored to extraforaminal tumor resection.

CONCLUSION

Retroperitoneal schwannomas pose a challenge due to their deep location. The lateral retroperitoneal approach provides a useful alternative for resection of a subset of retroperitoneal schwannomas.

Minimally Invasive Direct Lateral Transpsoas Approach for the Resection of a Lumbar Plexus Schwannoma: Technique Report

Objective  Traditional techniques for resection of lumbar plexus tumors have been associated with approach-related morbidity. We describe a case utilizing a minimally invasive transpsoas lateral access approach to resect a retroperitoneal tumor of the lumbar plexus.

Methods  We report a case with an extradural retroperitoneal schwannoma of the L4 nerve root that was treated with a minimally invasive direct lateral transpsoas approach using atraumatic tissue dilators and an expandable tubular retractor. The use of directional and continuous electromyographic monitoring was critical in locating the plexus and positioning the retractor immediately anterior to the tumor.

Results  The patient tolerated the procedure well without postoperative complications. The operative approach was direct and intraoperative blood loss was negligible. The patient demonstrated improved left leg strength and ambulation and resolution of paresthesias.

Conclusions  A minimally invasive direct lateral transpsoas access approach is an effective technique to safely and adequately resect extradural retroperitoneal lumbar plexus tumors.

Surgical management of Giant Lumbar Extradural Schwannoma: Report of 3 cases

Standard surgical approach for extradural paraspinal tumours has been through a unilateral facetectomy, inter-transverse or retroperitoneal approach. Some of these approaches destabilise the spine and consequently require a fusion procedure. Access to these tumours through a minimal access route can decrease tissue damage, fasten post-operative recovery and obviate the need for a concomitant fusion procedure. However, proper case selection and adequate pre-operative planning are important in choosing cases for a minimally invasive approach. We discuss three cases of giant extradural, paraspinal schwannomas. One case that was associated with listhesis along with the tumour situated more anteriorly and embedded in the psoas muscle was managed by lateral retroperitoneal route with simultaneous interbody graft followed by posterior interspinous stabilising device. The other two cases were managed by minimal access route using a 22mm fixed tubular retractor, one by a paramedian approach and one by far lateral approach. The technique and merits of the procedure are discussed.