Hemorrhagic thoracic schwannoma presenting with intradural hematoma and acute paraplegia after spinal manipulation therapy

Acute Neurological Aggravation Caused by Intratumoral Hemorrhage of a Cervical Dumbbell Schwannoma: Report of a Rare Case and Literature Review

Schwannomas are one of the most common types of primary intraspinal tumors. We report a rare case of neurological aggravation due to the intratumoral hemorrhage of a cervical schwannoma. A 65-year-old man presented with lower extremity weakness developing gradually. Tumor resection was performed one week after neurological aggravation occurred. After surgery, he recovered dramatically. There are vascular and mechanical hypotheses for the etiology of intratumoral hemorrhage of schwannoma. In the present case, falling and antiplatelet drugs may have caused the intratumoral hemorrhage. Optimal surgical timing remains controversial. Some reports reveal patients recovered well after urgent surgery. However, even if urgent surgery is performed, some have neurological sequelae. Others reveal patients recovered well after elective surgery without any sequelae. Because previous reports reveal the surgical procedure may damage the spinal cord, urgent surgery may not be compulsory and elective surgery may be a better treatment option. Further investigation is needed to clarify the etiology and optimal timing for surgical treatment of intratumoral hemorrhage.

Hemorrhagic Schwannoma of the Cauda Equina: Case Report and Review of the Literature

Spinal intradural hemorrhage is a rare event; the most common causes of spinal bleeding are traumas, medical therapy with anticoagulants and thrombolytics, vascular malformations, and congenital defects of coagulation. Rarely, spinal cord tumors may cause hemorrhage. Herein, we report the case of a patient with acute and quickly worsening lumbar pain: the neurological examination revealed a flaccid paraplegia caused by an intradural lesion extending on the right side of the spinal cord from T1 to L2 vertebral level. Pathological examination revealed an hemorrhagic schwannoma. Acute spinal subdural hemorrhage caused by spinal schwannomas is a very rare occurrence (29 cases only have been previously reported). Review of the literature with clinico-diagnostic features is presented, surgical treatment is explained, and pathological findings with possible etiopathogenesis of hemorrhage are described.

Acute paraplegia due to thoracolumbar schwannoma following trauma: A case report and literature review

Spinal schwannomas account for one third of primary spinal neoplasms. Clinical presentation is related to the tumor location. An atypical case of acute paraplegia following a fall, on the ground of a thoracolumbar schwannoma, without intratumoral hemorrhage, in a previously asymptomatic patient is reported. A 58-year-old male patient presented with acute paraplegia, and urinary and bowel incontinence, following a fall. The patient had no previous history of back and/or leg pain or neurological symptoms. Magnetic resonance imaging revealed a subdural mass, as well as a fracture of the right T12-L1 facet joint and the right transverse process. The patient underwent emergency T11-L1 wide laminectomy, exploration of the subdural space and T10-L2 posterolateral transpedicular stabilization and fusion. An intradural, extramedullary mass, causing severe cord compression, was found and excised. Pathology revealed schwannoma, without intratumoral hemorrhage. The patient recovered completely 6 months postoperatively. To the best of our knowledge, this is the first report of spinal intradural schwannoma causing sudden paraplegia in a previously asymptomatic patient in the setting of trauma, without intratumoral hemorrhage. Emergency canal decompression and complete excision of the tumor represent the optimal management of such cases.

Thoracic spine schwannoma presenting with traumatic spinal cord injury: A case report

Background:

The presentation of a thoracic spinal tumor due to high-impact trauma is quite rare and we found no other case reported.

Case Description:

This is a case report and literature review. A patient presented with severe paraparesis on day 4 after trauma. Thoracic MRI showed an oval image centered to T4-T5 suggestive of hemorrhage. The patient underwent a bilateral T4 and T5 laminectomy and microsurgically assisted intradural exploration. After laminectomy, we found no extradural lesions, so we proceeded to dural opening, after which we found a large extramedullary lesion which was completely removed. Pathology revealed a schwannoma. The patient had a very good recovery after surgery and motor rehabilitation. At 6 months after surgery, inferior limbs muscle strength was completely normal. We found no other case reported.

Conclusion:

Thoracic spine schwannomas are difficult to early diagnose unless there is a clinical suspicion. Initial presentation as bleeding after trauma was not described before. This presentation should be kept in the differential diagnosis of any patient with an acute neurological deficit without trauma signs on admission imaging.

Natural reduction in acute intratumoral hemorrhage of spinal schwannoma in the cauda equina

A 58-year-old woman presented with acute pain in her back and her left leg. Magnetic resonance imaging (MRI) revealed an intradural schwannoma with an intratumoral hemorrhage between the lower L4 vertebra and L5/S1 disk level. A follow-up MRI after one month revealed that the tumor had regressed from the middle of L5 to the L5/S1 disk level. The tumor was totally resected. There have been several reports of intratumoral hemorrhage of spinal schwannomas occurring at the cervical, thoracic, and conus levels; however, there has been only one previous report of it being seen at the L2-3 middle lumbar level and none at all at lower lumbar levels. This is the first report of an intratumoral hemorrhage of a schwannoma in the lower lumbar area. Furthermore, natural regression of an intratumoral hemorrhage of spinal schwannoma at lower lumbar levels has not previously been reported.

Thoracic adverse events following spinal manipulative therapy: a systematic review and narrative synthesis

Objectives: Spinal manipulative therapy (SMT) is widely used by manual therapists to manage spinal complaints. Notwithstanding the perceived relative safety of SMT, instances of severe thoracic adverse events (AE) have been documented. An evidence synthesis is required to understand the nature, severity and characteristics of thoracic AE following all SMT. The primary objective of this study was to report thoracic AE following SMT and secondly to report patient characteristics to inform further research for safe practice. Methods: A systematic review and data synthesis were conducted according to a registered protocol (PROSPERO CRD42019123140). A sensitive topic-based search strategy for key databases, gray literature and registers used study population terms and keywords, to search to 12/6/19. Two reviewers were involved at each stage. Using the Oxford Center for Evidence-based Medicine (CEBM) the level evidence was evaluated with grade presented for each AE. Results were reported in the context of overall quality. Results: From 1013 studies identified from searches, 19 studies (15 single case studies and 4 case series) reporting 21 unique thoracic AE involving the spinal cord tissues [nonvascular (n = 7), vascular (n = 6)], pneumothorax or hemothorax (n = 3), fracture (n = 3), esophageal rupture (n = 1), rupture of thoracic aorta (n = 1), partial pancreatic transection (n = 1). Reported outcomes included fully recovery (n = 8), permanent neurological deficit (n = 5), and death (n = 4). Conclusion: Although causality cannot be confirmed, serious thoracic AE to include permanent neurological deficit and death have been reported following SMT. Findings highlight the importance of clinical reasoning, including pre-thrust examination, as part of best and safe practice for SMT.

A Rare Chronic Presentation of Schwannoma with Hemorrhage

Spinal schwannomas are slow-growing benign tumors arising from the nerves. In the spinal cord, they arise most commonly from cervical and lumbar levels. They are mostly intradural extramedullary (IDEM) accounting for 30% of intradural tumors showing a female preponderance. They are seen occurring between 25 and 50 years of age. Most of these cases show acute presentation as hemorrhage within the tumor with weakness. This is a rare presentation by itself reported by only 12 cases world over. It is even rarer to see them show chronic presentation. We are reporting one such case of a 61-year-old female who presented to us with chronic low backache for 3 years with radicular symptoms in the bilateral lower limbs following a fall on her back. Magnetic resonance imaging was done which showed a well-defined IDEM lesion from L3 to L5 vertebral level which was isointense on T1 and hyperintense on T2 with a peripheral rim and short inversion time inversion-recovery showed fluid-fluid level within. Gradient-recalled echo showed blooming with no suppression on fat-sat and no diffusion restriction. A computed tomography angiography was done which ruled out vascular malformation. Intraoperatively, a large feeding vessel with a tumor was visualized after laminectomy was done for the corresponding levels. Postoperatively, the patient showed a significant decrease in radicular symptoms and was discharged after 2 weeks with an uneventful postoperative period. HPE of the lesion showed sheets of fascicles of elongated spindle cells arranged in loose myxoid matrix with hyperchromatic nuclei and scanty hemorrhage and lymphocytic infiltrates suggestive of schwannoma with myxoid degeneration. Immunohistochemistry also confirmed a diagnosis of schwannoma. From this case, it is seen that the diagnosis of a spinal schwnnoma showing delayed presentation with atypical imaging findings is a challenge and must needs a high index of suspicion and appropriate surgical planning.

Haemosiderin cap sign in cervical intramedullary schwannoma mimicking ependymoma: how to differentiate?

A 37-year-old female presented with gradually progressive asymmetric ascending paraesthesia and weakness involving bilateral upper and lower limbs. The MRI spine images revealed expansile intramedullary, solid cystic, peripherally enhancing lesion with a haemosiderin cap along the lower margin. The lesion extended into the left C5 and C6 nerve root exit zones, along with thickening and enhancement of the nerve roots. She underwent excision of the lesion, which revealed intramedullary schwannoma on histopathological examination. Presence of the cap, an extension of the lesion into the nerve root exit zone, with associated thickening and enhancement of the dorsal nerve roots should alert the radiologist to consider the possibility of intramedullary schwannoma rather than ependymoma. Schwannoma showing compact Antoni A area with Schwannian whorls and nuclear palisades (A,B) and loose Antoni B area with haemosiderin pigment (C). The tumour exhibits diffuse positivity for S-100 protein (D) and negativity for GFAP (E). [Stain: A-C: Haematoxylin and Eosin; D,E: Immunoperoxidase. Magnification = Scale Bar, A-E: 100μm].