Non-Syndromic Spinal Schwannomas: A Novel Classification

Cauda equina neuroendocrine tumors: A single institutional imaging review of cases over two decades

Cauda Equina Neuroendocrine Tumors (CE-NET), previously referred to as paragangliomas are a rare subset of spinal tumors, with limited data on imaging. Herein, we present a retrospective review of clinical and imaging findings of CE-NETs in ten patients who were evaluated at our institution over the past two decades. All patients had well-defined intradural lesions in the lumbar spine which demonstrated slow growth. A review of imaging findings revealed the presence of an eccentric vascular pedicle along the dorsal aspect of the tumor in 8 of the 10 patients (eccentric vessel sign), a distinctive finding that has not previously been reported with this tumor and may help improve the accuracy of imaging-based diagnosis. In all cases, a gross-total resection was performed, with resolution of symptoms in most of the cases.

Is laminectomy necessary for C1-C2 epidural schwannomas?

PURPOSE

Spinal schwannomas often require laminectomy for gross total resection. However, laminectomy may not be necessary due to the unique anatomy of epidural schwannomas at the C1-2 level, even with the intradural part. This study aimed to determine the need for laminectomy by comparing factors between patients who underwent laminectomy and those who did not and to identify the benefits of not performing laminectomy.

METHODS

Fifty patients with spinal epidural schwannoma confined to C1-C2 level were retrospectively collected and divided into groups based on whether laminectomy was intended and performed. In all cases where laminectomy was conducted, patients underwent laminoplasty using microplate-and-screws, which deviates from the conventional laminectomy approach. Tumor characteristics were compared, and a cut-off value for laminectomy was determined. Outcomes were compared between groups, and factors influencing laminectomy were identified. Postoperative changes in cervical curves were measured.

RESULTS

The diameter of the intradural part of the tumor was significantly longer in the laminectomy performed group, with a 14.86 mm cut-off diameter requiring laminectomy. Recurrence rates did not differ significantly between groups. Surgery time was substantially longer for the laminectomy performed group. No significant changes were observed in Cobb's angles of Oc-C2, C1-C2, and Oc-C1 before and after surgery.

CONCLUSION

The study showed that the diameter of the intradural part of the tumor influenced the decision to perform laminectomy for removing epidural schwannomas at C1-C2. The cut-off value of the diameter of the intradural part of the tumor for the laminectomy was 14.86 mm. Not performing laminectomy can be a viable option with no significant differences in removal and complication rates.

Factors Related to the Deterioration of Postoperative Lower Back Pain in Hemilaminectomy Approach for Lumbar Spinal Schwannoma Resection

Objective

This study aimed to explore the related risk factors in patients who underwent hemilaminectomy for lumbar spinal schwannoma resection and who experienced deterioration of postoperative lower back pain in comparison to preoperative pain levels.

Methods

This retrospective study recruited 61 patients from the First Affiliated Hospital of An Hui Medical University between January 2018 and June 2019. All data were collected from clinical records and analyzed at 1-month and at 1-year follow-up. The visual analog scale (VAS) was used to evaluate pain, and neurologic function was assessed using the Modified McCormick Scale. Intraoperative neurophysiological monitoring was used to assess neuronal integrity and mitigate injury. Statistical analysis of the data was performed using the SPSS version 19 software.

Results

Preoperative pain improved dramatically in the 1-year follow-up (VAS: preoperative, 3.84±2.19; 1-year follow-up, 2.13±2.26; P<0.001). The pain-improved group and worsened group showed a significant difference at 1-month (VAS: 1.76±1.56; 5.54±1.26; P<0.05) and at 1-year (VAS: 0.83±1.09; 4.80±1.58; P<0.05) follow-up. The pain-improved and worsened groups had a significant difference in tumor size and hemilaminectomy removal segments at 1-month and 1-year follow-up, but A-train occurrence on electromyography could only be seen as a statistical difference in the 1-month follow-up. Logistic regression analysis revealed that tumor size was an independent risk factor for postoperative lower back pain deterioration.

Conclusion

The hemilaminectomy approach is a safe and effective method that can dramatically relieve pain in spinal lumbar schwannoma resection. Tumor size is an independent risk factor for postoperative lower back pain. A-train on spontaneous electromyography has been shown to be a reliable predictive factor for the evaluation of postoperative lower back pain. However, further detailed analysis of A-train characteristics can provide a more accurate warning during surgery.

Intradural Extramedullary Tumors and Associated Syndromes

Most intradural tumors are located within the intradural extramedullary compartment, and the most common tumors are schwannomas and meningiomas. Other less common neoplasms include neurofibroma, solitary fibrous tumor, myxopapillary ependymoma, lymphoma, metastatic leptomeningeal disease, malignant peripheral nerve sheath tumor, and paraganglioma. Patients usually present with gait ataxia, radicular pain, and motor and sensory deficits due to chronic compressive myelopathy or radiculopathy. MRI is the modality of choice for detecting and evaluating intradural extramedullary spinal tumors. This imaging technique helps narrow the differential diagnosis and therefore decide treatment.

Percutaneous Full Endoscopic Management of Spinal Foraminal Schwannomas: Case Series

BACKGROUND

Schwannoma, a benign peripheral nerve sheath tumor, is perhaps only secondary to degenerative pathology as the most common lesion at neural foramen. The surgical dilemma here is either risking nerve injury because of inadequate exposure or the need for internal fixation because of facet joint sacrifice.

OBJECTIVE

To evaluate the feasibility and safety of management of foraminal schwannomas by percutaneous full-endoscopic technique.

METHODS

A single-center retrospective review was conducted on patients who underwent full-endoscopic resection of neural foraminal schwannomas. Tumors were grouped into either medial type or lateral type based on relevant location to the neural foramen, and respective surgical approaches were adopted. Data including preoperative neurological status, tumor size, surgery time, the extension of resection, and clinical outcomes were collected. The learning curve was plotted as surgical time/tumor size against case number.

RESULTS

A total of 25 patients were treated between May 2015 and March 2022. Gross total resection was achieved in 24 patients, and near-total resection in 1 case, with 1 patient experienced transient voiding difficulty. No tumor recurrence or spinal instability was detected in the short-term follow-up (median follow-up 22 months, range 3 months-6 years). Surgical efficiency improved with the number of cases operated on and remained stable after the initial 10 cases.

CONCLUSION

Percutaneous full-endoscopic technique is a safe and minimally invasive technique for the resection of foraminal schwannomas.

Spinal Nerve Sheath Tumors: Factors Associated with Postoperative Residual and Recurrent Tumors: A Single-Center Experience

BACKGROUND

Spinal schwannomas (SSs) are usually benign tumors with a good prognosis when treated by surgical excision. However, complete resection can be complicated by factors such as the tumor location and configuration. In the present study, we sought to identify the factors associated with incomplete surgical resection (residual) and the factors associated with tumor recurrence.

METHODS

We performed a retrospective review of 113 cases of SSs treated surgically from 2008 to 2021.

RESULTS

Of the 113 SSs, 102 were benign and 2 were malignant nerve sheath tumors. Of the 102 benign SSs, gross total resection (GTR) was performed for 87, with 8 displaying residual and 7, recurrent tumor. We found a significantly higher ratio of cervical and sacral tumors (P = 0.008 and P = 0.004, respectively), dumbbell and foraminal configurations (P < 0.0001 and P = 0.0006, respectively), and larger tumor volumes (P = 0.003) in the residual and recurrent cohorts compared with the GTR cohort. A second operation was performed for 2 patients in the residual and 4 patients in the recurrent cohorts. The total complication rate was 6%.

CONCLUSIONS

We found that most benign SSs will be amenable to GTR (85% of cases), with an excellent prognosis. The patients with residual or recurrent tumor were more likely to have had a cervical or sacral location, a dumbbell or foraminal configuration, and a larger tumor volume. Except for 1 new SS and 1 recurrent tumor that had necessitated a lateral approach, the remainder had been treated using a posterior approach. At surgery, ultrasonography of the canal is advisable to ensure that the intra- and extraspinal components of dumbbell lesions have both been entirely removed.

Paramedian Wiltse Approach for Giant Paraspinal Lumbar Schwannoma: Technical Note and Alternative Approaches

BACKGROUND

Paraspinal lumbar schwannomas are primarily located outside of the spinal canal with minimal extension into the neural foramen. Approaching these tumors through a traditional posterior approach can be challenging given their lateral location to the spine and is likely to require extensive bony removal and potential destabilization of the spine. Alternatives approaches have been identified that may circumvent the need for extensive bony removal.

OBJECTIVE

To examine the use of the paramedian Wiltse approach for giant extraspinal tumors and compare the approach with other nonposterior approaches.

METHODS

We present 2 cases in which the paramedian Wiltse approach is used to effectively approach large paraspinal schwannomas and achieve complete tumor resection without destabilization of the spine.

RESULTS

The paramedian Wiltse approach along with expandable retractors systems were able to achieve complete resection of the giant paraspinal schwannomas. Neural preservation was able to be achieved in one case which was facilitated by the exposure achieved through the posterior paramedian corridor that allowed for visualization of the proximal and distal ends of the tumor.

CONCLUSION

The paramedian Wiltse approach is an ideal approach to target large extraspinal schwannomas for complete resection and potential neural preservation without the need for destabilization of the spine.

Purely extradural thoracal Schwanoma: Case report

Introduction

and importance. Schwannomas are benign tumors that often occur in the medulla spinalis. It arises from the Schwann cells which form the sheath of peripheral nerves. Schwannomas comprise about 30% of primary intraspinal neoplasms and approximately 75% in intradural, 10% intra-extradural, and 15% extradural. Purely extradural schwannoma is rare.

Case presentation

We present two adult males with extradural thoracal schwannoma. In this case, the main complaint is paraparesis and followed by suffered low back pain and spastic. The initial symptoms of this tumor depend on the level of the tumor location. Usually begins with localized pain, sharp and transient, followed by radicular pain and radiculopathy. We reported cases of schwannoma of the thoracal spine that have presented with neurological involvement. As a result of contrast, an MRI of the spine showed tumor extradural mass lesion extending from thoracal 1–2 vertebral and thoracal 4–6 vertebral level.

Clinical discussion

The location of this tumor is rare because located in the extradural (15%), which are present between the bone structure and the dura. Surgery is the treatment of choice, in this case, usually results from excellent prognostic. This patient underwent hemilaminectomy and complete surgical resection.

Conclusion

Early diagnostic and complete surgical resection before the occurrence of severe symptoms will show an excellent prognosis.

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Purely extradural schwannoma is rare.

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We presented a schwannoma of the thoracal spine that have presented with neurological involvement.

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Early diagnostic and complete surgical resection before the occurrence of severe symptoms will show an excellent prognosis.

Benign Peripheral Non-cranial Nerve Sheath Tumors of the Neck

Benign peripheral non-cranial nerve sheath tumors are rare lesions, including both schwannomas and neurofibromas. These tumors arise from Schwann cells, and may originate from any peripheral, cranial, or autonomic nerve. Most of them are localized and sporadic but multifocal systemic forms can occur. Cervical sympathetic chain, brachial plexus, cervical plexus and spinal roots and nerves are the major nerve systems commonly affected. Dumbbell-shaped intra- and extradural tumors occur most commonly in the cervical spine, as well as purely extradural and paravertebral tumors. The management of these tumors has improved greatly owing to the developments in imaging techniques and surgical innovations such as endoscopically assisted approaches and robotic surgery. Microsurgical intracapsular excision of the tumor helped by the use of intraoperative fluorescent dyes and intraoperative neurophysiological monitoring minimize postoperative neural deficit, since most schwannomas are encapsulated. Most tumors can be removed with a low rate of complications and recurrence. Radiotherapy should be considered for growing lesions that are not amenable to surgery. In asymptomatic patients, observation and serial scans is an option for elderly infirm patients.

Lumbar radiculopathy associated radicular schwannoma: A case report and literature review

Lumbar radiculopathy is a clinical condition defined by symptoms of pain, weakness, numbness, or tingling due to lumbar nerve root compression in levels L1-L4. Typically, it is characterized by a narrowing near the nerve root possibly caused by stenosis, bone osteophytes, disc herniation, and similar conditions. Reports of lumbar radiculopathy brought about by the presence of a radicular schwannoma are exceedingly rare. In this paper, we discuss the case of a 67-year-old female patient, presenting with complaints of low back pain, numbness, and antalgic gait for the past eight months. Her physical examination revealed motor and sensor neurological deficits affecting the left lower limb. The electromyoneurography evaluation showed neurogenic atrophy of the left radicular area, while the MRI revealed the presence of a giant, radicular schwannoma at L4-L5 level. This case report aims to underscore the clinical course and management of lumbar radiculopathy caused by a rare L4-L5 radicular schwannoma. Our patient had no significant risk factors or previous spinal pathology.

Do Tumour Size, Type and Localisation Affect Resection Rate in Patients with Spinal Schwannoma?

Background and Objectives: Spinal schwannomas are benign tumours that can present with various symptoms such as pain, radiculopathy and neurological deficit. Gross total resection (GTR) is of key importance for local recurrence. The aim of this study is to describe the clinical characteristics, resection rate, clinical outcome, as well as tumour recurrence, in patients with non-syndromic spinal schwannomas and to clarify which factors affect the resection rate. Materials and Methods: Patients with non-syndromic spinal schwannomas that underwent surgical resection between January 2009 and December 2018 at a single institution were included. Demographic parameters, clinical symptoms, tumour localisation and size, surgical approach and complications were noted. Factors influencing the extent of resection, the surgeon’s decision regarding the approach and the occurrence of new postoperative deficits were evaluated. Results: Fifty patients (18 females) were included. The most common presenting symptom was radiculopathy (88%). The lumbar spine was the most commonly affected site (58%). Laminotomy (72%) was the preferred surgical approach overall and specifically for exclusively intraspinal schwannomas (p = 0.02). GTR was achieved in 76.0% (n = 38). In multivariate analysis, only tumour localisation within the spinal canal (p = 0.014) independently predicted GTR, whereas the type of approach (p = 0.50) and tumour volume (p = 0.072) did not. New postoperative persisting deficits could not be predicted by any factor, including the use and alteration of intraoperative neuromonitoring. Recurrence was observed in four cases (8%) and was significantly higher in cases with STR (p = 0.04). Conclusions: In this retrospective study, GTR was solely predicted by tumour localisation within the spinal canal. The decision regarding the utilisation of different surgical approaches was solely influenced by the same factor. No factor could predict new persisting deficits. Tumour recurrence was higher in STR.

Giant lumbar spinal schwannoma: a case report and literature review

We report a case of a 40-year-old female patient admitted to the hospital due to lumbar pain that spread to both legs and was associated with weakness of the lower extremities. Magnetic resonance imaging revealed an intradural - extramedullary tumor at the level of the T12 - L2 vertebra. The lesion was over 7 cm in greatest diameter and compressed the conus medullaris. The patient underwent surgery to remove the entire tumor. Postoperative pathology confirmed the diagnosis of schwannoma. The symptoms resolved almost completely without significant complications.

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.

Spinal schwannoma causes acute subarachnoid haemorrhage: A case report and literature review

BACKGROUND

Spinal schwannomas that arise from spinal nerve root sheaths are the most common intradural extramedullary spinal tumours and are often accompanied by nerve roots or spinal cord irritation symptoms. The phenomenon of spinal schwannoma causing subarachnoid haemorrhage (SAH) is rare, with ependymoma of the conus medullaris accounting for most cases.

CASE REPORT

A 45-year-old man was admitted to our hospital due to progressive lower limb weakness and sudden back pain after hard physical work. The patient had not been able to walk for 2hours upon admission. An emergency magnetic resonance imaging (MRI) scan showed that the spinal cord at the C6-T4 level was severely compressed by a subdural mass. During the emergency operation, exploration of the dura and arachnoid mater revealed a fresh blood clot covering a tumour located on the ventral side of the spinal cord. The size of the tumour was approximately 3×2×1cm without adhesion to the surrounding tissue, but the drainage vein was ruptured. Postoperative pathology showed that the tumour was a schwannoma with areas of fresh haemorrhage and focal necrosis.

CONCLUSIONS

Spinal schwannomas presenting with SAH are rare events. In our opinion, spinal pathology with rapid progression of neurological symptoms requires early diagnosis and emergency management. Complete excision of haemorrhagic tumours is the goal of treatment to prevent recurrence, which can effectively avoid irreversible damage to the spinal cord resulting from spinal cord compression.

Oversized primary intrapulmonary schwannoma: A case report and a review of the literature

BACKGROUND

Schwannomas, also known as neurilemommas, are benign, well-circumscribed encapsulated peripheral nerve sheath tumors with rather indolent evolution. Made up of cells closely related to normal myelinating Schwann cells, these neoplasms may arise from the peripheral nervous system as well as from spinal or cranial nerves. They are mostly found in the base of the skull, neck, chest wall, posterior mediastinum, posterior spinal roots, cerebellopontine angle, retroperitoneum, and flexor surfaces of the extremities. The incidence rate of spinal schwannoma is 0.3-0.5/100,000 cases per year with an average age of 50 at diagnosis. We report a case of intrapulmonary schwannoma, adding a review of the literature.

CASE DESCRIPTION

A 20-year-old female patient with no significant medical history, presented with pleuritic chest pain, shortness of breath, right upper limb weakness, and numbness. A computed tomography of the chest and magnetic resonance imaging showed a 7.2 × 10.5 × 8.3 cm mass in the posterior segment of the right upper lobe, arising from the right T5-6 neural foramen; a concurrent 16 mm thick right pleural effusion was also noticed yet without evidence of nodular enhancement. The findings suggested the presence of a neurofibroma or a schwannoma. Complete resection of the tumor was achieved through posterolateral thoracotomy; the ensuing histopathological and immunohistochemical examinations confirmed the presence of a schwannoma.

CONCLUSION

We believe this rare case of pulmonary invasive schwannoma illustrates the complex dynamics of this extremely rare entity; in this particular case, complete surgical excision proved to be crucial in terms of subacute management and local tumor control, at least at short and middle term. The patient is currently asymptomatic (6 months postsurgery) and remains on follow-up.

A Novel Classification and Its Clinical Significance in Spinal Schwannoma Based on the Membranous Hierarchy

BACKGROUND

Spinal schwannoma is a common benign tumor. However, the high recurrence rate and incidence of surgical complications are unsolved problems.

OBJECTIVE

To propose a morphological classification of spinal schwannoma based on tumor-membrane relationships to increase the gross total resection (GTR) rate and to decrease the incidence of surgical complications.

METHODS

Histological techniques were used to study 7 adult cadavers. Following picrosirius staining, the membranes around the nerve root were observed under a microscope. Data from 101 patients with spinal schwannoma were also collected for clinical analysis.

RESULTS

The sleeve around the spinal nerve root consisted of dura and arachnoid tissues. The space between them gradually narrowed and fused at the proximal pole of the nerve root ganglion. Spinal schwannomas were divided into 4 types based on membranous structure: intrapial (type I), subarachnoidal (type II), intra- and extradural (type III), and extradural growth (type IV). Types II and III were further subdivided into 2 subtypes. GTR was achieved in all patients (100%), with no tumor recurrence during follow-up. Overall functional status significantly improved postoperatively. A total of 59 patients (92%) showed improvement or significant improvement postoperatively. There was no difference in surgical outcomes among the tumor classifications (P = .618). No intraoperative vertebral artery injuries or postoperative cerebrospinal fluid fistula occurred.

CONCLUSION

Spinal schwannoma classification based on a membranous hierarchy provides an intuitive platform for preoperative planning and intraoperative safety. This classification scheme may help surgeons better define surgical goals and anticipate or even avoid complications from resection.

Functional outcome in intradural extramedullary tumor patients: Case series

Introduction

Intradural extramedullary (IDEM) spinal cord tumors account two thirds of all intraspinal tumors. These tumors produce pain syndromes, a variety of neurological symptoms-motor, sensory, sphincter or a combination of thereof. Preferred treatment is microsurgical radical resection. The objective of this study was analyzed and discuss about functional outcome in IDEM.

Presentation of case

We present serial case of 15 patients, that consist of 8 males and 7 females, with the mean age of 43,4 years old, ranging from 16 to 82 years old. The outcomes were followed up with Karnofsky Score and Tomita to analyzed metastasis of the tumor. The mean of Karnofsky score in this study was 74 with no patient had metastatic intradural tumor, therefore the Tomita score in these patients is incalculable.

Discussion

MRI confirmed the location and extent of the tumor for definitive diagnosis. We then performed excision of the tumor or decompression of the spinal canal followed by posterior stabilization if needed. Minimal complaint regarding pain and/or numbness were found. Post operation functional outcome of the patient is monitored using Karnofsky score.

Conclusion

In all except one patient, the functional outcome of the patients is greater than 50 based on Karnofsky score. In this case series, the good functional outcome is due to all tumor were primary tumor which originate from the spine. Furthermore, all tumor had benign characteristic based on the anatomical pathology result. In consequence, gross total resection can be achieved thus resulting a good overall functional outcome of the patients.

Need for arthrodesis following facetectomy for spinal peripheral nerve sheath tumors: an institutional experience and review of the current literature

OBJECTIVE

Spinal peripheral nerve sheath tumors (PNSTs) are a group of rare tumors originating from the nerve and its supporting structures. Standard surgical management typically entails laminectomy with or without facetectomy to gain adequate tumor exposure. Arthrodesis is occasionally performed to maintain spinal stability and mitigate the risk of postoperative deformity, pain, or neurological deficit. However, the factors associated with the need for instrumentation in addition to PNST resection in the same setting remain unclear.

METHODS

An institutional tumor registry at a tertiary care center was queried for patients treated surgically for a primary diagnosis of spinal PNST between 2002 and 2016. An analysis focused on patients in whom a facetectomy was performed during the resection. The addition of arthrodesis at the index procedure comprised the primary outcome. The authors also recorded baseline demographics, tumor characteristics, and surgery-related variables. Logistic regression was used to identify factors associated with increased risk of fusion surgery.

RESULTS

A total of 163 patients were identified, of which 56 (32 had facetectomy with fusion, 24 had facetectomy alone) were analyzed. The median age was 48 years, and 50% of the cohort was female. Age, sex, and race, as well as tumor histology and size, were evenly distributed between patients who received facetectomy alone and those who had facetectomy and fusion. On univariate analysis, total versus subtotal facetectomy (OR 9.0, 95% CI 2.01-64.2; p = 0.009) and cervicothoracic versus other spinal region (OR 9.0, 95% CI 1.51-172.9; p = 0.048) were significantly associated with increased odds of performing immediate fusion. On multivariable analysis, only the effect of total facetectomy remained statistically significant (OR 6.75, 95% CI 1.47-48.8; p = 0.025).

CONCLUSIONS

The authors found that total facetectomy and cervicothoracic involvement may be highly associated with the need for concomitant arthrodesis at the time of index surgery. These findings may help surgeons to determine the best surgical planning for patients with PNST.

Synchronous Presentation of a Cervical Spinal Schwannoma and Primary Progressive Multiple Sclerosis in a 65-year-old Man

Schwannomas are common benign neoplasms of the myelinating cells surrounding peripheral nerve axons. Though uncommon, lesions arising in the cervical spine may produce radicular pain and myelopathic weakness. Multiple sclerosis (MS) is a common autoimmune disorder with the capacity to mimic nearly any neurologic disease, including spinal cord neoplasms. We report the third case of synchronously presenting primary progressive MS and spinal schwannoma.

A 65-year-old man presented with six months of progressive weakness and pain of the right shoulder, forearm, and hand. MRI demonstrated a contrast-enhancing transforaminal lesion at C7, most consistent with a benign nerve sheath tumor. Additional history disclosed several years of worsening fatigue, accompanied by bilateral weakness and lancinating leg pain. MRI of the neuraxis demonstrated abnormalities consistent with chronic demyelinating disease intracranially and within the spinal cord; cerebrospinal fluid (CSF) analysis revealed nine oligoclonal bands and an elevated IgG index, resulting in the diagnosis of MS. Given the symptomatic C7 lesion, the patient subsequently underwent right C6-C7 facetectomy, gross total resection of the tumor, and C6-T1 posterior instrumented fusion. Postoperatively, the patient rapidly recovered normal right upper extremity function, and pathology confirmed benign schwannoma.

Synchronously presenting co-morbid neurologic diagnoses are exceedingly rare. Nonetheless, the high incidence and protean nature of MS make it particularly susceptible to such confounding clinical cases. Correspondingly, MS should be considered when neurologic abnormalities are not compatible with a focal radiographic lesion, and the present report emphasizes the value of a good history and exam in unraveling similarly challenging cases.