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    Schwannoma of The Lumbar Spine

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    kurnia
    This document discusses schwannoma of the lumbar spine. Some key points: - Schwannomas are benign nerve sheath tumors that arise from Schwann cells and account for 25% of all spinal tumors. - They are typically small and slow-growing but can become giant sized. MRI is used to evaluate location and extent. - Surgical approaches include standard posterior laminectomy or additional approaches like lateral extracavitary for tumors with extradural components. - The goal is complete resection while preserving nerve function if possible, though sometimes the entire nerve root must be sacrificed. Outcomes are generally good with low recurrence rates following gross total resection.

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    Schwannoma of The Lumbar Spine

    Uploaded by

    kurnia
    53 views35 pages
    This document discusses schwannoma of the lumbar spine. Some key points: - Schwannomas are benign nerve sheath tumors that arise from Schwann cells and account for 25% of all spinal tumors. - They are typically small and slow-growing but can become giant sized. MRI is used to evaluate location and extent. - Surgical approaches include standard posterior laminectomy or additional approaches like lateral extracavitary for tumors with extradural components. - The goal is complete resection while preserving nerve function if possible, though sometimes the entire nerve root must be sacrificed. Outcomes are generally good with low recurrence rates following gross total resection.

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    This document discusses schwannoma of the lumbar spine. Some key points: - Schwannomas are benign nerve sheath tumors that arise from Schwann cells and account for 25% of all spinal tumors. - They are typically small and slow-growing but can become giant sized. MRI is used to evaluate location and extent. - Surgical approaches include standard posterior laminectomy or additional approaches like lateral extracavitary for tumors with extradural components. - The goal is complete resection while preserving nerve function if possible, though sometimes the entire nerve root must be sacrificed. Outcomes are generally good with low recurrence rates following gross total resection.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    53 views35 pages

    Schwannoma of The Lumbar Spine

    Uploaded by

    kurnia
    This document discusses schwannoma of the lumbar spine. Some key points: - Schwannomas are benign nerve sheath tumors that arise from Schwann cells and account for 25% of all spinal tumors. - They are typically small and slow-growing but can become giant sized. MRI is used to evaluate location and extent. - Surgical approaches include standard posterior laminectomy or additional approaches like lateral extracavitary for tumors with extradural components. - The goal is complete resection while preserving nerve function if possible, though sometimes the entire nerve root must be sacrificed. Outcomes are generally good with low recurrence rates following gross total resection.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 35

    Schwannoma of

    The Lumbar Spine


    Dr. Ade Wirdayanto, SpBS
    RS Stroke Nasional Bukittinggi
    Introduction
    Spinal Tumor :
    15 % of primary CNS Tumor.
    Most primary CNS Spinal tumors are
    benign.

    Compartmental locations of Spinal


    Tumor
    1. Extradural (55%)
    2. Intradural Extramedullary
    (ID-EM) 40% : meningioma,
    schwannoma, lipoma, misc
    3. Intramedullary Spinal
    Cord Tumors 5%
    Schwannoma
    • Slow growing
    • Benign tumor
    • 0,3 to 0,4 per 100.000
    people annually
    • 25 % of all spinal tumor
    • Sporadically and solitary
    • Typically small
    • 11 % of them may be defined as giant
    • Extend over multiple vertebral level, have a large extraspinal
    extension, or extend into myofascial plane
    • 3-4% presenting with a schwannoma have multiple lesions
    • Also may occur in the setting of neurofibromatosis type 2
    • Derive from schwann cells of
    the dorsal nerve root, 23%
    arise from ventral nerve root.
    • Arises from a single nerve
    fascicle
    • A smooth globoid mass
    attached to a nerve, do not
    produce nerve enlargement,
    suspended eccentrically
    • Firm, encapsulated, can be
    cystic, hemorrhagic, or fat
    containing
    Configuration
    • Most are entirely intradural, but 8-32% may be completely
    extradural
    • 1-19% a combination
    • 6-23% are dumbbell
    • 1% intramedullary
    Dumbbell tumor
    • tumors that develop an “hourglass” shape as aresult of an
    anatomic barrier encountered during growth
    • Not all dumbbell tumors are schwannomas, e.g neuroblastoma
    • Most have a contiguous intraspinal, foraminal(usually
    narrower) and extraforaminal components (widening of the
    neural foramen is a characteristic finding,can be recognized
    even on plain films). The waist may also be due to a dural
    constriction
    Asazuma et al. Classification system for
    Dumbbell spinal Schwannoma
    • Types I, IIa, IIIa, some
    upper cervical IIIb and
    some VI are generally
    amenable to a posterior
    approach
    • IIa and IIIa usually require
    total facetectomy for
    complete removal.
    • Reconstruction may be
    needed if substantial
    posterior disruption occurs
    Anterior and combined
    anterior/posterior approachs
    • Asazuma et al. recommend
    a combined approach for
    type IIb, IIc and IIIb lesions
    where the extraforaminal
    extension is large
    • Reconstruction with
    instrumentation was
    required for some tumors
    (10% of all patients treated)
    Location and Clinical
    • Gottfried ON, Binning MJ, Schmidt MH. Surgical Approaches to Spinal
    Schwannomas. Contemp Neurosurg.2005; 27:1–8
    Histology
    • Composed of compact and interwoven bundles of long, spindle
    shaped Schwann cells ( Antony type A tissue), which often are
    intermingled with sparse areas of more polymorphic Schwann
    cells embedded in a loose eosinophilic matrix ( Antony type B
    tissue)
    Radiology
    • MRI is used to evaluate the location and extent of the
    schwannoma.
    • Important to selecting a surgical approach
    • Evaluate the tumor relations to major vessel, including the
    vertebral artery or abdominal vasculature
    • CTA or MRA is indicated when tumors extend into the
    transverse foramen or adjacent to major vessels
    Surgical Approach
    Standard Posterior Approach
    • Many spinal schwannomas
    present eccentrically,
    dorsolateral to the spinal cord,
    and, therefore, are accessible via
    a posterior or posterolateral
    approach and are easily seen
    after the dura is opened.
    • Unilateral laminectomy, with or
    without facetectomy, or far
    lateral approaches may be used
    for eccentrically located ventral
    tumors.
    • Ventrolaterally located
    schwannomas often require
    dentate ligament sectioning to
    obtain adequate visualization.
    • In some ventral schwannomas,
    the tumor may provide the
    necessary spinal cord retraction
    to provide access via the
    standard posterior exposure.
    • A divided dentate ligament or a
    noncritical nerve root may be
    retracted to provide further
    ventral exposure.
    • Tumor resection is performed
    under microscopic magnification
    and with intraoperative
    electrophysiological stimulation
    and recording techniques, including
    motor and somatosensory-evoked
    potentials.
    • After the schwannoma is exposed,
    the plane of dissection on the tumor
    surface must be identified.
    • An arachnoid membrane often
    adheres to the tumor and must be
    incised and reflected off the tumor
    surface.
    • the tumor and its capsule are
    cauterized to decrease the size of the
    tumor and its vascularity.
    • The normal proximal and distal
    aspects of the involved nerve are
    exposed, and the attachment to the
    involved nerve root is identified.
    • Internal debulking may be performed
    with an ultrasonic aspirator.
    • The schwannoma then is separated
    from the nerve. In some cases, it is
    necessary to sacrifice the nerve root
    for tumor removal, although usually it
    is possible to preserve fascicles of the
    nerve root.
    • Functioning nerve fascicles often can
    be dissected free and swept
    circumferentially off the surface of an
    underlying schwannoma, thus
    preserving their function.
    • Furthermore, in a schwannoma of
    dorsal root origin, it usually is
    possible to separate the tumor from
    the adjacent ventral root without
    causing resulting injury.
    • Some proximally located
    schwannomas may be embedded in
    the pia, and resection of these tumors
    may require resection of a segment of
    the pia.
    • Overall, many schwannomas that are located completely
    intradurally may be approached through a laminectomy, but
    very large tumors, tumors that are located extradurally, or those
    with an extradural component often require an additional or
    different surgical approach to achieve gross total resection.
    Lumbar Schwannoma
    Open Approaches
    • McCormick described surgical
    management of dumbbell and paraspinal
    tumors of the thoracic and lumbar spine.
    • The lateral extracavitary approach was
    used for single-stage tumor resection in
    six patients with complex dumbbell or
    paraspinal schwannomas of the thoracic
    and lumbar spine.
    • Gross total resection was achieved in all
    cases, and none of these patients required
    a fusion procedure.
    • The lateral extracavitary approach
    provides exposure of intradural
    structures, the anterior and posterior
    paraspinal regions, the ventral spinal
    canal, and the vertebral body.
    • First, the intradural aspect of the
    schwannoma is resected via a
    standard laminectomy.
    • Then, a unilateral facetectomy and
    a Tshaped lateral dural incision
    over the root sleeve are made to
    provide contiguous exposure of the
    foraminal portion of the tumor
    once the spinal cord is
    decompressed.
    • The dura then is closed, and,
    finally, the anterior paraspinal
    component is resected through the
    lateral portion of the exposure.
    Nerve Sacrifice
    • It is usually possible to preserve some fascicles of the nerve
    root, although sometimes section of the entire nerve root is
    required.
    • New deficits may not occur since involved fascicles are often
    nonfunctional, and adjacent roots may compensate.
    • The risk for motor deficit is higher for schwannomas than for
    neurofibromas, for cervical vs. lumbar tumors, and for cervical
    tumors with extradural extension.
    Outcome
    • Recurrence is rare following gross total excision, except in the
    setting of NF2
    TERIMAKA
    SIH

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