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