Combined approach for cervical schwannomas with large extraforaminal extension

Background Data : About 75% of Spinal schwannoms are intradural, 10%intra-extradural and 15% are completely extradural . These tumors are usually slowly growing and reach a large size before becoming symptomatic. The tumors which are totally or partially located in the epidural space (dumbbell tumors) are either intraspinal, foraminal or extraspinal. These dumbbell forms represent about 18 % of the total percentage of whole spinal schwannomas, but they are responsible for almost half of the cervical schwannomas When these tumors have large extraforaminal part it become so difficult to achieve total excision through a single approach . Study design : This is a retrospective study. Purpose: To evaluate the efficacy and safety of combined approach for excision of these large tumors closely related to the vertebral artery Patients and Methods : This study was conducted in Mansoura University Hospital on 6 patients two males and four females their age ranged (22-50) years with cervical spinal schwannoms with large lateral extra formaninal component. All patients were assessed clinically and radiologically using CT and MRI cervical spine and vertebral artery angiography before surgery. Posterior approach through a hemilaminectomy with facet preservation was used for excision of the intraspinal part without disturbing the cervical spine stability and with limited postoperative neck pain and a lateral approach for excision the extraspinal extension to avoid so much manibulation on the vertebral artery. Follow up MRI cervical spine was done postoperatively for follow up. Results : Combined approach was done for all patients with complete excision of the tumors . One patient developed CSF Leake after surgery that stopped after lumbar drain insertion . There was no mortality in this study. Conclusion : Cervical spinal schwannoms with large lateral extra formaninal component need combined approach to achieve complete surgical excision , avoid vertebral artery injury and preserve stability .