|Year : 2018 | Volume
| Issue : 5 | Page : 180-183
Treatment results in the same surgery method of the high cervical spinal schwannoma
Chien-Yu Ou1, Ching-Min Nien2, Yu-Hua Huang3
1 Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
2 Chung Shan Medical University, Taichung, Taiwan
3 Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
|Date of Submission||26-Jul-2017|
|Date of Decision||14-Oct-2017|
|Date of Acceptance||21-Feb-2018|
|Date of Web Publication||17-Oct-2018|
Dr. Yu-Hua Huang
Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Niao Sung District, Kaohsiung
Source of Support: None, Conflict of Interest: None
Background: The aim of this study was to explore the outcomes for patients with high cervical spinal schwannoma after microsurgery.
Materials and Methods: This retrospective study enrolled ten patients who received high cervical schwannomas microsurgery. The data collected retrospectively include sex, Karnofsky Performance Status (KPS) score before surgery, and KPS score after surgery.
Results: The KPS scores of the patients changed from 30 to 90 (average 70) before surgery to KPS scores of 50 to 90 (average 82) upon discharge. The duration of the follow-up in the clinics was 2–192 months (average 44). The mean hospital stay was 7–35 days (average 12.4 days). We used paired t-test and found a significant improvement of the KPS score.
Conclusion: High cervical spinal neoplasm is relatively rare and the surgery is technically challenging. Many articles discussed the classification of tumors or surgical approaches, while few studies explored the outcome of the surgery. In this article, the patients with high cervical spinal neoplasm all underwent the same type of surgery. After the surgery, the patients' quality of life had shown significant improvement.
Keywords: Cervical spinal neoplasm, outcome, schwannoma
|How to cite this article:|
Ou CY, Nien CM, Huang YH. Treatment results in the same surgery method of the high cervical spinal schwannoma. Formos J Surg 2018;51:180-3
|How to cite this URL:|
Ou CY, Nien CM, Huang YH. Treatment results in the same surgery method of the high cervical spinal schwannoma. Formos J Surg [serial online] 2018 [cited 2019 Mar 20];51:180-3. Available from: http://www.e-fjs.org/text.asp?2018/51/5/180/243578
| Introduction|| |
Schwannoma is a neurogenic tumor originating from a Schwann cell. It comprises almost one-third of the primary spinal neoplasms. However, neurinomas of the first three cervical nerve roots are rare. They represent approximately 5% of all spinal neurinomas., This type of schwannoma may be intradural [Figure 1]a and [Figure 1]b, extradural [Figure 2]a and [Figure 2]b, or hourglass form [dumbbell type, [Figure 3]a and [Figure 3]b. In this study, we retrospectively recorded the clinical features, surgical findings, radiologic features, and preoperative and postoperative Karnofsky Performance Status (KPS) Scale.
|Figure 1: (a) Intradural type schwannoma, axial view. (b) Intradural type schwannoma, sagittal view|
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|Figure 2: (a) Extradural type schwannoma, axial view. (b) Extradural type schwannoma, sagittal view|
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|Figure 3: (a) Hourglass form (dumbbell type) schwannoma, axial view. (b) Hourglass form (dumbbell type) schwannoma, sagittal view|
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The surgery for high cervical spinal neoplasm is difficult and carries high risk. The objectives of this study were to investigate whether the benefits of the surgery justify its risks and to assess the actual improvement in the postoperative quality of life.
| Materials and Methods|| |
This retrospective cohort study was carried out at Kaohsiung Chang Gung Memorial Hospital, a 2715-bed medical center in Taiwan. After obtaining consent from the institutional review board, we reviewed ten patients who had undergone cervical laminectomy with resection of high cervical schwannoma in the neurosurgical department from January 2003 to December 2009.
The diagnosis of cervical spine schwannoma was established on the basis of patient history and physical examination in conjunction with magnetic resonance imaging (MRI) scans. All patients suffered from neck pain or other neurologic deficits resulting from high cervical spinal schwannoma. The level of affected nerve roots was determined from MRI scan findings.
Definition of high cervical schwannoma
In this study, schwannomas arising from C1, C2, and C3 spinal nerve roots were regarded as high cervical spinal schwannoma. We divided the tumors into intradural, extradural, and dumbbell (combined intra and extradural) types.
All ten patients were followed up with cervical spine MRI at the outpatient department for at least 2 months after surgery.
Data were analyzed with SPSS version 20.0 (IBM SPSS Statistics, Armonk, NY, USA). Descriptive statistics were presented as frequencies (percentages) or as mean and standard deviation (SD). We examined KPS pre- and postoperatively using paired t-test. P < 0.05 was considered statistically significant.
The study was conducted in accordance with the Declaration of Helsinki and was approved by the local ethics committee of the institute. Informed written consent was obtained from all patients prior to their enrollment in this study.
| Results|| |
The ten patients included seven males and three females [Table 1]. The mean age was 51.9 years (SD, 15.2 years; range, 19–72 years). The underlying medical conditions included four cases of diabetes mellitus and four cases of hypertension. The mean duration of operation was 8.2 h (SD, 2.8 h; range, 4–12 h). The mean operative blood loss was 390 mL (SD, 448 mL; range, 100–1300 mL). The mean tumor diameter was 29.5 mm (SD, 8.7; range, 17–45 mm). The length of hospital stay on average was 12.4 days (SD, 8.2 days; range, 7–35 days). The mean preoperative KPS was 70 (SD, 20; range, 30–90). The mean discharge postoperative KPS was 82 (SD, 13.9; range, 50–90). The mean final postoperative KPS was 84 (SD, 13.4; range, 50–90). The mean duration of follow-up after operation was 44 months (SD, 57.5 months; range, 2–192 months). Among the ten patients, the tumors originated from either C1 or C3 (five patients in each group). In respect of the tumor morphology, eight patients had both intradural and epidural tumors and among the two remaining patients, one was restricted within the dura and the other was only growing epidurally. Tumors in five patients could not be completely removed due to the epidural growth of the tumors out of the foraminal space. One patient underwent second surgery 24 h after the original one due to poor drainage, which led to epidural region hematoma accumulation. Thus, the patient had a longer stay in the hospital.
The study compared KPS scores in the ten patients pre- and postoperation using paired t-test. The 95% confidence interval of the difference was −23.6 to −4.3 with P = 0.01. Thus, there was a significant improvement in the KPS scores between the pre- and postsurgery assessments [Table 2].
| Discussion|| |
Spinal schwannomas, which account for approximately 30% of primary spinal tumors,,, originate predominately from the sensory root of the spinal nerve. They may become symptomatic in patients at any age but are most commonly encountered in the fifth decade.,,
The patients included in this study underwent posterior cervical exposure and laminectomy with removal of tumor. During the high cervical laminectomy, extra care needs to be taken because literature review demonstrates a relatively high incidence of vertebral artery anomalies in the upper cervical spine. During high cervical spine posterior exposure, vertebral artery injury must be carefully avoided. If the surgery site is not clear enough, computed tomography angiography is recommended for preoperative vertebral artery evaluation.
For spinal schwannoma classification, Eden's 1958 classification was used. All patients underwent posterior approach and laminectomy with removal of tumor and five patients had gross total resection. None of the patients were given laminoplasty, and one patient exhibited swan neck change in the C-spine in postsurgery follow-up. The results indicate that the KPS scores of patients improved significantly after the surgery. Although one patient received emergency surgical intervention for removal, due to the occurrence of hematoma accumulation at epidural space at the day of the original surgery, the KPS score of this patient was also improved during the postsurgery follow-up.
All the patients only underwent the laminectomy of the cervical vertebra corresponding to the tumor location and no damage was made to the facet joint. However, for giant schwannomas, laminectomies of multiple vertebrae must be performed, or the facet joint may be damaged; in such a case, laminoplasty or pedicle screw implantation and posterolateral fusion are recommended to avoid unstable cervical vertebrae in the future.
There have been many studies of spinal schwannoma, but most of them discussed spinal schwannoma classification or surgical methods. Few have discussed the outcome of the surgery. Here, pre- and postsurgery KPS scores were used to assess the improvement in the quality of life of the patients after the surgery, and the results indicated that the improvement of the KPS scores in patients is statistically significant.
| Conclusion|| |
High cervical spine schwannoma is not common in clinical practice. The technical requirements and the risks of the surgery are high. Surgeons have to be familiar with the vertebral artery pathway in the upper cervical spine. Surgeons new to the procedure should seek guidance from more experienced colleagues, if available. The quality of life of patients with high cervical spine schwannoma can be improved significantly after the surgery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nittner K. Spinal meningiomas, neurinomas and neurofibromas and hourglass tumours. In: Vinken PJ, Bruyn GW, editors. Handbook of Clinical Neurology. Tumours of the Spine and Spinal Cord. Vol. 20. Amsterdam: North-Holland: Elsevier; 1976. p. 177-322.
Goel A, Muzumdar D, Nadkarni T, Desai K, Dange N, Chagla A, et al.
Retrospective analysis of peripheral nerve sheath tumors of the second cervical nerve root in 60 surgically treated patients. J Neurosurg Spine 2008;8:129-34.
Lot G, George B. Cervical neuromas with extradural components: Surgical management in a series of 57 patients. Neurosurgery 1997;41:813-20.
Herregodts P, Vloeberghs M, Schmedding E, Goossens A, Stadnik T, D'Haens J, et al.
Solitary dorsal intramedullary schwannoma. Case report. J Neurosurg 1991;74:816-20.
Ross DA, Edwards MS, Wilson CB. Intramedullary neurilemomas of the spinal cord: Report of two cases and review of the literature. Neurosurgery 1986;19:458-64.
Seppälä MT, Haltia MJ, Sankila RJ, Jääskeläinen JE, Heiskanen O. Long-term outcome after removal of spinal schwannoma: A clinicopathological study of 187 cases. J Neurosurg 1995;83:621-6.
Levy WJ, Latchaw J, Hahn JF, Sawhny B, Bay J, Dohn DF, et al.
Spinal neurofibromas: A report of 66 cases and a comparison with meningiomas. Neurosurgery 1986;18:331-4.
Salah S, Horcajada J, Perneczky A. Spinal neurinomas. – A comprehensive clinical and statistical study on 47 cases. Neurochirurgia (Stuttg) 1975;18:77-84.
Molinari RW, Chimenti PC, Molinari R Jr., Gruhn W. Vertebral artery injury during routine posterior cervical exposure: Case reports and review of literature. Global Spine J 2015;5:528-32.
Albert AF, Kirkman MA, du Plessis D, Sacho R, Cowie R, Tzerakis NG, et al.
Giant solitary cystic schwannoma of the cervical spine: A case report. Clin Neurol Neurosurg 2012;114:396-8.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]