- 43M, left-hand dominant
- PMHx: NF1, right leg malignant nerve sheath tumor s/p resection, chemotherapy, and radiation at 15
- PSHx: right AKA for osteomyelitis (non-healing femur fracture s/p ORIF)
- FHx: skin lesions on father's side
- SoHx: smoking x25y, +EtOH, marijauna
- Presented to neurosurgery clinic
- Back pain radiating down RLE to the stump x7m
- PE: GCS 15, full strength, RLE amputated at hip, 1+ reflexes, stable walking with crutches
Pelvic MRI without Contrast - Axial T1WI, Axial T2WI, Coronal T1WI, Coronal T2WI
Pelvic MRI T1WI with Contrast - Axial and Coronal
Enhancing right L3-4 and L5-S1 paraspinal lesions consistent with neurofibromas with slight extension into the distal neural foramen but no significant extension into the spinal canal.
- 42 mCi F-18 FDG IV
- Mildly hypermetabolic well-circumscribed low density right paraspinal mass measuring 7.3 x 6.8 cm most suggestive of a neurogenic tumor, likely neurofibroma given patient's clinical history.
- Malignant Peripheral Nerve Sheath Tumors
- Approach: anterior trans-abdominal
- Multidisciplinary operation
- Vascular surgery - exposure and closure
- Neurosurgery - tumor resection
- Forwent intraoperative neuro-monitoring due to patient's right AKA
- Intraoperative frozen: nerve sheath tumor, favors Schwannoma
Supine position with lower thoracic and abdominal areas exposed.
A right curvilinear incision was proposed and marked.
The tumor was exposed with several nerves draping over the capsule.
Gross specimen of the tumor
Tumor cavity within the capsule.
Tumor capsule was preserved, as well as the nerves attached to it.
The wound was closed with Dermabond.
- Recovered well neurologically
- Resolved back and radiating pain
- Hgb dropped to 7 and required RBC transfusion
- Urinary retention required replacement of Foley
- Frozen: favored schwannoma
- Permanent: schwannoma
- +Antoni A and B
- Nerve sheath tumor, benign
Benign Schwannomas and neurofibromas have different techniques because of different patterns of fascicular involvement.
- Intraoperative monitoring
- Grows extrinsic to its parent fascicles
- Well-defined capsule - perineurium and nerve bundles
Surgical strategies for peripheral nerve schwannoma based on the intraoperative neurophysiological monitoring - ScienceDirect ↩︎
A precise excision technique for schwannomas - European Journal of Plastic Surgery ↩︎