- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
Kristopher T. Kimmell
Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
DOI:10.4103/2152-7806.156566Copyright: © 2015 Feldman M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Feldman M, Kimmell KT, Replogle RE. Resection of an Occipital–Cervical Junction Schwannoma through a modified minimally invasive approach: Technical Note. Surg Neurol Int 07-May-2015;6:
How to cite this URL: Feldman M, Kimmell KT, Replogle RE. Resection of an Occipital–Cervical Junction Schwannoma through a modified minimally invasive approach: Technical Note. Surg Neurol Int 07-May-2015;6:. Available from: http://surgicalneurologyint.com/surgicalint_articles/resection-occipital-cervical-junction-schwannoma/
Background:Minimally invasive spine (MIS) techniques have been available for many years, but their application has been largely limited to degenerative spine diseases. There are few reports in the literature of using MIS techniques for removal of neoplasms. We report our experience using a modified MIS technique for removal of an occipital–cervical junction (OCJ) schwannoma with attention to technical aspects of this approach.
Case Description:A 64-year-old male presented with several months of neck pain radiating to the shoulder with bilateral hand numbness. The patient had evidence of early myelopathy on examination. Magnetic resonance imaging (MRI) demonstrated enhancing intradural lesion with significant mass effect on the spinal cord. The mass extended extradurally through the right C1 neural foramen. Imaging characteristics were suggestive of a schwannoma. The patient underwent a minimally invasive far lateral approach to the OCJ for resection of the lesion. A Depuy Pipeline™ expandable retractor was used for visualization. Surgical resection was performed with microscopic visualization. Somatosensory evolved potentials (SSEP) monitoring was used. The patient tolerated the procedure well. Postoperative imaging demonstrated gross total resection. No intra- or postoperative complications were noted. The patient was discharged home on postoperative day 2. At 1-month follow-up, his preoperative symptoms were resolved and his wound healed excellently.
Conclusion:In properly selected patients, minimally invasive approaches to the OCJ for resection of mass lesions are feasible, provide adequate visualization of tumor and surrounding structures, and may even be preferable given the lower morbidity of a smaller incision and minimal soft tissue dissection.
Keywords: Minimally invasive spine, occipital–cervical junction, schwannoma, technique
Schwannomas are among the most common spinal tumors, with an annual incidence of 3–4 per million.[
Over the past decade, minimally invasive spine (MIS) techniques have emerged and may serve to reduce the postoperative pain and musculoligamentous and bony destruction after spinal surgery.[
The use of minimal exposure for the resection of cervical neoplasms is an area of recently increasing study and tremendous potential. One small study examined the benefit of a midline posterior approach for upper cervical schwannomas with minimized but traditional exposures and found this successful in tumor resection.[
Given the growing body of evidence on the efficacy of MIS, we believe that MIS techniques are safe for resection large upper cervical benign neoplasms and present our own experience with a modified MIS technique for resection of an OCJ schwannoma.
A 64-year-old male presented with a complaint of several months of neck pain radiating into his right arm, as well as bilateral hand anesthesia. He denied any weakness or difficulty walking. His past medical history was notable only for hypertension and hyperlipidemia. He had a distant history of hand surgery and a pilonidal cystectomy, and denied any past head or back operations. Neurologic examination was notable for a subtle drift of the right upper extremity as well as one to two beats of clonus in both feet. Hoffman's sign was absent bilaterally. The remainder of his neurologic and physical examination was normal.
Magnetic resonance imaging (MRI) of the cervical spine demonstrated a right-sided extramedullary lesion at the C1-C2 level with an intradural component causing significant compression of the spinal cord. The mass also had a large extradural component extending through the right neural foramen and tracking along the nerve root. The mass avidly enhanced and showed some evidence of cystic degeneration [
Operative technique: Modified minimally invasive far lateral approach
Position and preliminary incision/dissection
The patient was brought to the operating room and underwent general anesthesia. SSEP monitoring was used. The patient was placed in the lateral position with the right side up and head in three-point fixation with the neck flexed and the contralateral ear tipped toward the contralateral shoulder. An incision was marked from the mastoid tip inferiorly 4 cm paralleling the posterior border of the sternocleidomastoid muscle. Preliminary dissection was performed under direct visualization with a surgical knife and electrocautery. Metzenbaum scissors were used to continue the dissection down to the suboccipital triangle. The lamina and transverse process of C2 were visualized. Multiple dilators were placed in series on the C2 lamina. Correct placement of the dilators on C2 was confirmed by fluoroscopy. Next the dilators were moved cranially to allow visualization of the oblique muscle bridging the C2 and C1 laminae and transverse processes. The muscle was divided with electrocautery and reflected to allow excellent visualization of the underlying bony anatomy, and subsequently the Depuy Pipeline™ retractor was inserted and expanded [
Hemilaminectomy and tumor debulking
The tumor was readily visible underneath the arch of C1 extending both caudally and cephalad, as well as laterally. Hemilaminectomy of C1 and partial hemilaminectomy of the superior aspect of C2 were performed to allow visualization of the tumor in its entirety as well as the surrounding critical structures. Under microscopic visualization, the tumor was debulked piecemeal. The vertebral artery and its venous plexus were well visualized [
The dura was closed using an on-lay patch of Duragen and Duraseal. The fascial and subcutaneous layers were closed in routine interrupted watertight fashion [
The patient had a very good postoperative course. His mean postoperative pain score was 2. MRI of the cervical spine on postoperative day 2 demonstrated gross total resection [
In this case report, we describe the first noted resection of an OCJ schwannoma with a modified minimally invasive far lateral approach. This patient had an excellent operative and functional outcome.
MIS approaches to cervical tumor debulking are becoming increasingly common, but there still exists a dearth of descriptive literature attesting to their safe and beneficial use. This may be in part due to many of the reasons discussed previously, namely a restricted surgical field and concerns about adequate tumor access, exposure, and visualization of surrounding anatomic structures. Preliminary studies have actually demonstrated the opposite, with one notable study showing that MIS approaches were able to effectively remove cervical intradural, extramedullary neoplasms with less blood loss and shorter operative times.[
Some authors have voiced caution over the use of MIS techniques for the OCJ. However, this case demonstrates that this region can be safely approached with MIS techniques. Although there are a paucity of reports, Lu et al. have previously described their experience with the use of a MIS approach for treatment of Bowhunter's syndrome in an adolescent caused by a subocciptal bony spur with excellent technical and clinical results.[
The key for our operative approach was the use of careful dissection to identify bony landmarks; in our case the lamina and lateral mass of C2, followed by the use of dilators and an expandable retractor to obtain a suitable corridor for visualization of the tumor and surrounding anatomy. Our technique was predicated on several key items: First, an excellent working knowledge of OCJ anatomy. The senior author has performed many procedures in this region. Second, the approach was predicated on a substantive exposure to MIS techniques, as the senior author has performed hundreds of previous MIS procedures. With this solid foundation, this novel modified MIS approach could be attempted with reasonable safety to the patient.
Because of their novelty, especially for neoplastic indications, MIS procedures are operator dependent and there is an expected learning curve for MIS procedures. With the proliferation of MIS techniques accelerating, Mannion et al. proposed criteria for the use of MIS, suggesting that these approaches should be taken only if they do not have increased risk, offer some tangible benefit to the patient, and can achieve the same surgical goals.[
We posit that our experience with this case shows that MIS techniques can be used for approaches to the OCJ, even for tumors more complex and expansive than may be suggested by the current literature. Furthermore, we suggest that the described far lateral approach achieves good surgical field access while minimizing the postoperative pain and risks of instability associated with more extensive procedures.
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