|Year : 2022 | Volume
| Issue : 3 | Page : 178-181
Solitary intraosseous schwannoma of cervical spine: A rare case report
Yogesh Madhukar Sawakare, Sagar Patil, Vernon Velho
Department of Neurosurgery, JJ Hospital and Grant Government Medical College, Mumbai, Maharashtra, India
|Date of Submission||26-Nov-2021|
|Date of Acceptance||18-Mar-2022|
|Date of Web Publication||13-Sep-2022|
Yogesh Madhukar Sawakare
Department of Neurosurgery, Sir J.J. Hospital, Byculla, Mumbai - 400008, Maharashtra
Source of Support: None, Conflict of Interest: None
Intraosseous schwannoma in the spine is a rare tumor. Complete resection is mandatory for avoiding recurrence in such cases. Resection followed by stabilization was very important in this case as the cervical vertebra was destroyed completely. Postsurgery patients had significant improvement in neurological symptoms.
Keywords: Resection, Schwannoma, tumor
|How to cite this article:|
Sawakare YM, Patil S, Velho V. Solitary intraosseous schwannoma of cervical spine: A rare case report. J Spinal Surg 2022;9:178-81
| Introduction|| |
Schwannoma is a soft-tissue tumor that arises from nerves. It is a benign nature lesion although malignant variety also has been reported. They represent one-third of primary spinal tumors. Intraosseous tumor location is very rare. The lesion presents as a challenge in diagnosis and planning further treatment. It can occur by either intraosseous or an extraosseous origin which grows and erodes the bone. As the tumor grows out of the bone, it can compress surrounding structures. They can manifest as compression of the spinal cord or the spinal nerves leading to radiculopathy or myeloradiculopathy.,, Click or tap here to enter text.
We report a rare case of a cervical intraosseous schwannoma in the cervical vertebra destroying the vertebral body.
They can be referred to as ancient schwannoma which is reported in the thorax, head and neck, retroperitoneum, and lower extremities in elderly patients.
| Case Report|| |
A 38-year-old female presented with swelling and pain in the right side of the neck for a year [Figure 1]a which gradually increased in size. The patient also noticed radiculopathy on the C5 and C6 with tingling paresthesia, numbness associated with weakness of the right upper limb which gradually progressed for 1 year.
|Figure 1: (a) Photograph showing tumor in lateral aspect of neck (b) X-ray lateral showing destroyed C4 vertebral body (c) computed tomography C spine lateral showing destroyed C4 vertebral body (c) magnetic resonance imaging contrast axial showing heterogenous enhancing tumor with cystic component arising from the vertebral body and extending laterally (d) magnetic resonance imaging contrast coronal showing heterogenous enhancing tumor arising from the vertebral body and extending laterally (e) computed tomography axial showing tumor occupying the C4 vertebral body|
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On examination, the patient had weakness of right-hand grip and elbow and shoulder abduction. Right claw hand was seen with atrophy of thenar and hypothenar area. Reflexes of the right upper were increased. The local examination was suggestive of a swelling located in the posterior triangle of the neck not attached to platysma or sternocleidomastoid muscles. The X-ray cervical spine revealed a destroyed osteolytic C4 vertebral body with a sclerotic rim [Figure 1]b.
Computed tomography (CT) cervical spine was suggestive of a tumor occupying the C4 vertebral body with loss of height by 50% [Figure 1]f. An extradural homogenous enhancing mass with the central area of necrosis through was seen in the C3 and C4 vertebral levels displacing the cord to left, loss of fat planes with the internal jugular vein, abutting the common carotid artery, and extending from the spinal canal through C3 right neural foramina with paravertebral extension measuring 3.5 cm × 3.7 cm × 5 cm (AP × TR × CC). Extraspinally, it was located in the posterior cervical space with the displacement of the sternocleidomastoid without any infiltration [Figure 1]c.
Magnetic resonance imaging (MRI) cervical spine was suggestive of a mass originating from the vertebra with displacement of the ventral soft-tissue structures. In both T1- and T2-weighted images, tumor was hyperintense. Heterogeneous contrast enhancement was seen with no infiltration of the surrounding structures [Figure 1]d and [Figure 1]e. Overall, the lesion was evaluated as benign and the differential diagnosis included aneurysmal bone cyst, eosinophilic granuloma of bone, giant cell tumor, and schwannoma.
Malignant differentials considered were metastasis, (solitary) myeloma, chordoma, or a sarcoma. Surgical excision was planned by anterior approach following the tumor down to the vertebral body. The tumor was well encapsulated, soft, pinkish-red, moderately vascular, suckable with vertebral body invasion [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d. Intraoperative, the tumor was seen in the subplatysmal plane and extensive destruction of the vertebral body with extension from the C4 vertebral body with compression of the cord and exiting nerve roots. Thorough curettage of the tumor was done, followed by expandable cage placement at the C4 vertebra [Figure 2]d and [Figure 2]e. Complete resection of the tumor was done. The final histopathology report was suggestive of an intraosseous schwannoma with evidence of calcifications, hyalinization, and cystic degeneration.
|Figure 2: (a) Intraoperative photo showing encapsulated tumor in subplatysmal plane (b) Final specimen (c) Intraoperative photo showing tumor in C4 vertebral body (d) Intraoperative photo showing expandable cage at C4 level for stabilization of C spine (e) X-ray lateral showing expandable implant at C4|
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| Discussion|| |
Many tumors can involve the vertebral body. Intraosseous schwannomas are very rare comprising just 0.2% of all bone tumors. Most of the spinal schwannomas are intradural about 70%, the rest being extradural or intraosseous. Bone has some myelinated tissue which can give rise to the origin of these tumors, thereby explaining their rarity.
They can have three different origins arising from the bone itself, nutrient canal, or extraosseous causing bone erosion. Locations described are mandible, long bones, cranial bones, ribs, scapula, sacrum, calcaneum, and small bones of the hands, of which mandible is the most common.
Entrapment of the Schwann cells arising from the neural crest may explain their intraosseous nature. The first case of vertebral involvement was described by Dickson.,,,,,,
The growth of these tumors is slow so the patient presents with a long duration of symptoms.
Sites in the spine involved are the lumbar site (44%), cervical (31%), and thoracic site (25%). These intraosseous tumors are more invasive and larger as compared with others. They tend to invade the vertebral body, pedicle, and enlargement of the neural forminas.
They can cause spinal cord compression extradurally and lead to neurological deficits.
Grossly, schwannomas are well-defined, encapsulated, soft-to-firm, moderately vascular tumors. As the tumor grows from the bone, it tends to destroy it slowly and also the surrounding structures.
Histologically, they have Antoni A consisting of a densely packed area of spindle-shaped cells arranged in bundles or fascicles and Antoni Type B tissue which is less cellular with hazard arranged spindle-shaped cells. Characteristic Verocay bodies are seen comprising stacked nuclei seen in a palisading pattern more commonly in Antoni A Type. Immunohistochemistry, protein S100 is positive.
The differentials in these cases considered are chordoma, metastasis, osteoid osteoma, solitary myeloma, chondrosarcoma, aneurysmal bone cyst, giant cell tumor, and angioma.
Intraosseous schwannomas do not have sex prediction. They are seen in the middle decades of life from 3rd to 6th. Imaging in these cases comprises X-ray, CT, and MRI imaging. Radiological findings consist of a lytic defect with cortical erosion without the periosteal new bone formation and the absence of central calcification or ossification.
CT scan informs about the bony architecture of the involved and surrounding bones. MRI gives information about the extent of the lesion, soft-tissue involvement, relationship with vascular structures around, and invasiveness of the lesion.
In 2002, Sridhar classified schwannomas into five types and additional two types as shown in [Figure 3] and [Table 1]. Our case according to intraoperative findings can be classified in Class VII.
|Figure 3: Diagrammatic representation of modified Sridhar classification|
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Surgical excision is the treatment of choice in such cases. Intraosseous schwannoma has a capsule as was also observed in our case. Incomplete resection may lead to recurrence. Therefore, complete resection is mandatory to ensure a complete cure.
During excision, instability may occur due to destroyed vertebral bodies which entails instrumentation to stabilize the spine. Postoperative deficits may improve with physiotherapy.
As seen in our case, the tumor was imaged thoroughly, followed by an anterior approach. It was completely removed with the eroded C4 vertebral body, followed by stabilization by an expandable titanium implant. Recurrence depends on histopathology, the malignant variety being more susceptible. Malignant schwannoma is even resistant to chemotherapy and radiotherapy.
The postoperative patient had a significant improvement in pain. Physiotherapy improved the right upper limb weakness over a period of 3 months. During a follow-up period of 1 year, there was no evidence of recurrence or any new deficits.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
| Conclusion|| |
Schwannoma is a benign tumor. Intraosseous schwannoma is a rare entity but curable if treated properly. It is a challenge to diagnose this tumor. Imaging comprises CT and MRI. Complete surgical resection is the treatment in these cases as incomplete excision can lead to recurrence. As the vertebral bodies tend to be destroyed, stabilization of the involved segment is important. Histopathology is important for confirmation and further prognosis. Benign forms have a better prognosis than malignant variety.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]