D'Andrea Giancarlo, Sessa Giovanni, Picotti Veronica, Raco Antonino
S. Andrea Hospital, Institute of Neurosurgery, University of Rome "La Sapienza", Rome, Italy.
Case Rep Surg. 2016;2016:1876765. doi: 10.1155/2016/1876765. Epub 2016 Sep 27.
We report the case of a large lumbar schwannoma eroding the vertebra and originating from spinal canal with invasion of the retroperitoneal space. We also review all the cases in literature reporting lumbar schwannomas eroding the vertebral bodies and invading the retroperitoneal space focusing on the surgical strategies to manage them. Spinal CT-scan revealed a 44 mm × 55 mm inhomogeneous soft-tissue mass arising from the right L5-S1 neural foramen and its most anterior portion had a clear colliquative aspect. Magnetic resonance image showed a neoplastic lesion with homogeneous low signal in T1WI, heterogeneous signal in T2WI, and strong enhancement in postgadolinium examination. It developed as well in the retroperitoneal space, posteriorly to the iliac vein, up to the psoas muscle with wide erosion of the omolateral conjugate foramen. We performed a one-step combined approach together with the vascular surgeon because the lesion was too huge to allow a complete resection via a posterior approach and furthermore its tight relationship with the psoas muscle and the iliac vessels in the retroperitoneal space should be more safely managed via a retroperitoneal approach. We strongly suggest a 1-step surgery first approaching the dumbbell and the intraspinal schwannomas posteriorly achieving the decompression of the spinal canal and the cleavage of the tumor cutting the root of origin and the vascular supply and valuating the stability of the spine for potential artrodesis procedure. The patient must be then operated on via a retroperitoneal approach achieving the complete en bloc resection of the tumor.
我们报告了一例巨大的腰椎神经鞘瘤，该肿瘤侵蚀椎体，起源于椎管并侵犯腹膜后间隙。我们还回顾了文献中所有报告腰椎神经鞘瘤侵蚀椎体并侵犯腹膜后间隙的病例，重点关注处理这些病例的手术策略。脊柱CT扫描显示，一个44mm×55mm的不均匀软组织肿块起源于右侧L5-S1神经孔，其最前部有明显的液化表现。磁共振成像显示，肿瘤性病变在T1加权像上呈均匀低信号，在T2加权像上信号不均匀，增强扫描后呈明显强化。肿瘤还发展至腹膜后间隙，位于髂静脉后方，直至腰大肌，外侧椎间孔有广泛侵蚀。由于病变巨大，无法通过后路完全切除，而且其与腹膜后间隙的腰大肌和髂血管关系密切，因此我们与血管外科医生一起采用了一步联合手术方法，通过腹膜后入路能更安全地处理。我们强烈建议采用一步手术，首先从后方处理哑铃形和椎管内神经鞘瘤，实现椎管减压并切断肿瘤起源根和血管供应，评估脊柱稳定性以考虑可能的关节固定手术。然后必须通过腹膜后入路对患者进行手术，实现肿瘤的完整整块切除。
