Introduction
Spinal schwannomas are the most common intradural extramedullary spinal tumors. They arise from the sheath of spinal nerve roots and are typically benign and slow-growing. These tumors account for a notable proportion of spinal neoplasms, often presenting with radicular pain, sensory changes, or progressive weakness depending on location and size. This article combines a detailed case report with a focused review of the literature to summarize current understanding of presentation, diagnostic workup, management, and outcomes for spinal schwannomas.
Case Presentation (Illustrative Case)
While the specifics of individual cases vary, a representative presentation involves a patient with progressive back pain and radicular symptoms, with or without motor weakness. Magnetic resonance imaging (MRI) is the preferred modality for evaluation, typically showing a well-circumscribed, enhancing mass adjacent to a nerve root. Surgical excision is the treatment of choice, with gross total resection aiming to minimize recurrence while preserving neurological function. Intraoperative neurophysiological monitoring is often employed to protect critical neural structures. Postoperative recovery generally follows a favorable trajectory when complete removal is achieved.
Clinical Presentation and Diagnosis
Spinal schwannomas most commonly present in middle-aged adults but can occur across a broad age range. Symptoms reflect tumor location along the spinal axis, with thoracic and lumbosacral regions being frequent sites. Key clinical features include:
- Localized back or neck pain, sometimes radicular in nature
- Progressive sensory disturbance or paresthesias
- Weakness or gait disturbance in advanced cases
- Signs of myelopathy when the mass exerts continuous spinal cord compression
Imaging with MRI typically reveals a well-defined lesion that is isointense to hypointense on T1-weighted images and hyperintense on T2-weighted sequences, with robust enhancement after gadolinium administration. The radiologic differential includes meningioma, neurofibroma, and other intradural extramedullary tumors. Definitive diagnosis, however, is histopathological, demonstrating Antoni A and Antoni B areas with S-100 protein positivity characteristic of schwannomas.
Management and Outcomes
Management centers on surgical resection. The goals are complete tumor removal while preserving neural function and spinal stability. Key considerations include:
- Choice of surgical approach tailored to tumor location and extension
- Intraoperative monitoring of motor and somatosensory evoked potentials
- Assessment of nerve root involvement and the feasibility of sacrifice versus preservation
- Postoperative rehabilitation to optimize functional recovery
Gross total resection is associated with excellent long-term control and low recurrence rates for spinal schwannomas. Subtotal resection may be necessary in complex cases, potentially requiring adjuvant radiotherapy in select situations. Complications can include transient nociceptive changes, cerebrospinal fluid leaks, or, rarely, neurologic deterioration, underscoring the importance of meticulous surgical technique and careful patient selection.
Review of the Literature
A comprehensive review of existing studies confirms that spinal schwannomas represent a substantial fraction of intradural extramedullary tumors. Across series, most patients experience symptom improvement or stabilization following surgery, with favorable functional outcomes particularly when tumors are fully resected. Factors influencing prognosis include tumor size, location, duration of symptoms, and preoperative neurological status. Recurrence is uncommon after complete resection, though regular follow-up with MRI is advised given the indolent nature of some lesions and the potential for late recurrence.
Implications for Practice
Clinicians should maintain a high index of suspicion for spinal schwannomas in patients presenting with localized spinal pain and progressive neurological signs. A structured diagnostic pathway with MRI, followed by surgical planning that emphasizes complete resection and preservation of function, yields the best outcomes. Multidisciplinary collaboration, including neurosurgery, radiology, pathology, and rehabilitation, enhances diagnostic accuracy and postoperative recovery.
Conclusion
Spinal schwannomas are a common, typically benign cause of intradural extramedullary spinal disease. Combined analysis of case reports with broader literature highlights the effectiveness of surgical management and the importance of early recognition. Ongoing research continues to refine diagnostic criteria, surgical techniques, and follow-up strategies to further improve patient outcomes.
