Combined Minimally Invasive Approach Using Microsurgery and Thoracoscopic Surgery for Resecting a Dumbbell-Type Thoracic Schwannoma

Abstract

We present a case of a thoracic schwannoma with an intravertebral component, a so-called "dumbbell-type" tumor, that was resected with a combined minimally invasive approach using microsurgery and thoracoscopic surgery simultaneously. A 31-year-old man was admitted to our hospital for treatment of a thoracic schwannoma 45 mm in maximal diameter at the level of the third thoracic vertebra. After the tumor was separated from intravertebral structures by using a microsurgical technique via the posterior approach with a hemilaminectomy and minimal unilateral facetectomy, the mass was removed completely by using video thoracoscopy. We stress that this approach should be the most useful and less invasive technique for treating the dumbbell-type of thoracic neurogenic tumor compared with a single or combination technique involving thoracotomy, multi-level laminectomy and costotransversectomy. Below, we make some notes on this technique from the neurosurgeon's standpoint.

Clinical Analysis of Video-assisted Thoracoscopic Spinal Surgery in the Thoracic or Thoracolumbar Spinal Pathologies

“…In the early 1990s, VATS techniques were applied to the treatment of spinal disease simultaneously by both Rosenthal et al in Germany and Mack et al in the United States 23,27) . Recently VATS have been used for management of thoracic and thoracolumbar junction pathologies, including thoracic disc herniation, fractures, tuberculosis spondylitis, idiopathic scoliosis, neuromuscular spinal deformity, congenital scoliosis, tumors 1,2,4,6,[8][9][10][11][12][13][14][15][16][17][18]21,25,26,29,30) . Using thoracoscopic surgery, anterior and anterolateral reconstruction can be performed to provide effective anterior load-bearing.…”

Extended thoracotomy for a thoracic lesion

“…[1][2][3] The presenting history is usually unremarkable and non-specific; local and radicular pains are typical presenting features. 4 Optimal surgical approach of these tumours remains a debatable topic with different authors advocating competing strategies. Dumb-bell tumours of the lower thoracic spine incur a risky surgical procedure due to the reduced size of the spinal canal and close proximity of the artery of Adamkiewicz.…”

“…6,7 Conversely a two-staged approach has been reported elsewhere by combining a posterior and transthoracic approach by either thoracotomy 2,8 or thoracoscopy. 3,4,9 The transthoracic approach is favoured for large dumb-bell tumours with greater anteroposterior (AP) extension to give better accessibility and visualisation of the anterior paraspinal extension. 6,1,5 However, the iatrogenic consequences of a large thoracotomy can be considerable due to pulmonary dysfunction, pain and infection.…”

“…6,1,5 However, the iatrogenic consequences of a large thoracotomy can be considerable due to pulmonary dysfunction, pain and infection. 4 A posterior approach without opening the pleura does remove this risk. 6 A minimally invasive approach would therefore appear suitable for smaller dumb-bell tumours with limited AP paraspinal extension and without involvement of major neurovascular or visceral structures.…”

Resection of thoracic dumbbell neurinomas: Single postero-lateral approach or combined posterior and transthoracic approach?

“…Most dumbbell tumours are neurogenic tumours, including schwannoma, neurofibroma, ganglioneuroma, and neuroblastoma; schwannomas account for about 90% of all dumbbell tumours. 4 Dumbbell schwannomas are best visualised on MRI as well-demarcated regularly enhancing lesions; the spinal level can be clearly defined on sagittal images, and axial, sagittal, and coronal images show the tumour extension within and outside the spinal canal as well as its relationship to the spinal cord and paraspinal structures. 1 Dumbbell schwannomas typically manifest with a 2-3-year history of local pain with or without radicular pain.…”