Tailored Single-Level Laminoplasty and Multilevel Unilateral Hemilaminectomy Approach for Large Thoracic Intradural Schwannoma

Abstract

The optimal approach to intradural tumors remains controversial. All the techniques may have advantages and disadvantages when applied alone. Combining two different techniques in a tailored way could be safer and more effective for individual patients. A 53-year-old female patient was admitted to our clinic with complaints of back pain, walking difficulty, and numbness in her left foot that had been going on for one and a half years. Gadolinium-enhanced: -enhanced T1-weighted magnetic resonance imaging of the thoracic spine revealed a contrast-enhanced intradural extramedullary mass lesion, ∼40 × 15 mm in size, with a cystic component; the lesion extended from the level of the lower end plate of the T7 vertebral body to the mid-level of the T9 vertebral body. The patient was operated on using a tailored laminoplasty–hemilaminectomy technique, and gross total resection of the intradural extramedullary large tumor was achieved. Gross total excision of large intradural extramedullary schwannomas can be safely performed using a tailored laminoplasty–hemilaminectomy approach, where unilateral hemilaminectomy can be performed at multiple levels, whereas laminoplasty is limited to a single level.

 

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Resumo

A abordagem ideal para tumores intradurais permanece controversa. Todas as técnicas podem ter vantagens e desvantagens particulares quando aplicadas isoladamente. Combinar duas técnicas diferentes de maneira personalizada pode ser mais seguro e eficaz para pacientes individuais. Uma paciente do sexo feminino, de 53 anos, foi admitida em nossa clínica com queixas de dor nas costas, dificuldade para caminhar e dormência no pé esquerdo, sintomas que duravam um ano e meio. A ressonância magnética da coluna torácica ponderada em T1 com contraste de gadolínio revelou uma lesão intradural extramedular com realce de contraste, aproximadamente 40 × 15 mm de tamanho, com um componente cístico; a lesão se estendia desde o nível da placa terminal inferior do corpo vertebral de T7 até o nível médio do corpo vertebral de T9. A paciente foi operada utilizando uma técnica personalizada de laminoplastia–hemilaminectomia, e foi alcançada a ressecção total macroscópica do grande tumor intradural extramedular. A excisão total macroscópica de grandes schwannomas intradurais extramedulares pode ser realizada com segurança usando uma abordagem de laminoplastia–hemilaminectomia personalizada, onde a hemilaminectomia unilateral pode ser realizada em vários níveis, enquanto a laminoplastia é limitada a um único nível.

 

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Keywords

extramedullary - intradural - laminectomy - laminoplasty - thoracic schwannoma - spinal tumors - unilateral hemilaminectomy

Palavras-chave

extramedular - intradural - laminectomia - laminoplastia - schwannoma torácico - tumores espinhais - hemilaminectomia unilateral

Introduction

Recently, the growing population and resource shortages have necessitated reducing surgical treatment costs and shortening hospital stays without compromising care.[1] Implementing safer, more effective modifications of existing surgical methods can benefit both individual patients and society.[2] [3] [4]

The optimal surgical approach to intradural tumors remains controversial, although the traditional approach for the removal of intradural tumors has been laminectomy.[5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] Unilateral hemilaminectomy may provide specific advantages, such as less intraoperative bleeding, less postoperative back pain, and shorter hospital stays, compared with laminectomy.[24] In this way, the use of extensive metallic implants, which can cause artifacts in postoperative radiological images and difficulties in dose adjustment in radiotherapy, is avoided. However, although unilateral hemilaminectomy can provide a better perspective at an oblique angle, laminectomy provides a clearer and more accurate view at the right angle.

Thus, we present a case where a patient with a large intradural extramedullary spinal mass was surgically treated using a tailored combined approach: single level laminoplasty combined with multilevel unilateral hemilaminectomy.

 

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Case Description

A 53-year-old female presented with back pain, walking difficulty, and left foot numbness for one and a half years. On examinations, an ataxic gait, paresis of muscle strength around +4/5 in the left lower extremity, and hypoesthesia in the left leg and foot were detected. Gadolinium-enhanced T1-weighted magnetic resonance (MR) imaging of the thoracic spine revealed a contrast-enhanced intradural extramedullary mass lesion, ∼40 × 15 mm in size, with a cystic component. The tumor extended from the level of the lower end plate of the T7 vertebral body to the mid-level of the T9 vertebral body. The mass had significantly compressed the spinal cord and displaced it to the right side. A small part of the tumor extended into the T8 left neural foramen ([Fig. 1 A-E]).

Fig. 1 Radiological examination of the patient. (A): Preoperative contrast-enhanced T1-weighted sagittal magnetic resonance (MR) image showing an intradural extramedullary tumoral mass. (B, C): Preoperative axial T2-weighted and contrast-enhanced T1-weighted MR images. (D): Postoperative T2-weighted sagittal MR image showing gross total removal of the tumor. (E): Postoperative contrast-enhanced T1-weighted sagittal MR image showing gross total removal of the tumor.

Surgical Technique

The patient agreed to undergo the procedure and gave informed, written consent for the publication of this case report. The patient was positioned on the operating table in the prone position under general anesthesia. The electromyographic activity was monitored using a NIM-Eclipse neuromonitoring system (Medtronic Inc, Minneapolis, USA) during the surgical procedure. A midline skin incision of 6–8 cm was made between the T6 and T10 vertebral levels. Under a surgical microscope (Leica Mikrosysteme Vertrieb GmbH, Wetzlar, Germany), using No. 1 and 2 Kerrison rongeurs, the T8 lamina was cut bilaterally and removed in one piece with its spinous process.

After the dura and arachnoid were opened in the midline, a vascular tumor with a yellowish cyst in the rostral region became visible ([Fig. 2A, B]). The spinal cord was seen on the right side of the large tumor. After removing a 2–3 mm portion of the T7 left lamina with a width of 4–5 mm, the rostral pole of the tumor and the proximal spinal cord could be seen under the dura, but the caudal pole of the tumor mass was not visible. Therefore, the lumbosacral fascia was additionally cut on the left side of the T9 vertebral spinous process, and the muscles were dissected subperiosteally on the left side only. The muscles were retracted using a Markham–Meyerding hemilaminectomy retractor. A T9 left-sided hemilaminectomy of 8–9 mm in width was performed using an electric high-speed microdrill (Aesculap Inc., Pennsylvania, USA) and Kerrison rongeurs. The integrity of the facet joints was always preserved. The dural opening was then extended caudally until the distal pole of the tumor and the uncompressed spinal cord were visible in the hemilaminectomy exposure area. The dura covering the tumor was carefully stripped, and dural tack-up stitches were placed.

Fig. 2 Intraoperative photos. (A): Cyst and bulk of the tumor. (B): After the cyst was punctured, the rostral spinal cord was seen to be adherent to the tumor mass. (C): The last remnant of the tumor was dissected from the spinal cord and nerve roots. (D): The intact decompressed spinal cord was visible after the gross total removal of the tumor.

The spinal cord was observed to be markedly compressed and shifted to the right along the entire extent of the tumor. The tumor cyst was punctured, and tumoral fluid was collected and sent for pathological examination with a piece of tumoral tissue for frozen section. The vascular tumoral tissue was then debulked, dissected, and carefully detached from the spinal cord and nerve roots using microneurosurgical instruments and bipolar coagulators. Special suction tubes with round, smooth, atraumatic tips of various diameters, which could be used as blunt dissectors, were utilized in all microsurgical manipulations except drilling. Using a Cerullo suction regulatory apparatus (Aesculap Inc., Pennsylvania, USA), it was possible to work at very low vacuum pressure during arachnoidal dissection. Gross total resection of the tumor was achieved except for a small foraminal part of the tumor extending to the T8 left neural foramen, which was coagulated using bipolar forceps ([Fig. 2C, D]).

The arachnoid and dura were closed with running 6–0 silk sutures watertightly. Several additional interrupted stitches were needed where slight cerebrospinal fluid leakage was observed. An adhesive dural allograft (Hemopatch, Baxter Healthcare SA, Zurich, Switzerland) was placed in this dural section as reinforcement ([Fig. 3A]). The dura was then sealed with Tisseel fibrin sealant (Baxter International Inc., Illinois, USA). T8 laminoplasty was performed using titanium miniplates (Osimplant, Ankara, Turkey) and screws ([Fig. 3B, C, D]). Meticulous haemostasis was achieved, and no drainage tube was placed in the wound. No electrophysiological decrease or loss was observed during neuromonitoring. The estimated blood loss was 230 mL, and the surgery lasted ∼4 hours from incision to closure. The postoperative course was uneventful. Histopathology confirmed a benign spindle cell schwannoma, categorized as WHO grade 1.

Fig. 3 Intraoperative and postoperative radiological demonstration of the tailored laminoplasty–hemilaminectomy approach. (A): T8 laminectomy and T9 left hemilaminectomy areas seen after the closure of the dura. (B): T8 laminoplasty was performed. (C): T8 laminae were fixed using miniplates and screws. (D): Three-dimensional reconstruction of a postoperative computed tomography scan.

 

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Discussion

This case report demonstrates that gross total excision of a large intradural extramedullary schwannoma can be safely achieved using a tailored laminoplasty–hemilaminectomy approach with minimal metallic implants. In our technique, unilateral hemilaminectomy can be performed at multiple levels, while laminoplasty is limited to a single level. In this case, single level laminoplasty and partial hemilaminectomy at two levels were sufficient for safe exposure. An artistic illustration of this technique is shown in [Fig. 4].

Fig. 4 Artistic illustration of the tailored laminoplasty–hemilaminectomy approach (sketch by the corresponding author).

Although intraspinal schwannomas are benign, their rarity makes them difficult to distinguish from other tumors both preoperatively and intraoperatively, complicating surgical planning.[25] While spinal schwannomas may recur within the first few years following surgical resection, 95% of cases do not experience recurrence.[25] However, subtotal resection increases the risk of recurrence, making total resection the preferred surgical goal.

Numerous surgical techniques and their modifications have been reported for the removal of intradural tumors, including laminectomy, laminoplasty, split laminotomy, unilateral hemilaminectomy, unilateral multilevel interlaminar fenestration, and unilateral hemilaminoplasty.[12] [14] [21] [23] [26] [27] [28] [29] [30] All of these techniques may have their own advantages and disadvantages when applied alone. Laminectomy may cause kyphotic deformity and spinal instability.[9] [27] [31] At the same time, although laminoplasty is thought to preserve spinal stability more than laminectomy does, it is still insufficient for preserving the stability of the spine in the context of a multilevel tumor.[32] [33] [34] [35] The unilateral hemilaminectomy method has been shown to cause less spinal deformity and instability than laminectomy.[8] [9] [24] [28] [29] [30] [35] [36] [37] [38] Median split laminotomy and para-split laminotomy are techniques that provide surgical access to the spinal canal by utilizing the elasticity of the annular structures surrounding the canal.[26] These split laminotomy techniques have been suggested to help preserve spinal stability and may serve as a viable surgical option for certain multi-level intraspinal tumors with well-defined borders.[26]

Naturally, there are limitations to the application of minimally invasive techniques. For example, in para-split laminotomy, a smaller portion of bone is removed compared with hemilaminectomy; however, to achieve adequate surgical exposure, the bone must be distracted using a lamina retractor. This process carries a risk of fractures to the lamina, pedicle, and even the vertebral body.[26] Some surgeons have expressed concern that unilateral hemilaminectomy would be insufficient to provide adequate surgical exposure and would not allow total removal of the intradural tumors.[9] [24] Moreover, they have suggested that a midline myelotomy may not be possible when approaching intramedullary tumors with hemilaminectomy. Indeed, if hemilaminectomy is performed on the side of the tumor, the position of the spinal cord under pressure will not be visible until the final stage of the surgery. If it is performed on the spinal cord side, then the fragile spinal cord may be exposed to surgical trauma at the very beginning of surgery.

To address these challenges, combining single level laminoplasty with multilevel hemilaminectomy may offer a safer surgical approach by mitigating the disadvantages of each technique when used independently, while still harnessing their benefits. However, it is important to note that generalizations cannot be made from a single case.

 

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Conclusion

Gross total excision of large intradural extramedullary schwannomas can be safely performed using a tailored laminoplasty–hemilaminectomy approach, where unilateral hemilaminectomy can be performed at multiple levels, whereas laminoplasty is limited to a single level.

 

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Conflict of Interest

The authors declare no competing financial interests and no sources of funding and support, including any for equipment and medications.

Acknowledgments

The authors would like to thank senior operating room staff Mr.Mevlüt Çalıaltı and scrub nurses Mrs.Ruken Algül, Mrs.Kübra Doğan, Mrs.Aslı Yıldız and Mrs.Zeynep Gündüz. Without their dedicated work, this surgery would not have been possible. The authors are grateful to Dr. Cengiz Aras for his unique assistance in creating this study.

Ethics Statement

The study was conducted in accordance with the Declaration of Helsinki for experiments involving human participants. The patient consented to the procedure and provided informed, written consent for the publication of this case report. All data was anonymized.

Authors' Contributions

Original conception (NB), data collection and analysis (NB, MAK, SS, ATŞ, FÇ, TT, BEA), writing of the manuscript (NB, MAK, SS), revision of the manuscript (all the authors) and final approval (all the authors).

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Publication History

Received: 18 August 2024

Accepted: 09 June 2025

Article published online:
08 July 2025