J Neurol Surg A Cent Eur Neurosurg 2014; 75 - p47
DOI: 10.1055/s-0034-1383777

Transforaminal Retrojugular Approach (TFRA) for Resection of Dumbbell Nerve Sheath Tumors in the Cervical Spine

L. Bobinski 1, M. Levivier 1, S. Kishore 1, J. M. Duff 1
  • 1Neurosurgical Service, University Hospital of Lausanne (CHUV), Lausanne, Switzerland

Aims: Based on modern MR imaging, we consider the true dumbbell spinal tumors to have an intradural component within the spinal canal, expanding through the neural foramen and forming an extradural component paraspinally. Surgical treatment of these tumors is challenging in the subaxial cervical spine. In standard posterior approach the resection of extradural component integrity of the facet joint must be sacrifice with risk for instability. Additionally, the proximal control of the adjacent vertebral artery is impossible in event of a vessel injury. We describe a simplification of retrojugular technique which enables one stage gross total resection of the dumbbell tumors as described above with neither mobilization of vertebral artery (VA) nor spinal stabilization. Dural reconstruction was performed using mobilized local vascularized muscle flap.

Methods and Results: Of a total number of 17 patients treated with TFRA technique for cervical tumors between 2007 and 2013, 4 patients (Neurofibroma, Schwanomma, Hemangioblastoma and MPNST (malign peripheral sheath tumor) presented with true cervical dumbbell tumor in subaxial spine as described above. Clinical presentation was neck pain with progressive radiculopathy of affected nerve roots and progressive myelopathy. All patients were followed clinically and radiologically post op. for average 12 months (range 6 to 24 months) with postoperative MRI. We achieved 100% gross total resection confirmed by post op MRI. The post op complications included: mild and transient weakness in corresponding nerve root, which improved during follow-up in 3 patients. The fourth patient with MPNST expired 9 months later because of progression and dissemination of the disease despite of post-operatively adjuvant therapy. There was one incomplete Horner’s syndrome postoperatively. One patient developed a pseudomeningocele in the neck, several weeks after the surgery. This was successfully revised with the same vascularized flap technique.

Conclusions: The anatomical features of dumbbell tumors makes the surgery challenging.

The advantages of TFRA are gross total resection of extradural and intradural components with proximal control of VA, minimal blood loss, a novel duraplasty with vascularized muscle flap and no need for spinal stabilization as described in detail above. We believe that this technique can be used in selective cases as an option for surgical treatment of cervical dumbbell tumors.