Removal of cervical spinal tumor with large inferio-lateral extension through anterolateral (interscalene and transforaminal) approach
A thirty years old male presented with neck pain and left sided brachialgia. His neck movements were restricted and painful (mild to moderate pain). There was an ill-defined fixed mildly tender mass in left lower posterior triangle of neck. Hoffman's sign was bilaterally positive. But motor, sensory and autonomic functions including reflexes were normal in all limbs. Other general and systemic examination revealed no abnormality. MRI of cervical spine showed a 4 × 6 × 4 cm intradural extramedullary tumor with paraspinal extension through left C6 and 7 intervertebral foramen [Figure –]. Plain X-ray cervical spine showed large intervertebral foramen between C6 and 7 on left side [Figure and ].\nAnterolateral (interscalene) approach was used to remove the tumor completely.\nSupine position; with 20 ° elevation of head and neck. Head was turned to right side. Left shoulder was slightly elevated and kept on slight traction toward the leg.\nUnder the operating microscope, a 4 cm transverse incision was made 4 cm above the middle third of left clavicle that extended over the posterior part of sternocleidomastoid muscle and anterior part of trapezius [].\nAfter cutting of subcutaneous tissue and platysma in the same line of skin incision investing layer of deep cervical fascia was cut along the posterior border of sternocleidomastoid 3 cm up and down to the skin incision line. Tumor was found after deep fascial incision. Sternocleidomastoid muscle was retracted anteriorly to exposure anterior scalenus muscle. On the anterior surface of anterior scalenus muscle phrenic nerve was identified and safeguarded by medial mobilization. Anterior scalenus muscle was cut above its insertion to scalenus tubercle of first rib after taking care not to injure subclavian vessels. Sternocleidomastoid muscle was retracted anteriorly and trapezius muscle was retracted posteriorly and the tumor was dealt. Fascia over the tumor capsule was dissected and tumor debulking was started but it was very hard and minimally vascular. Tumor was debulked by cutting with micro-scissor and sharp BP blade (No. 11). After removal of lateral part of tumor upper and middle trunk of brachial plexus came in view that were safeguarded. Medial part of the tumor was relatively soft and suck able, so removed by suctioning. Intraspinal intradural part was dealt through the C6 and 7 intervertebral foramen which was already capacious. The tumor easily came out through the dural opening along with arachnoid which was peeled off and tumor removed completely [Figure –]. Any bony work for foraminal enlargement was not needed and spinal stability seemed to be intact. Vertebral artery did not come in view. A portion of arachnoid remained outside the spinal canal through the dural opening with leaking of CSF. The redundant arachnoid was put inside the dura but closure of dural opening was not possible. For prevention of CSF leak, pseudo-meningocele or arachnoid herniation two pieces of thigh fat was put in the dead space. Wound was closed in layers without drain.\nPost operatively patient recovered uneventfully. Histopathological examination of operative specimen reported schwannoma Antoni A. His neurology after operation was intact. Postoperative MRI at the end of 4 months after operation showed no residual tumor but there was a pseudo-meningocele with grafted fat at the operated site [Figure –].