Artikel
Patho-anatomical, clinical and surgical nuances in the operative treatment of solitary paraspinal (ancient) neurinomas
Pathoanatomische, klinische und operationstechnische Aspekte der chirurgischen Behandlung solitärer paraspinaler Neurinome
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Veröffentlicht: | 8. Mai 2019 |
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Objective: Paraspinal (ancient) neurinomas present specific surgical and approach-related challenges due to their intimate relationship to large vessels and diverse organs. The feasibility, safety, and technical nuances in the operative treatment were analyzed in a large cohort.
Methods: This is a retrospective study of clinical and anatomical characteristics, approach-related considerations, and operative results. Size, location, and spatial relationship to vessels and nerve plexus were analyzed using pre-operative MRI, MRA and intraoperative findings. Peri-operative complications were reviewed. Statistical analysis was performed using SPSS 24 (IBM, Armonk, NY, USA).
Results: 63 patients (36f; age: 14–77y) were analyzed. Location was cervical in 16 cases, (25%), thoracic in 23 (37%), lumbar in 13 (21%) and pre-sacral in 11 patients (17%). Mean tumor diameter was 5.5±2.8cm (range: 2.9–15.6cm). Neurologic symptoms were related to tumor location and significantly more common in cervical vs. lumbar vs. pre-sacral vs. thoracic entities (p<0.01). 39 tumors arose from the sympathetic trunc, the remainder were located in immediate proximity to a nerve plexus. 51 neurinomas (81%) were situated next to large veins. The size of those veins was underestimated on pre-operative MRA due to subtotal compression in 47% of cases. 62 tumors (98%) were totally resected (R0). In 38 patients, resection was performed “en-bloc” without prior debulking. Tumor removal entailed ventrolateral cervical, lateral (retro-pleural) thoracic and anterior (retroperitoneal) lumbo-sacral approaches using intraoperative neuromonitoring for neurinomas related to a plexus. New postoperative sensory deficits were observed in 3 patients (5%). Two patients (3%) required blood transfusions due to intraoperative hemorrhage. No new motor deficits were encountered.
Conclusion: Ancient neurinomas are a rare entity, localized along the ventro-lateral spine. Thus, ventrolateral retro-pleural and retro-peritoneal approaches are required for their safe surgical removal. Complication avoidance focusses on early identification and protection of peri-capsular veins. In our cohort, 98% of tumors were safely and completely resected with minimal morbidity.