Carolyn Rachofsky, BA
Medical Student
Albert Einstein College of Medicine
Bronx, New York, United States
Eric Chang, BS
Medical Student
Western University of Health Sciences - College of Osteopathic Medicine of the Pacific
Riverside, California, United States
Tommy Chen, BS
Medical Student
Touro College of Osteopathic Medicine
New York, New York, United States
Anthony Iuso, DO
Resident Physician (PGY3)
Montefiore Medical Center
Bronx, New York, United States
Michelle Stern, MD
Attending Physician
Department of Physical Medicine and Rehabilitation, Jacobi Medical Center / North Central Bronx Hospital
Bronx, New York, United States
A 33-year-old female presented with two days of bilateral weakness (lower > upper extremity), impaired sensation, and urinary incontinence. She reported paresthesia of the back and upper extremity for ~8 months, but did not seek care until she couldn’t walk. MRI revealed an intradural extramedullary mass (C6/7-T2 measuring 47mm), causing cord compression. Neurosurgery performed emergent subtotal resection (STR) and biopsy. Pathology revealed schwannoma. Postoperatively, she demonstrated neurological deterioration and received steroids.
Discussions: Possible differentials for intradural extramedullary tumors include meningiomas, nerve sheath tumors (NSTs) (schwannoma, neurofibroma, malignant peripheral NST), and lymphoma. NSTs can be associated with genetic syndromes (NF2, schwannomatosis) or sporadic. Sporadic NSTs are more common in older individuals (5th-7th decades). Schwannomas are typically slow-growing and can be asymptomatic. One study showed 29.8mm as the mean presenting size for cervical schwannomas. Tumors can cause cord compression with growth. Standard treatment is gross total resection (GTR) (achieved in 74-94% of cases), with the goal of maintained/improved neurologic function. STR may be used if GTR is unattainable. In one study, STR was more common in cervical tumors, potentially due to the intricate anatomy and proximity to the vertebral artery. Postoperatively, deficits are reported in 13-27% of patients and are greater with STR. Generally, possible causes of postoperative neurologic worsening include surgical removal, cord compression, hematoma, and swelling.
Conclusions:
A sporadic schwannoma is less common in a younger patient (33), but has been reported previously. Our patient was unusual in that she had a large (47mm), vascular tumor in a challenging area (c-spine) that was difficult to debulk. Due to its location and vascular features, it required transfer to another institution for total resection. This case adds to the literature on intradural extramedullary tumors, which are rare and diverse. It underscores the heterogeneous presentations and outcomes that can occur with these tumors.
