Paravertebral neurogenic tumors with intraspinal extension: preoperative evaluation and surgical approach.

AIM OF WORK: To achieve adequate excision of paravertebral neurogenic tumors with intra spinal extension, safe decompression of spinal cord and preservation of spine stability. PATIENTS AND METHODS: From Nov. 2000 till July 2009 sixteen patients of paravertebral neurogenic tumors with intraspinal extension (dumbbell tumors) were operated upon by combined team work of surgical oncology and neurosurgery at the National Cancer Institute and at Kasr- Al Einy Hospitals, Cairo University. All patients had CT with guided biopsy and MRI to evaluate extent of tumor bone invasion, intraspinal component, to decide surgical approach and the need for spine fixation. Patients were referred postoperatively to I.C.U for stabilization of general condition. Follow-up with radiology was done for a period from 3-36 month. RESULTS: The group of patients were 9 males and 7 females with age range 1.5-47 year, 8 patients had tumors in post. Mediastinum, 7 in the retroperitoneal space and one in the cervicothoracic inlet. Benign schwannoma were diagnosed in 5 cases, malignant schwannoma in 3, neurofibromatosis in one case, neuroblastoma in 3 cases, ganglioneuroblastoma in 2 cases and ganglioneuroma in 2 cases. Anterior transthoracic resection through posterolateral thoracotomy was used in 6 cases, anterior transabdominal resection was done in 6 cases through midline or transverse incisions. Combined anterior and posterior approach was used in 3 cases while Posterior approach was done in one case using medial para scapular incision. Delivery of the tumor was done in 8 cases, widening of the intervertebral foramina in 3 cases, costotransversectomy with lateral laminectomy in 3 cases while posterior laminectomy and total vertebrectomy was done in one case. We fixed the spine in 3 cases using Z-plate and screws, lateral plates and screws with either iliac crest or isobone graft. All cord compression manifestations improved postoperatively with perfect spine stability. Morbidity was detected in 3 cases in the form of (graft and plate infection in posterior approach case, and limited spine mobility in 2 cases) while mortality of local and distant recurrence within 16-19 month was registered in 3 cases. CONCLUSION: Para vertebral neurogenic tumors with intra spinal extension could be diagnosed and evaluated with very high accuracy using C-T in adjunct with MRI. C-T guided biopsy can select patients with pathological diagnosis that could be sensitive to pre operative chemotherapy and/or radiotherapy to facilitate surgery. Adequate surgical resection is feasible in a combined team work with different surgical approaches and possible spine fixation. KEY WORDS: Para vertebral - Neurogenic tumors - Intra spinal extension - Surgical approach.