One-stage removal of a giant thoracic paraspinal shamrock-shaped schwannoma via modified hemilaminectomy and posterolateral thoracotomy

Background contextParaspinal neurogenic tumors in the thoracic region are not a rare clinical entity in neurosurgical practice. They usually consist of intrathoracic and intraspinal parts, namely dumb-bell type. However, in some rare cases, they might display a bidirectional extraspinal growing pattern, compromising three components with intraspinal, intrathoracic, and subcutaneous parts, thus appearing to be shamrock-like. Despite its benign nature, the removal of this type of tumor could be challenging for both neurosurgeons and thoracic surgeons, especially when the tumor has grown to an enormous size.PurposeWe present a case of a giant paraspinal shamrock-shaped schwannoma in the T9–T12 level resected completely by one-stage combined surgery of hemilaminectomy and posterolateral thoracotomy performed by an interdisciplinary team of neurosurgeons and thoracic surgeons.Study design/settingOperating room of a large tertiary medical center where expertise and equipment of neurosurgery, thoracic surgery, and neuroanesthesia are readily available.MethodsUnder generalized anesthesia, the patient was intubated with a double-lumen endotracheal tube to allow one-lung ventilation during the thoracotomy, and he was then placed in the left lateral position. Because of the giant subcutaneous mass, the normal hemilaminectomy could not be carried out like it usually would be. Thus, we did slight modification to the standard hemilaminectomy; first, by elevation of a skin flap to allow in situ excision of the subcutaneous portion of the tumor, then followed by a standard unilateral laminectomy to remove the intraspinal portion, done by neurosurgeons, and finally, posterolateral thoracotomy to remove the intrathoracic part, performed by a thoracic team.ResultsThe postoperative magnetic resonance imaging scan showed complete removal of the tumor, and the patient experienced an improvement in lower extremity muscle weakness with no new neurological deficits.ConclusionsThis is the first case to demonstrate the removal of giant paraspinal shamrock-shaped schwannoma in the thoracic level. The combined approach of modified hemilaminectomy and posterolateral thoracotomy was proven to be appropriate in managing such cases, making this procedure a potential addition to present methods.