Surgical Technique in the Removal of C2 Schwannoma with Maximal Preservation of the Surrounding Supportive Tissue : A Case Report

Abstract

A high incidence of cervical spine instability after resection of dumbbell type cervical neurinoma with laminectomy has been reported. Intraoperative disruption of the muscles and ligaments attached to the C2 process is relevant to the significant loss in the range of movement (ROM) and the malalignment that manifest late postoperatively. A case of C2 neurinoma in a 48-year-old female that was successfully managed with maximal preservation of the surrounding supportive tissue is presented. She was admitted with a six-month history of progressive tetraparesis, bilateral paresthesia of the limbs, bowel and bladder dysfunction. Imaging studies revealed a large extradural dumbbell shaped tumor at C1/2, extending postero-laterally, that was severely compressing the spinal cord. The vertebral artery was displaced antero-laterally, the C1-C2 intervertebral space extended, and the C2 lamina partially eroded. The tumor appeared to be enclosed by the rectus capitis posterior major and inferior oblique muscle. Thus, a midline posterior approach without laminectomy was adopted and the tumor extirpated without detaching the surrounding muscle and ligament from their insertion. Neither nuchal pain nor loss of ROM developed postoperatively. During a 6-month follow-up period, no sign of the surrounding muscle atrophy was detected on the follow-up MRI, and the cervical alignment was well preserved as confirmed on a plain X-radiography. The preservation of the surrounding supportive tissue during the surgical intervention of the cervical spine is important to avoid instability. Our technical adaptation of the posterior approach to the C2 neurinomas is discussed and the literature regarding the approaches to C2 dumbbell tumors is reviewed.