Neurosurgical Consultants: Spine & Spinal Cord Tumor Facts: C. Neurofibroma

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C. NEUROFIBROMA

Mr. I. H.* is a 61 year old male CT scan technician with a 6 month history of lower back and bilateral leg pain experienced mostly on changing from a seated position to standing. An MRI scan demonstrated an ovoid "enhancing" mass at the L1 (Lumbar) level.

Figure 1A (Left): MRI Scan (Un-enhanced T2-weighted Image-Sagittal View) The T12-L1 level ovoid-shaped tumor (Curved Arrow) appears to arise from ONE NERVE ROOT (Upper Horizontal Arrow) with that Nerve Root appearing to EMERGE FROM THE TUMOR (Lower Horizontal Arrow) suggesting that this will prove to be a NEUROFIBROMA.
Figure 1B (Right): MRI Scan (Gadolinium Enhanced - Axial View-Same Patient) The "enhancing" (white to light grey appearance) tumor (Curved Arrow) occupies over ½ of the Spinal Canal. The Nerve Roots (the dark appearing structures indicated by the Straight Arrows) are displaced forward. (COMPARE THIS TO THE OPERATIVE PHOTOS IN FIGURES 3-5)

SURGICAL TREATMENT

The LEFT-SIDED surgical approach consisted of a MINIMALLY INVASIVE MICROSURGICAL BILATERAL INFERIOR T12, COMPLETE L1 AND SUPERIOR L2 LAMINECTOMY using a UNILATERAL TECHNIQUE. A COMPLETE RESECTION OF THE LARGE INTRADURAL NEUROFIBROMA THAT WAS EMBEDDED WITHIN THE NERVE ROOTS OF THE CAUDA EQUINA WAS CARRIED OUT.

Figure 2A (Left) & 2B (Right): Intra-operative Lateral & Antero-posterior X-rays for "localization" and placement of the Minimally Invasive "X-tube" retractor.

Figure 3: Operative Photo The Neurofibroma (Curved Arrow on the RIGHT side of the photo) originates from one Nerve Root (Curved Arrow on the Left of the photo) and lies among and is embedded within the Nerve Roots (Straight Arrows) of the Cauda Equina.

Figure 4: Operative Photo The Lower End of the Neurofibroma (Curved Arrow on the LEFT side of the photo) INVOLVES THE ONE NERVE ROOT (Curved Arrow on RIGHT) and lies among and displaces the Nerve Roots (Straight Arrows) of the Cauda Equina. THIS DISTAL PORTION OF THE NERVE ROOT MUST BE CUT (near the tip of the Up-curved Arrow) IN ORDER TO REMOVE THE TUMOR. (The sacrifice of this Sensory Nerve Root which will not produce a detectable neurological deficit.)

Figure 5: Operative Photo (Same Patient) The Neurosurgeon has gently displaced the tumor inferiorly in order to access the upper portion of the Nerve Root as it enters the Neurofibroma (Curved Arrow). The other Nerve Roots (Straight Arrows) that surround the tumor have been carefully separated from their arachnoidal attachments to the Neurofibroma in preparation for cutting the PROXIMAL END of the SINGLE NERVE ROOT ENTERING THE TUMOR. (The cut will occur near the tip of the Up-curved Arrow.)

Figure 6: Operative Photo (Same Patient) The Neurofibroma has been completely removed. Notice how many other Nerve Roots are now visible that were previously compressed and displaced by the intradural tumor. (COMPARE THIS TO FIGURES 3-5)

FOLLOW-UP

The patient was mobilized within a short period of time post-operatively and went home on the fourth post-operative day. He does not have any detectable neurological deficit.

Mr. H. wrote about this experience as follows: "The surgery was much easier than I could ever have expected. I spent only 2 days in the Intensive Care Unit and was dismissed on the 4^th day following surgery. I found that a minimum of pain medication kept me comfortable. After 2 weeks post surgery, I found that I did not need any pain medication. After 5 weeks post surgery, I returned to full time with no restrictions except to limit the amount of weight picked up or carried to what I could pick up with one hand. I am glad that I selected Dr. Lazar and Minimally Invasive Surgery for my spinal cord tumor treatment."