Search

Schwannomas are typically benign tumors that arise from the sheaths of nerves in the peripheral nervous system. In the spine, schwannomas usually arise from spinal nerve roots and are therefore extramedullary in nature. Surgical resection-achieving a gross total resection, is the main treatment modality and is typically curative for patients with sporadic tumors. In this video, we present the case of a 38-yr-old male with worsening left leg radiculopathy, found to have a lumbar schwannoma. Preoperative imaging demonstrated that the tumor was at the level of L4-L5. A laminectomy at this level was performed with gross total resection of the tumor. The key points of the video include use of intraoperative fluoroscopy to confirm surgical level and help plan surgical exposure, use of ultrasound for intradural tumor localization, and advocating for maximum safe resection using neurostimulation. The patient tolerated the surgery well without any complications. He was discharged home with no additional therapy needed. Appropriate patient consent was obtained., (© Congress of Neurological Surgeons 2021.)

This is a surgical video of a computed tomography (CT)-guided percutaneous radiofrequency ablation of the spinal trigeminal tract and nucleus caudalis for refractory trigeminal neuropathic pain.1,2 Many have contributed historically, among them, Sjoqvist3 in 1938 first described destruction of the descending medullary trigeminal tractus via open craniotomy.3-6 In 1967 and 1968, Crue7 and Hitchcock8 independently developed a percutaneous tractotomy technique. Although Kanpolat9,10 first described the use of CT imaging for percutaneous creation of a single tractotomy/nucleotomy lesion resulting in satisfactory pain relief for 85% of patients. The spinal trigeminal tract is a descending fiber pathway containing central processes of first-order afferent neurons from cranial nerves V, VII, IX, and X. The spinal trigeminal nucleus is the terminal projection of the spinal trigeminal tract comprised of 3 subnuclei: oralis, interpolaris, and caudalis. The nucleus caudalis is the most caudal of the 3 subdivisions of the spinal trigeminal nucleus and houses the cell bodies of second-order afferent neurons critical in nociception of the face. Lesioning of the spinal trigeminal tract and nucleus caudalis can provide pain relief without affecting facial sensation or trigeminal motor function.9,11-13 Percutaneous radiofrequency ablation is performed using anatomical landmarks, serial CT scans, impedance monitoring, and functional confirmation to ensure appropriate insertion of the probe to the target of interest prior to lesioning. This procedure remains uncommon in current practices even among functional neurosurgery pain specialists but offers a low-risk, minimally invasive treatment option for refractory facial pain.14 This procedure was done under Institutional Review Board guidance (H-41228: retrospective chart review of patients undergoing spine surgery for pain). The risks and benefits were explained, and the patient consented to videography/procedure. Images in the video used with permission from the following: Carter HV. Anatomy of the Human Body. Wikimedia Commons [Public Domain]. https://commons.wikimedia.org/wiki/File:Gray698.png. Published 1918. Accessed June 30, 2019; Carter HV. Anatomy of the Human Body. Wikimedia Commons [Public Domain]. https://commons.wikimedia.org/wiki/File:Gray784.png. Published 1918. Accessed June 30, 2019; Reprinted from Kanpolat Y, Kahilogullari G, Ugur HC, Elhan AH, CT-guided percutaneous trigeminal tractotomy-nucleotomy, Neurosurgery, 2008, 63(1 Suppl 1), ONS147-53; discussion ONS153-5, by permission of the Congress of Neurological Surgeons; Madhero88. Onion Distribution of Pain and Temperature Sense by Trigeminal Nerve. Wikimedia Commons [Creative Commons BY 3.0 license]. https://en.wikipedia.org/wiki/File:Onionskinddistribution.svg#/media/File:Onionskinddistribution.svg. Accessed June 30, 2019., (Copyright © 2020 by the Congress of Neurological Surgeons.)