Successful Laminectomy with Tumor Removal for Intradural Schwannoma

Chief Complaints

The patient had a medical history of Diabetes Mellitus (DM) and Hypertension (HTN), both of which were managed with medication. She also had a history of a post-laparoscopic salpingectomy performed for hydrosalpinx about two months ago.

On examination, the patient was conscious, coherent, and oriented to time, place, and person. She was moderately built and nourished. Her vitals were stable, with a normal heart rate, blood pressure, and respiratory rate. On systemic examination, there was no tenderness in the abdominal region, and the cardiovascular and respiratory systems were normal. The neurological examination showed a power of 4+/5 in both lower limbs, with normal muscle tone and flexor plantar responses.

Upon admission to PACE hospitals, the patient underwent a comprehensive clinical evaluation, along with the patient’s medical history and diagnostic investigations conducted by the Neurosurgery team.

Laboratory and special investigations were conducted as part of the preoperative assessment. Complete blood counts (CBC) revealed thrombocytosis and neutrophilic leukocytosis, but no systemic infection was evident. Viral screening for HIV, Hepatitis B, and Hepatitis C was negative. Renal function tests and serum electrolytes were stable, with mild hyponatremia noted and corrected during the hospital stay. Chest X-ray demonstrated normal heart size and clear lung fields. Blood and urine cultures initially revealed bacterial growth, for which appropriate antibiotics were administered, with subsequent cultures showing no further growth.

Neuroimaging investigations, including Computed Tomography (CT) and Magnetic Resonance Imaging (MRI), demonstrated a well-defined intradural extramedullary lesion at the L2-L3 levels. The lesion showed mass effect on the adjacent cauda equina nerve roots. The possibility of Schwannoma was suggested.

Based on the confirmed diagnosis, the patient was advised to undergo L2-3 Intra Dural Sol – Schwannoma Treatment in Hyderabad, India, under the expert care of the Neurosurgery Department. 

After a detailed consultation with Dr. U. L. Sandeep Varma, Consultant Neurosurgeon, along with cross-consultation by Dr. Govind Verma, Interventional Gastroenterologist, a comprehensive neurological assessment and radiological evaluation were performed to determine the most appropriate management and therapeutic approach. The patient presented with low back ache, bilateral lower limb paresthesias, radiculopathy, and urinary urge incontinence, and neuroimaging confirmed an L2–L3 intradural extramedullary lesion causing compression of the cauda equina nerve roots, suggestive of schwannoma.

The clinical evaluation revealed features of progressive neural compression with early bladder involvement. It was determined that L2–L3 laminectomy with excision of the intradural tumor under general anaesthesia was identified as the most appropriate surgical intervention. This procedure was aimed at complete tumor removal, decompression of neural elements, relief of symptoms, and prevention of further neurological deterioration.

The patient and her family members were counseled in detail regarding the diagnosis, surgical intervention, postoperative care, medication adherence, physiotherapy, and the need for regular follow-up to optimize long-term recovery.

Following the decision, the patient was scheduled to undergo an L2–L3 Laminectomy Surgery in Hyderabad at PACE Hospitals along with complete excision of the intradural tumor under the expert supervision of the Neurosurgery Department.

The procedure involved the following steps:

• Patient Positioning and Preparation: Under strict aseptic precautions, the patient was administered general anaesthesia and positioned prone. The operative field was thoroughly painted and draped in a sterile manner.

• Surgical Exposure: A vertical midline incision was made over the lumbar region. The incision was deepened in layers, and the paraspinal muscles were carefully separated to expose the posterior elements of the spine.

• Laminectomy and Dural Access: L2–L3 laminectomy was performed to decompress and access the spinal canal. The dura was then carefully incised to expose the intradural space.

• Tumor Identification and Excision: A space-occupying lesion (SOL) was identified among the nerve roots, with one root/filum observed entering the lesion. The tumor, which was soft and cystic in consistency, was meticulously dissected from adjacent nerve roots and excised in a piecemeal fashion, ensuring maximal safe removal.

• Reconstruction and Wound Closure: Duroplasty was performed using 4-0 nylon sutures and reinforced with Duragen. The removed bone fragments were repositioned in the laminectomy site. A drain was placed, and the wound was closed in layers under aseptic conditions, followed by sterile dressing application.

Postoperatively, the patient was shifted to the Intensive Care Unit (ICU) for overnight observation. The surgical drain was removed on postoperative day 2, following which the patient was ambulated. She developed abdominal pain for which a medical consultation was obtained and appropriate advice was followed. The Foley’s catheter was removed after intermittent clamping. The patient was mobilized under physiotherapy guidance and received regular physiotherapy sessions. An orthopedic opinion was taken, and conservative management for bilateral knee pain was advised. The patient was planned for discharge with continuation of medications and physiotherapy as advised.

Upon discharge, the patient was prescribed medications for the prevention of postoperative infection, management of neuropathic pain and radicular symptoms, gastric protection, nerve healing and neuroregeneration, short-term anti-inflammatory and analgesic effect, and relief of dizziness and vertigo. She was also advised to undergo treatment to regulate bowel movements and prevent constipation, along with supportive therapy for gastrointestinal comfort. In addition, medications were continued for long-term control of hypertension and diabetes mellitus as per her existing medical condition, with instructions for regular adherence and follow-up.

The patient was advised that she may take a bath and resume routine activities such as walking and climbing stairs as tolerated. She was instructed to avoid strenuous exercises and heavy lifting. Continuation of physiotherapy as advised was recommended to support recovery and improve functional outcomes. The patient was also advised to strictly follow the prescribed medications and attend regular follow-up visits as scheduled.

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as fever, headache, weakness, discharge from wound, severe pain, vomiting, convulsions, or decreased consciousness.

The patient was advised to return for a follow-up with the Neurosurgeon in Hyderabad at PACE Hospitals after 2 weeks for clinical review and assessment of recovery. Stapler removal was advised after 4 days. The patient was also advised to return after 1 month for further orthopaedic evaluation and management of both knee joints.

This case highlights an intradural extramedullary tumor at L2–L3 managed successfully with laminectomy and complete excision under general anesthesia. Postoperatively, the patient remained stable with improvement in radicular symptoms and satisfactory neurological recovery. The recovery was uneventful with good wound healing and early mobilization supported by physiotherapy, and continued rehabilitation with regular follow-up was advised for further functional improvement and monitoring.