Combined retropleural thoracotomy and posterior spinal approach for thoracic dumbbell Schwannoma: Case series and review of the literature


      • Dumbbell schwannomas with intrathoracic extension are difficult to cure surgically.
      • Ventral/ventrolateral approaches to the thoracic spine confer increased morbidity.
      • Unstaged, posterior-only approach to schwannomas with ventral extension is feasible.



      Dumbbell schwannomas of the thoracic spine are challenging to cure surgically. Surgeons are familiar with posterolateral approaches to the spine, however, these may provide inadequate exposure for large tumors extending to ventral extraspinal compartments. Ventrolateral transpleural approaches offer direct access to the ventral thoracic spine and intrathoracic cavity, though are associated with increased morbidity and pulmonary complications, and may necessitate a staged procedure in order to address concomitant dorsal pathology. Herein we describe our experience with single-stage, posterior approach to dumbbell schwannomas with large ventral extraspinal components, and review the literature regarding surgical approaches for these tumors.


      Retrospective review of patients who underwent a single-stage, posterior spinal surgery for thoracic dumbbell schwannomas from 2008 to 2018. Inclusion criteria were age > 18 years and ventral thoracic tumor component.


      Three patients underwent a simultaneous retropleural thoracotomy and posterior spinal approach, through a single incision, for the resection of dumbbell (intradural and extradural) schwannomas. Mean age was 49.7 years and 2 patients were female. All patients were neurologically intact at baseline. Lesions were 4–8.2 cm in the largest dimension (mean 6.1 cm). GTR was achieved in all patients. One pleural rent occurred intraoperatively; there were no other intraoperative or perioperative complications. At a mean follow-up of 14.1 months all patients remained motor and sensory intact and there was no evidence of recurrence.


      The combined retropleural thoracotomy-posterior spinal approach provides safe and sufficient access for resection of large dumbbell schwannomas of the thoracic spine.


      GTR (gross total resection), EBL (estimated blood loss), NST (nerve sheath tumor), MRI (magnetic resonance imaging), PET (positron emission tomography), VATS (video-assisted thoracoscopic surgery)


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Clinical Neuroscience
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Engelhard H.H.
        • Villano J.L.
        • Porter K.R.
        • Stewart A.K.
        • Barua M.
        • Barker F.G.
        • et al.
        Clinical presentation, histology, and treatment in 430 patients with primary tumors of the spinal cord, spinal meninges, or cauda equina.
        J Neurosurg Spine. 2010; 13: 67-77
        • Chamberlain M.C.
        • Tredway T.L.
        Adult primary intradural spinal cord tumors: a review.
        Curr Neurol Neurosci Rep. 2011; 11: 320-328
        • Jinnai T.
        • Hoshimaru M.
        • Koyama T.
        Clinical characteristics of spinal nerve sheath tumors: analysis of 149 cases.
        Neurosurgery. 2005; 56: 510-515
        • Safaee M.
        • Parsa A.T.
        • Barbaro N.M.
        • Chou D.
        • Mummaneni P.V.
        • Weinstein P.R.
        • et al.
        Association of tumor location, extent of resection, and neurofibromatosis status with clinical outcomes for 221 spinal nerve sheath tumors.
        Neurosurg Focus. 2015; 39: E5
        • Abe J.
        • Takami T.
        • Naito K.
        • Yamagata T.
        • Arima H.
        • Ohata K.
        Surgical management of solitary nerve sheath tumors of the cervical spine: a retrospective case analysis based on tumor location and extension.
        Neurol Med Chir (Tokyo). 2014; 54: 924-929
        • Ghostine S.
        • Vaynman S.
        • Schoeb J.S.
        • Cambron H.
        • King W.A.
        • Samudrala S.
        • et al.
        Image-guided thoracoscopic resection of thoracic dumbbell nerve sheath tumors.
        Neurosurgery. 2012; 70: 461-468
        • McCormick P.C.
        • Post K.D.
        • Stein B.M.
        Intradural extramedullary tumors in adults.
        Neurosurg Clin N Am. 1990; 1: 591-608
        • Ozawa H.
        • Kokubun S.
        • Aizawa T.
        • Hoshikawa T.
        • Kawahara C.
        Spinal dumbbell tumors: an analysis of a series of 118 cases.
        J Neurosurg Spine. 2007; 7: 587-593
        • Agha R.A.
        • Sohrabi C.
        • Mathew G.
        • Franchi T.
        • Kerwan A.
        • O’Neill N.
        • et al.
        The PROCESS 2020 Guideline: Updating Consensus Preferred Reporting Of CasESeries in Surgery (PROCESS) Guidelines.
        Int J Surg. 2020; 84: 231-235
        • Schick U.
        • Marquardt G.
        • Lorenz R.
        Recurrence of benign spinal neoplasms.
        Neurosurg Rev. 2001; 24: 20-25
        • Payer M.
        • Radovanovic I.
        • Jost G.
        Resection of thoracic dumbbell neurinomas: single postero-lateral approach or combined posterior and transthoracic approach?.
        J Clin Neurosci. 2006; 13: 690-693
        • Jules J.A.
        • Guarnieri J.M.
        • Alkofer B.
        • Le Rochais J.P.
        • Icard P.
        Posterior intrathoracic neurinoma cure: a transforaminal resection after a thoracotomy.
        Ann Thorac Surg. 2005; 79: 1411-1412
        • Akwari O.E.
        • Payne W.S.
        • Onofrio B.M.
        • Dines D.E.
        • Muhm J.R.
        Dumbbell neurogenic tumors of the mediastincum. Diagnosis and management.
        Mayo Clin Proc. 1978; 53: 353-358
        • Vallieres E.
        • Findlay J.M.
        • Fraser R.E.
        Combined microneurosurgical and thoracoscopic removal of neurogenic dumbbell tumors.
        Ann Thorac Surg. 1995; 59: 469-472
      1. McCormick PC. Surgical management of dumbbell and paraspinal tumors of the thoracic and lumbar spine. Neurosurgery. 1996;38(1):67-74; discussion 74-65.

        • Grillo H.C.
        • Ojemann R.G.
        • Scannell J.G.
        • Zervas N.T.
        Combined approach to “dumbbell” intrathoracic and intraspinal neurogenic tumors.
        Ann Thorac Surg. 1983; 36: 402-407
        • Nakamura H.
        • Komagata M.
        • Nishiyama M.
        • Taguchi M.
        • Kawasaki N.
        Resection of a dumbbell-shaped thoracic neurinoma by hemilaminectomy: a case report.
        Ann Thorac Cardiovasc Surg. 2007; 13: 36-39
        • Takami T.
        • Yamagata T.
        • Chokyu I.
        • Ikeda H.
        • Tsuyuguchi N.
        • Ohata K.
        Surgery of spinal nerve sheath tumors originating from C1 or C2 of high cervical spine.
        Neurol Med Chir (Tokyo). 2010; 50: 1044-1049
        • Takamura Y.
        • Uede T.
        • Igarashi K.
        • Tatewaki K.
        • Morimoto S.
        Thoracic dumbbell-shaped neurinoma treated by unilateral hemilaminectomy with partial costotransversectomy–case report.
        Neurol Med Chir (Tokyo). 1997; 37: 354-357
        • Diaz P.
        • Maillo A.
        • Hemández J.
        • Morales F.
        • Jiménez M.F.
        • Moreta J.A.
        • et al.
        Subarachnoid-pleural fistula as a complication of the lateral-extracavitary approach to thoracic intraspinal neurinoma.
        Spine. 1995; 20: 1515-1518
        • Han P.P.
        • Dickman C.A.
        Thoracoscopic resection of thoracic neurogenic tumors.
        J Neurosurg. 2002; 96: 304-308
        • Onesti S.T.
        • Ashkenazi E.
        • Michelsen W.J.
        Transparaspinal exposure of dumbbell tumors of the spine. Report of two cases.
        J Neurosurg. 1998; 88: 106-110
        • Shadmehr M.B.
        • Gaissert H.A.
        • Wain J.C.
        • Moncure A.C.
        • Grillo H.C.
        • Borges L.F.
        • et al.
        The surgical approach to “dumbbell tumors” of the mediastinum.
        Ann Thorac Surg. 2003; 76: 1650-1654
        • Thorat J.D.
        • Rajendra T.
        • Thirugnanam A.
        • Ng I.B.
        Single-stage posterior midline approach for dumbbell tumors of the thoracic spine, with intraoperative CT guidance.
        Surg Neurol Int. 2011; 2: 31
        • Akwari O.E.
        • Dozois R.R.
        • Weiland L.H.
        • Beahrs O.H.
        Leiomyosarcoma of the small and large bowel.
        Cancer. 1978; 42: 1375-1384
        • Miura J.
        • Doita M.
        • Miyata K.
        • Yoshiya S.
        • Kurosaka M.
        • Yamamoto H.
        Horner’s syndrome caused by a thoracic dumbbell-shaped Schwannoma: sympathetic chain reconstruction after a one-stage removal of the tumor.
        Spine. 2003; 28: E33-E36
      2. Lucas S, Cendan E, Auque J, Civit T, Caremelle S, Braun D. [Asymptomatic giant thoracic dumbbell neurinoma. Apropos of a case]. J Chir (Paris). 1992;129(2):81-87.

        • Agrawal A.
        • Srivastava S.
        • Joharapurkar S.R.
        • Gharde P.
        • Ubeja G.
        Single stage complete excision of large thoracic dumbbell schwannoma by modified posterior approach.
        Surg Neurol. 2008; 70: 432-436
        • Maiman D.J.
        • Larson S.J.
        • Luck E.
        • El-Ghatit A.
        Lateral extracavitary approach to the spine for thoracic disc herniation: report of 23 cases.
        Neurosurgery. 1984; 14: 178-182
        • Cherqui A.
        • Kim D.H.
        • Kim S.-H.
        • Park H.-K.
        • Kline D.G.
        Surgical approaches to paraspinal nerve sheath tumors.
        Neurosurg Focus. 2007; 22: 1-10
        • Ohtsuka T.
        • Kohno T.
        • Nakajima J.
        • Yagyu K.
        • Furuse A.
        Thoracoscopic resection of schwannoma: a report of two cases.
        Kyobu Geka. 1994; 47: 719-722
        • Endo S.
        • Murayama F.
        • Otani S.-I.
        • Tetsuka K.
        • Hasegawa T.
        • Sato Y.
        • et al.
        Alternative surgical approaches for apical neurinomas: a thoracoscopic approach.
        Ann Thorac Surg. 2005; 80: 295-298
        • Liu H.-P.
        • Yim A.P.C.
        • Wan J.
        • Chen H.
        • Wu Y.-C.
        • Liu Y.-H.
        • et al.
        Thoracoscopic removal of intrathoracic neurogenic tumors: a combined Chinese experience.
        Ann Surg. 2000; 232: 187-190
        • Venissac N.
        • Leo F.
        • Hofman P.
        • Paquis P.
        • Mouroux J.
        Mediastinal neurogenic tumors and video-assisted thoracoscopy: always the right choice?.
        Surg Laparosc Endosc Percutan Tech. 2004; 14: 20-22
        • Lan Z.G.
        • Chen H.F.
        • Huang S.Q.
        • Pu Q.
        One-stage removal of a giant thoracic paraspinal shamrock-shaped schwannoma via modified hemilaminectomy and posterolateral thoracotomy.
        Spine J. 2012; 12
        • Dickman C.A.
        • Apfelbaum R.I.
        Thoracoscopic microsurgical excision of a thoracic schwannoma. Case report.
        J Neurosurg. 1998; 88: 898-902
        • Konno S.-I.
        • Yabuki S.
        • Kinoshita T.
        • Kikuchi S.-I.
        Combined Laminectomy and thoracoscopic resection of Dumbbell-type thoracic cord tumor.
        Spine. 2001; 26
        • Chen J.C.
        • Tseng S.H.
        • Chen Y.
        • Tzeng J.E.
        • Lin S.M.
        Cervical dumbbell meningioma and thoracic dumbbell schwannoma in a patient with neurofibromatosis.
        Clin Neurol Neurosurg. 2005; 107: 253-257
      3. Barrenechea IJ, Fukumoto R, Lesser JB, Ewing DR, Connery CP, Perin NI. Endoscopic resection of thoracic paravertebral and dumbbell tumors. Neurosurgery. 2006;59(6):1195-1201; discussion 1201-1192.

        • Li Y.
        • Wang B.
        • Li L.
        • Lu G.
        Posterior surgery versus combined laminectomy and thoracoscopic surgery for treatment of dumbbell-type thoracic cord tumor: A long-term follow-up.
        Clin Neurol Neurosurg. 2018; 166: 31-35