Spinal schwannoma

Dr Francis Deng and A.Prof Frank Gaillard◉◈ et al.

Spinal schwannomas are benign nerve sheath tumours within the spinal canal,
typically arising from spinal nerve roots. They are one of the two most
common intradural extramedullary spinal tumours, representing 15-50% of such
lesions.

This article specifically relates to spinal schwannomas. For a general discussion

of schwannomas, refer to the main article: schwannoma.

Epidemiology
They have a peak incidence in the fifth through seventh decades . There is no
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significant sex predilection.

Associations
The vast majority of spinal schwannomas are solitary and sporadic (95%) . 10

However, there is an association with neurofibromatosis type 2 (NF2). In patients

with NF2, almost all spinal nerve root tumours are schwannomas or mixed
tumours. In a young adult without the NF2 mutation, the finding of multiple
schwannomas may meet criteria for schwannomatosis.

Clinical presentation
As spinal schwannomas usually arise from the dorsal sensory roots, patients
commonly present with pain. Radicular sensory changes also occur. Weakness
is less common. Myelopathy may occur if the lesion is large.

Radiographic features
Schwannomas are in most instances indistinguishable from neurofibromas. Refer
to the article on spinal nerve sheath tumours for a discussion of their
radiographic appearance.

The vast majority of spinal schwannomas are intradural extramedullary in

location. Rarely (1%), intramedullary tumours are found .
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They are most frequently seen in the cervical and lumbar regions, far more
frequently than in the thoracic spine.
In general, schwannomas appear as solid, well-defined, rounded lesions, often
with associated adjacent bony remodelling. When large, they may either align
themselves with the long axis of the cord, forming sausage-shaped masses that
can extend over several levels, or may protrude out of the neural foramen,
forming a dumbbell-shaped mass.

MRI
Although neurofibromas and schwannomas can look identical, schwannomas are
frequently associated with haemorrhage, intrinsic vascular changes
(thrombosis, sinusoidal dilatation), cyst formation and fatty degeneration. These
findings are rare in neurofibromas .8

Signal characteristics include :

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 T1: 75% are isointense, 25% are hypointense.

 T2: more than 95% are hyperintense, often with mixed signal
 T1 C+: virtually 100% enhance
An exception to the above signal characteristics is melanotic schwannomas,
which are T1 hyperintense and T2 hypointense.

Treatment and prognosis

Schwannomas are slow growing lesions but can nevertheless be debilitating.
They almost never undergo malignant change. Surgery is the treatment of
choice. Gross total resection is usually curative for patients with sporadic
tumours. For patients with NF2, there is a high incidence of new tumour
formation.

Differential diagnosis
The main differentials are:

 neurofibroma
 meningioma
 paraganglioma
 myxopapillary ependymoma
 intradural extramedullary metastases
For a discussion of helpful distinguishing features, please refer to spinal nerve
sheath tumours.
See also
 neoplasms of the spinal canal
 intradural extramedullary spinal tumours
 spinal nerve sheath tumours
A vividly-enhancing 2.7 cm (L) x 1.2 cm x 1.4 cm (D) heterogeneous T2 hyperintense intradural /
extramedullary mass, with broad dorsal dural base (but no dural tail) is centred in the right side of the mildly
expanded spinal canal at C2 and C3. This severely compresses and displaces the mildly hyperintense spinal
cord to the left, with increased epidural enhancement noted to extend along the right C3-C5 nerve roots.

The resultant severe spinal canal stenosis extending from C2 to C3/4 is further compounded by a contained 5
mm diameter C3/4 superiorly-projecting central posterior to right paracentral disc extrusion.

A vividly-enhancing 2-3 cm isointense extra-axial mass, compatible with a globular meningioma, is partially
imaged posteriorly in the left posterior fossa. This extends superiorly across the tentorium cerebelli, indenting
the posterior left cerebellar hemisphere and inferior occipital lobe, with mild adjacent vasogenic oedema.
There is an extramedullary, intradural lesion, of lows T1 and high T2 signal, which is vividly, but heterogenously
enhancing on post contrast images.
Large intra-extradural mass eroding the borders of the right neuroforamen and the dorsal contour of the L4
vertebral body. Marked rim sclerosis suggests a non-aggressive lesion.
Large, enhancing extra-axial mass in the upper lumbar spinal canal deviating the conus to the left and
expanding the spinal canal by way of posterior vertebral body "scalloping". The post-op scan shows an
extensive laminaectomy and pseudo-meningocoele.

Histology revealed a schwannoma.