Schwannoma

Clinical history
This 47-year-old male presented with a two year history of progressive numbness of the fingers of the right hand. Six months before examination he developed the same symptoms in his right foot, which in a few weeks time, progressed to the entire leg. At the same time he noticed weakness of the right hand, which interfered with his ability to work.

Neurological examination showed loss of all deep tendon reflexes of the right arm, mild paresis of the right hand, and decreased pain and temperature sensation at the level of C7. Grade of disability: McCormick I.

Plain X-ray demonstrated only straightening of the cervical spine.

MRI
Image 1: Sagittal T1WI (left) and T2WI.
Image 2: Sagittal without (left) and with Gd T1WI.
Image 3: Sagittal PD and T2WI.

At the level of C5 a well-defined, slightly hypointense intramedullary lesion is seen on T1WI. The lesion is hypointense on PD images and markedly hypointense on T2WI. The associated edema is best seen on the T2WI as hyperintense areas. The lesion enhances intensely and homogeneously after contrast administration.

Surgery

Video 1 : Schwannoma.
Total removal of the tumor, clearly originating from a nerve root and impinging on the spinal cord.

Stage 1: Commencing surgery.
Stage 2: Opening of the arachnoid over the tumor.
Stage 3: View of the extramedullary portion of the tumor.
Stage 4: View of the cleavage plane between the schwannoma and the spinal cord.
Stage 5: Identification of the nerve root where the schwannoma originates.
Stage 6: Section of the rootlets.
Stage 7: Separation of the tumor secured with a suture.
Stage 8: The tumor is completely removed.   

Histology
Intramedullary schwannoma.

Post-operative clinical course
The neurological condition improved rapidly after surgery, and only mild paresis of the right hand persisted after one year.