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Dumbbell-shaped jugular foramen schwannomas: surgical management, outcome and complications on a series of 16 patients

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Abstract

Schwannomas of the lower cranial nerves are very rare and the dumbbell-shaped ones are even rarer. The authors report their experience in managing such lesions, usually presenting either with intra- and/or extra-cranial extension through an enlarged jugular foramen. The juxtacondylar approach without sacrificing the labyrinth was used; clinical, radiological and complication features are discussed and analysed. This is a case series study on 16 consecutive patients with lower cranial nerves schwannomas surgically managed during a 14-year period using the juxtacondylar approach. In 13 cases, a complete resection has been achieved whereas in three, the excision was near total. The tumour nerve origin has been identified only in ten cases (62.5%). No death or additional post-operative cranial nerve deficits occurred. Aspiration pneumonia developed in one patient and cerebrospinal fluid leak in another. Pre-operative lower cranial nerve deficits improved in all patients. At a mean follow-up of 6.6 years (range 2–14 years), no radiological tumour recurrence was recorded amongst the patients having complete resection as well as no tumour progression in the group of near total removal. Jugular foramen schwannomas can be radically and safely resected with no additional neurological deficit if a careful pre-operative evaluation and the appropriate surgical approach is implemented. Finally, full cranial nerve functional recovery may be expected after complete resection.

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Authors and Affiliations

  1. Department of Neurosurgery, Lariboisiere University Hospital, 2 rue Ambroise-Paré, 75475, Paris Cedex 10, France

    S. Chibbaro, G. Mirone, O. Makiese, D. Bresson & B. George

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  1. S. Chibbaro
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  2. G. Mirone
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  3. O. Makiese
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  4. D. Bresson
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  5. B. George
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Correspondence to S. Chibbaro.

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Comments

Takeshi Mikami, Tomakomai, Japan

In this report, the authors present a series of patients with dumbbell-shaped jugular foramen schwannomas. As the authors state, schwannomas of the lower cranial nerves are extremely rare, so this case series is exceptionally valuable.

The outcome and long-term follow-up prognoses are extremely good, and this paper will allow readers to learn about the surgical management of such cases from experienced surgeons. The stepwise schematic illustration and the intra-operative photograph will be quite helpful to improve readers’ understanding of the practical aspects of the procedure. Nevertheless, it must be noted that the authors have not included any conclusions concerning the intra-operative monitoring of the lower cranial nerves based on their data, though surely some of their cases must have benefited from intra-operative monitoring. Intra-operative neurophysiologic monitoring enables surgeons to identify anatomically indistinct neural structures by their neurophysiologic function; this allows us to avoid lesioning critical structures in the course of the surgical procedure. This omission leaves the door open for further studies in the management of dumbbell-shaped jugular foramen schwannomas, specifically in the use of intra-operative neurophysiological monitoring.

Toshio Matsushima, Saga, Japan

The dumbbell-shaped jugular foramen schwannoma of the lower cranial nerves is one of the tumours which usually cannot be totally or sub-totally removed without neurological deficits such as swallowing disturbance or facial paresis. However, the authors reported good surgical results of large series of dumbbell-shaped schwannomas.

The reasons they were able to remove the tumours totally or sub-totally with minimum neurological deficits seem to be due to their surgical approach. The jugular foramen can be approached from several directions.

The authors used the juxtacondylar route in which the jugular foramen was approached from the posterior side and the posterior wall of the jugular foramen was opened for removal of the tumour. They reported that they were able to macroscopically preserve the lower cranial nerve from which the tumour originated in all cases and that all patients showed improvement of pre-operative lower cranial nerve deficits.

This surgical approach has anatomical advantages to minimize the injury of not only the lower cranial nerves but also the facial nerve. I agree to their opinion that the juxtacondylar route is the best approach for the dumbbell-shaped jugular foramen schwannoma growing intra- and extra-cranially. In the approach, the posterior condylar canal and the posterior condylar emissary vein are good intra-operative anatomical landmarks.

Imad N. Kanaan, Riyadh, Saudi Arabia

The manuscript reflects the experience of the senior author in surgical management of dumbbell-shaped jugular foramen schwannomas in 16 patients using juxtacondylar approach. It is a prospective study and can be classified as level 3 evidence with satisfactory good quality cohort and good mean follow-up. Randomisation is not applicable due to the rarity of the disease. We concurred with the authors’ conclusion that careful pre-operative evaluation and intra-operative neurophysiological monitoring are essential for safe removal of the lesion and better outcome and this of course added to the experience of surgeon and the proper selection of the surgical approach based on tumour site of origin and extension (Pellet’s classification). We also agree with the authors that the approach should avoid the sacrifice of the labyrinth. This precaution is feasible in the juxtacondylar approach as well as in the pre-sigmoid or retromastoid approach. The detailed description of juxtacondylar approach had been published earlier by the senior author, who had adopted this approach for different type of lesions in this location. The emerging role of stereotactic radiosurgery/fractionated radiotherapy is well recognised in our contemporary practice; however, it should be reserved for patients in poor clinical condition or patient who refused surgery on residual tumour with signs of tumour progression. A stronger validation of this treatment is as correctly stated awaiting more consolidation of experiences and a longer follow-up.

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Chibbaro, S., Mirone, G., Makiese, O. et al. Dumbbell-shaped jugular foramen schwannomas: surgical management, outcome and complications on a series of 16 patients. Neurosurg Rev 32, 151–159 (2009). https://doi.org/10.1007/s10143-009-0188-2

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