Object. Confusion exists regarding the term giant spinal schwannoma. There are a variety of nerve sheath tumors that, because of their size and extent, justify the label “giant schwannoma.” The authors propose a classification system for spinal schwannomas as a means to define these giant lesions. The classification is confined to tumors that are essentially intraspinal, with or without extraspinal components. Lesions that erode the vertebral bodies (VBs) and extend posteriorly and laterally into the myofascial planes are classified as giant “invasive” spinal schwannomas. Methods. The records of patients with giant invasive spinal schwannoma were analyzed. The radiological features, operative approaches, and intraoperative findings were noted. Ten patients with giant invasive tumors were surgically treated over the last 8 years. Six patients were male. Erosion of the posterior surface of the VBs was the diagnostic finding demonstrated on plain x-ray films. Magnetic resonance imaging delineated the extent of the tumors and helped in preoperative planning. Radical excision of the tumors in multiple stages was possible in eight of the 10 patients. Dural reconstruction was required in four patients. All patients required fusion, and an additional stabilization procedure was undertaken in three patients. Conclusions. The authors conclude that giant invasive schwannomas are uncommon lesions and propose a new classification system. Because of their locally “invasive” nature and extension in all directions, careful preoperative planning of the surgical approach is very important. Although radical excision is possible and promises good results, recurrences may occur and multiple surgical procedures may be required.

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Cysts associated with meningiomas, although uncommon, are certainly not rare. The peritumoral and the intratumoral cysts form distinct subtypes needing separate consideration. Cystic meningiomas are only rarely malignant.

A rare complication of ventriculoperitoneal shunting (VPS) is bowel perforation by the peritoneal catheter of the shunt tube. Rarer still is the peroral extrusion of such a perforated shunt. A two-month-old infant with history of neonatal meningitis, presented with a large head, bulging fontanelle, and hydrocephalus. A VPS was inserted. The child was doing well till the age of eight months, when following vomiting, the peritoneal end of the shunt came out through the mouth. The shunt was removed and antibiotics started. At follow up after 12 months, the child was doing well. Peroral extrusion of the shunt tube needs prompt treatment, including removal of the extruded shunt tube, and attention to bowel perforation and possible cerebrospinal fluid infection. The reported patient is younger than the five cases reported earlier. Strategies in the management of this complication are reviewed. An individualized approach is essential for the successful treatment of this rare complication.

Traditionally, spinal extramedullary tumours are approached by a wide multilevel laminectomy and a midline dural incision. This exposure may result in immediate or delayed instability of the spine, and exposes the spinal cord to the possibility of inadvertent injury during surgery. To avoid these complications the authors have, in 27 patients, used a limited unilateral approach to remove extramedullary tumours. The approach entails bone removal which is limited to the lateral half of the lamina on the side of the tumour and may or may not include the medial part of the facet joint. A lateral dural flap exposes the tumour without exposing the cord. Extraspinal extensions of the lesion may be approached by extending the laminectomy further laterally to the facet joint. This technique has been used in the cervical, thoracic and the lumbar spine to radically remove the lesion in all cases. There were no complications. The authors conclude that extramedullary lesions of the spine can be removed radically by this approach which allows direct access without cord or root retraction, and with little disturbance to the normal anatomy.