Minimally Invasive Direct Lateral Transpsoas Approach for the Resection of a Lumbar Plexus Schwannoma: Technique Report

Abstract

Objective Traditional techniques for resection of lumbar plexus tumors have been associated with approach-related morbidity. We describe a case utilizing a minimally invasive transpsoas lateral access approach to resect a retroperitoneal tumor of the lumbar plexus. Methods We report a case with an extradural retroperitoneal schwannoma of the L4 nerve root that was treated with a minimally invasive direct lateral transpsoas approach using atraumatic tissue dilators and an expandable tubular retractor. The use of directional and continuous electromyographic monitoring was critical in locating the plexus and positioning the retractor immediately anterior to the tumor. Results The patient tolerated the procedure well without postoperative complications. The operative approach was direct and intraoperative blood loss was negligible. The patient demonstrated improved left leg strength and ambulation and resolution of paresthesias. Conclusions A minimally invasive direct lateral transpsoas access approach is an effective technique to safely and adequately resect extradural retroperitoneal lumbar plexus tumors.

The natural history of incidental retroperitoneal schwannomas

“…In our practice, periodic imaging is performed to monitor changes. In recent years, endoscopic or robotic minimally invasive surgery is also being employed for the management of retroperitoneal schwannomas, with an acceptable rate of surgical complications [17–19]. Ji et al reported complication rates of 12.5% with laparoscopic resection of retroperitoneal schwannomas [18], while Liu et al reported complication rates of 12% with robotic resections of benign retroperitoneal tumors, including schwannomas [19].…”

Direct Lateral Minimally Invasive Approach for Excision of a L1/L2 Neurofibroma—A Technical Note and Literature Review

“… 2 However, there are only a handful of case reports utilizing this technique for the resection of lumbosacral paravertebral and nerve sheath tumors and these have all been at lower lumbar levels (L3–L5). 3 4 5 6 To the best of our knowledge, this is the first reported case describing a nuanced technique performed at the thoracolumbar junction at L1. The unique anatomic considerations at this junctional level include adjacent proximity of diaphragm and 12th rib superiorly, lung pleura anteriorly, and retroperitoneum posteriorly.…”

Paramedian Wiltse Approach for Giant Paraspinal Lumbar Schwannoma: Technical Note and Alternative Approaches

“…Direct lateral approaches have risen in popularity for management of degenerative spine disease because the trajectory circumvents excess tissue in the posterior spine and allow for direct trajectory to the lateral spine. 30 Benjamin et al 9 reported resection of a small L4 lumbar plexus schwannoma using a direct lateral transpsoas approach using tubular retractors. One potential disadvantage of the direct lateral approach is that the location of the proximal nerve root is at the opposite end of the tumor.…”

“…One potential disadvantage of the direct lateral approach is that the location of the proximal nerve root is at the opposite end of the tumor. Benjamin et al 9 described docking their tubular retractor at the L4/5 disk space just anterior to the nerve root to allow for early identification of the nerve root. This patient developed new dysesthesias in the L4 distribution postoperatively and was discharged on day 5.…”

“…Alternative approaches, including paramedian, lateral, and anterior approaches, have been described that allow for more direct access to the paraspinal region with various advantages and disadvantages. 6-11 These approaches have become more popular with the advancement of minimally invasive techniques which allow for minimal bone removal to avoid postoperative instability. 12…”