CASE REPORT Extended lateral parascapular approach for resection of a giant multi-compartment thoracic schwannoma Giacomo G. Vecil & Ian E. McCutcheon & Ehud Mendel Received: 25 April 2008 / Accepted: 17 October 2008 / Published online: 18 November 2008 # Springer-Verlag 2008 Abstract Background Resection of giant thoracic schwannomas is challenging and usually requires a staged approach. The resection of the intraspinal component, usually via lam- inectomy, is done in one sitting and the intrathoracic component, via thoracotomy, follows at another. We describe the complete resection of a massive multi- compartmental thoracic schwannoma by an extended lateral parascapular approach. Method and findings The tumor, which presented with local pain and scapular displacement, had intrathoracic paraspinal (10 × 5 × 4 cm), posterolateral upper thoracic paramuscular (19 × 7 × 4 cm), foraminal, and epidural components. It was removed at a single sitting, via a posterior extended lateral parascapular approach that did not require staged procedures, multiple incisions, or reposi- tioning of the patient. This operation included resection of the thoracic, foraminal, and intraspinal components and posterior stabilization with pedicle screws and rods. There were no postoperative neurological complications. Conclusions The extended lateral parascapular approach allows complete resection of giant multi-compartment schwannomas of the thoracic spine that extend from the canal into the thoracic cavity. It also permits posterior stabilization through the same incision used for tumor removal. Keywords Giant schwannoma . Posterior mediastinal mass . Dumbbell tumor . Posterior approach Introduction When benign neurogenic tumors extend transforaminally from the paraspinal space into the spinal canal, their removal becomes difficult. Until recently, this often required separate approaches to deal with the intrathoracic and intraspinal components, but the two-stage approach, using laminectomy followed by thoracotomy, risks neuro- logical complications regardless of the initial approach [10]. In recent years the value of a single-stage procedure has become more apparent [1, 15, 27, 31]. In particular, Fessler and colleagues have described a lateral parascapular approach which they used to approach small upper thoracic lesions without violating the pleura [9]. Recently, the trend towards minimally invasive approaches has fostered trans- thoracic microsurgical endoscopy (thoracoscopy) for resec- tion of intrathoracic neurogenic tumors [3, 7, 12, 30]. However, this approach is not recommended when intra- spinal extension is present [13]. This report describes the successful resection of a large dumbbell thoracic schwan- noma, during which the sheer size of the tumor and multi- level extension precluded staying extrapleural. We describe the use of a previously unreported intrapleural extension of the lateral parascapular approach that facilitated complete resection of a massive schwannoma via a single-stage procedure. Case report History and Clinical Findings This 34-year-old man presented with a 14-year history of an enlarging posterior thoracic mass. At the time of presentation the lesion produced an obvious physical deformity with a palpable mass beneath and displacement of the right scapula. He had Acta Neurochir (2008) 150:1295–1300 DOI 10.1007/s00701-008-0154-8 G. G. Vecil : I. E. McCutcheon (*) : E. Mendel Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Unit 442, Houston, TX 77030, USA e-mail: imccutch@mdanderson.org