Spinal Schwannoma presenting due to torsion and hemorrhage: Case report and review of literature

Background context The presentation of a tumor due to torsion, with hemorrhage from presumed reperfusion injury as a result of infarction of the lesion, is extremely rare and may be different than typical tumor presentation. Purpose The aim was to describe a patient with a rare case of twisted intradural nerve sheath myxoid Schwannoma. Study design This was a case report and a review of literature. Methods A patient presented with acute onset of severe pain was found to have minimally enhanced intradural extramedullary cystic lesion. The patient underwent bilateral L2 and L3 laminectomy and microsurgically assisted intradural exploration. Results At laminectomy and intradural exploration, it was found to be a Schwannoma, which had rotated above and below, with obvious color change consistent with either infarction or hemorrhage. Because the color change ceased abruptly at the site of the torsion, we presumed that the mechanism of the hemorrhage in and around the Schwannoma found at pathologic evaluation was due to the torsion. The torsion caused vascular insufficiency (likely venous) and produced subsequent reperfusion-related hemorrhage, because of the compression of the vascular supply coming from the proximal and distal ends of the root of origin. The patient did well with complete resolution of his symptoms and 11 years of pain relief. Conclusions This acute infarction of the tumor and the associated nerve caused the acute pain syndrome that is not commonly associated with lumbar Schwannomas. Patients with acute onset of severe radiating pain may have torsion of a benign tumor arising from the nerve in question.