Presentation and surgical management approaches of giant presacral and sacral schwannomas: a case report and systematic review and meta-analysis

Background Giant sacral and presacral schwannomas are very rare conditions and their prevalence is estimated to account for only 0.3 to 3.3% of overall schwannomas. Current published literature about these tumors is limited to case reports and small case series. In this paper we systematically reviewed and analyzed the available literature on giant sacral schwannomas focusing on identifying the presenting symptoms, Klimo type, surgical approach, recurrence rate and postoperative complications. Methods Following the PRISMA guidelines, we conducted a literature search on electronic databases to obtain the relevant studies until March 2024. We included reports of surgically managed giant sacral schwannomas; either involving tumor of at least 2 adjacent vertebra or had a maximum diameter of 5 cm or more. Presenting symptoms, tumor size, morphology, surgical approach and postoperative complications were reported. Results A total of 102 studies with 201 unique patients were included in our analysis (mean age 45.4 +/- 9.8, 49.7% females). The most common presenting symptoms were lower extremity radicular pain (19.5%), lower back pain (14.1%), lower extremity numbness or paresthesia (9%), and constipation (7.6%). Most surgeries used an open posterior approach (40.1%) or open anterior approach (33.5%). Postoperative complications occurred in (29.3%) of patients and 10% had local recurrence or progression of their tumor. On linear regression the volume of the tumor could significantly predict the estimated amount of blood loss (P = 0.03). We found that an anterior approach was far more likely to be used in patients with Klimo type III, (P < 0.001). Similarly, posterior approach was mostly used for Klimo type I and type II (P < 0.001). Conclusion The management approach of giant sacral and presacral schwannomas are mainly tailored according to the tumor size and location. Due to the benign nature and the overall recurrence rate of the tumor, frequent imaging follow-up is required after safe resection with adequate clean margins.