Anesthetic Management and Considerations During Surgical Dissection of a Schwannoma Causing Severe Cervical Spinal Canal Stenosis and Vertebral Artery Compression

Neurosurgical cases require meticulous anesthetic planning and execution by the anesthesiologist. This report aims to illuminate the careful considerations required in several aspects of anesthetic management, including spinal positioning during intubation/throughout the case, neuromonitoring, and anesthetic agent selection to ensure adequate neural tissue perfusion and optimal outcomes in neuroanesthesia cases. We describe the anesthetic case of a large cervical spine schwannoma resection in a 64-year-old woman who experienced various neurological symptoms due to this mass. MRI revealed that the mass was causing severe spinal canal stenosis, jugular vein effacement, and compression of the vertebral artery. This patient, classified as an American Society of Anesthesiologists (ASA) III, was optimized in preoperative clinic visits. She was deemed an appropriate candidate for a posterior cervical spine laminectomy with tumor resection and instrumentation which was recommended by both Otolaryngology and Neurosurgery. Intraoperatively, a video laryngoscopy was performed to limit extreme cervical spine movement during intubation. To allow for continuous neuromonitoring throughout the case, intravenous infusions of propofol and remifentanil were the primary anesthetic along with half a minimum alveolar concentration of sevoflurane to avoid intraoperative awareness. No major neurological changes were noted during the case. Additionally, ASA standard monitoring, an arterial line, and a Bispectral Index (BIS) monitor were utilized. All anesthetic agents were titrated to achieve optimal blood pressure and BIS readings. The surgery was completed successfully and the patient did not require transfusion of any blood products. She was successfully extubated and transferred to the neurocritical care unit with no postoperative complications.