• Valentina Pizzuti, Paolo di Russo, Vincenzo Esposito, and Roberta Morace.
• Department of Neurosurgery, IRCCS Neuromed, Pozzilli (IS), Italy; Department of Neurology and Psychiatry, Sapienza University, Rome, Italy.
• World Neurosurg. 2019 May 1.

BackgroundPresacral schwannomas are rare benign tumors that may reach large size before becoming symptomatic. Total surgical removal has been considered the best treatment option. Tumors arising from the presacral area are commonly managed through anterior approaches, whereas posterior approaches are used for pure intrasacral tumors or large lesions with both intra and presacral extension, alone or in combination with anterior approaches.MethodsWe describe a quick and minimally invasive navigation-guided posterolateral approach to a right presacral L5 schwannoma. The lesion was microsurgically removed through high-speed drilling of the upper portion of the right sacral ala, under intraoperative neurophysiological monitoring.ResultsThe postoperative course was unremarkable and the patient experienced improvement in his sensory disturbance. Postoperative magnetic resonance imaging (MRI) and computed tomography (CT) scan showed the complete excision of the lesion and the removal of the upper sacral ala with preservation of the right L5-S1 articular complex. The histological examination confirmed a Schwannoma (WHO Grade I).ConclusionsThe posterolateral trans-sacral ala approach may represent a minimally invasive option in the surgical management of presacral well-circumscribed benign tumors. Spinal navigation could be properly used to facilitate lesion exposure, and to minimize the bone removal. The intraoperative neurophysiological monitoring is an essential tool for the preservation of the lumbosacral nerve roots.Copyright © 2019 Elsevier Inc. All rights reserved.

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