Biportal endoscopic resection of thoracic schwannoma: surgical technique and strategies to overcome key challenges.

Biportal endoscopic spine surgery (BESS) has emerged as a minimally invasive technique for various spinal disorders, but its application in intradural extramedullary tumors (IDEMs) remains limited due to technical challenges. These include maintaining optimal irrigation pressure, ensuring safe and controlled tumor dissection, achieving hemostasis, and preventing cerebrospinal fluid (CSF) leakage. We report the case of a 59-year-old female who presented with progressive lower limb weakness, gait disturbance, and sphincter dysfunction. Magnetic resonance imaging (MRI) revealed a T10-T11 intradural extramedullary schwannoma causing severe spinal cord compression. The tumor was successfully resected using BESS under intraoperative neuromonitoring (IONM). We provide a detailed description of the surgical technique and strategies to overcome the key challenges associated with this approach, including stable irrigation pressure control, dural suspension for field stabilization, two-handed microsurgical dissection, piecemeal tumor removal with careful hemostasis, and watertight dural closure with endoscopic suturing. The operation lasted 150 minutes with an estimated blood loss of 180 mL. Postoperative MRI confirmed total tumor removal without spinal cord injury or CSF leakage. The patient experienced significant neurological recovery, including improved motor function and restoration of bladder control. Continued improvement was observed at the two-month follow-up, with enhanced lower limb strength and resolution of sensory disturbances. This case demonstrates the feasibility of BESS for thoracic IDEMs and suggests it may serve as a viable minimally invasive alternative in selected cases. To improve outcomes, further refinements in endoscopic visualization, microsurgical technique, and instrumentation are essential, and additional studies are warranted to confirm the long-term safety and efficacy of this approach.