Giant supraclavicular schwannoma involving the cervical nerve root: surgical management and perioperative neurological monitoring—a case report

In the human body, the neck is a crowded highway of vital structures. Major blood vessels, the windpipe, the voice box, and a complex network of nerves all run through a relatively small space, connecting the brain to the arms and the rest of the body. Among these nerves are bundles of specialized cells called Schwann cells, which act like protective insulation around the nerve fibers. Occasionally, these cells grow out of control, forming a benign, or non-cancerous, tumor known as a schwannoma. While these growths are generally slow-growing and harmless, their location can turn a routine medical issue into a high-stakes challenge. When such a tumor forms deep in the neck, particularly near the collarbone where it can press against or wrap around major nerves and blood vessels, removing it without causing permanent damage becomes a delicate balancing act. Surgeons must navigate a minefield of anatomy to excise the mass while preserving the patient's ability to move their arm and feel their hand.

This story centers on a specific case where a team of surgeons faced one of these difficult scenarios. A forty-seven-year-old woman arrived at the hospital with a lump on the right side of her neck that she had noticed for over a month. The mass was painless and had not caused her any trouble with swallowing or breathing, but it was firm and did not move easily under the skin. To understand what they were dealing with, the medical team used advanced imaging. Scans revealed a large, mixed-density mass in the right supraclavicular region, which is the area just above the collarbone. The tumor measured approximately fifty-eight millimeters at its widest point, roughly the size of a large plum. More importantly, the images showed that the growth was not just sitting on top of the tissues; it extended deep toward the spine, reaching into the opening where the nerve roots exit the spinal column. The scans also highlighted that prominent blood vessels were coursing right around the tumor, creating a complex web of life-sustaining structures that the surgeons would have to work around.

Before attempting to remove the mass, the team performed a needle biopsy to confirm the diagnosis. The tissue sample showed a spindle cell tumor, and further testing confirmed it was a schwannoma. The cells tested positive for specific markers that identify them as nerve-sheath tumors, and a test for cell division showed a very low rate, indicating the tumor was not aggressive. Despite the benign nature of the growth, its size and deep location meant that simply cutting it out would be risky. The surgeons planned a procedure that would involve not just removing the tumor, but also carefully exploring the surrounding blood vessels and nerves to free them from the mass. They also prepared for the possibility of significant blood loss, given how many vessels were wrapped around the growth.

The surgery took place under general anesthesia. The patient was positioned with her right shoulder elevated to give the surgeons the best access to the area. They made a curved incision about ten centimeters long over the mass and carefully peeled back the layers of skin and muscle. Inside, they found a firm, oval-shaped tumor measuring seven by five by four centimeters. As suspected, the mass was deeply embedded in the neck muscles and was tightly bound to the surrounding nerves and blood vessels. The tumor appeared to have grown directly from a thick bundle of nerve fibers. The surgeons worked with extreme precision, dissecting along the outer shell of the tumor to separate it from the healthy tissue. They managed to remove the entire mass, but because the tumor had grown from a thick nerve bundle, that specific section of the nerve had to be removed along with the tumor to ensure it was gone completely. The wound was then irrigated, and a large empty space was left behind where the tumor had been. To fill this gap and help the tissue heal, the surgeons used a flap of the patient's own fascia, a tough connective tissue, to reconstruct the area.

The operation lasted one hour and fifty minutes. During the procedure, the team lost approximately four hundred milliliters of blood, which required a transfusion of one and a half units of packed red blood cells and two hundred and twenty milliliters of plasma. Once the surgery was complete, the patient was moved to the recovery ward in stable condition. The medical team knew that the immediate hours after the surgery were critical. Because the neck contains the airway and major blood vessels, a collection of blood, known as a hematoma, could form in the wound and compress the throat, making it difficult to breathe. To prevent this, they placed a drain in the incision to let any fluid escape and applied a salt bag to gently compress the area. They monitored the patient's vital signs, the amount of fluid coming out of the drain, and her ability to move and feel her right arm.

In the days following the operation, the patient's recovery was closely watched. On the first day, she reported a mild numbness in the fingertips of her right hand, a common reaction when nerves are manipulated during surgery. However, her muscle strength remained perfect, and her hand remained warm and well-perfused. Over the next few days, this numbness gradually faded. By the fifth day, the patient was ready to go home. The wound was healing well, the drain had been removed, and she had no trouble breathing or swallowing. A follow-up scan one month later showed that the surgical site was healing, with only a slight enlargement of the nerve root where the tumor had been, but the patient had no pain or other symptoms.

This case highlights the complexity of removing large tumors from the neck. The surgeons found that while standard risk scores can help predict complications, they do not always capture the unique challenges of a specific patient's anatomy. In this instance, the tumor's deep location, its connection to a thick nerve, and the rich network of blood vessels surrounding it required a tailored approach. The success of the surgery relied not just on the skill of the cut, but on the careful planning before the operation and the vigilant monitoring after. By combining precise imaging, gentle dissection, and a recovery plan that paid close attention to both bleeding and nerve function, the team was able to remove a difficult tumor while preserving the patient's neurological function. The outcome suggests that for these complex cases, a personalized strategy that adapts to the specific findings of the surgery is essential for a safe recovery.