Case Study: Neurosurgery

Pediatric Neurosurgery Patient with a Paraspinous S1 Nerve Sheath Tumor

An 11-year old girl who was a member of a Jehovah’s Witness family, presented to an outside hospital with progressive right leg weakness and right lower abdominal pain  of one-month duration.  The MRI scan revealed an S1 extradural tumor and she was referred to Johns Hopkins for our Neurosurgical expertise as well as our ability to care for patients who do not accept blood transfusion. When the patient was identified as the child of a Jehovah’s Witness family,  the surgeons consulted with the Center for Bloodless Medicine and Surgery and our clinical coordinator came to visit the patient and her family during her preoperative visit.

Although the patient was pre-menarchal (not yet menstruating), she had a microcytic anemia (mean corpuscular volume of 78; hemoglobin 8.8 g/dL). The family also reported that she liked to chew on ice a lot (termed PICA) – which is a symptom of iron-deficiency anemia. 

Given the typically low blood loss with extradural and nerve sheath tumor resections, the family was counseled that we would do everything possible to avoid transfusion, but legally if there was life-threatening anemia, we would be obligated to treat her accordingly with a transfusion.  We told the family we did not think this would be exceedingly unusual with this type of surgery. 

The surgery was scheduled and a pediatric anesthesia team provided the care she needed.  The estimated blood loss was minimal, and the tumor was resected without complications.  The operative note described an S1 hemilaminectomy, and resection of an intraspinal and proximal intraforaminal right-sided S1 schwanoma. She was admitted to the pediatric ICU (PICU) for an overnight stay and was then transferred to a regular pediatric floor.  Intravenous patient controlled analgesia (PCA) was prescribed for her using dilaudid, and she was then transitioned to oral pain medications by postoperative day #2.  Gabapentin was also given for some lingering pain and numbness that the clinicians thought would likely resolve on its own.  She was discharged on oral iron supplements (iron sulfate 325 mg orally three times per day), to be followed up by her private medical doctor 8 weeks after discharge.