Neurosurgery notes/Tumours/Meningioma/Spinal meningiomas

Spinal meningiomas

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Meningioma

General

  • Slow growing intra-dural extra-medullary tumour
  • Associated with NF2 rarely ( suspect in young patients or multiple lesions)

Numbers

  • 2nd most common IDEM (after schwannoma)
  • Much rarer compared to intracranial meningiomas ( less than 10% of all meningiomas)
  • Gender
    • Strong female preponderance ( 5 times male)
  • Age :
    • 40 – 70 years.
    • Mean 50 years

Location

  • Thoracic (common)
  • Lumbar (rare)
9% 73% 29 % 35 % 17% 10%

Symptoms

  • At onset
    • Pain – local or radicular 42%
    • Motor deficits 33%
    • Sensory symptoms 25%
    • Sphincter disturbance
  • At presentation
    • Pain – local or radicular 53%
    • Motor deficits 92%
      • Pyramidal signs only 26%
      • Walks with aid 41%
      • Anti-gravity strength 17%
      • Less than anti-gravity strength 6%
      • Paralyses 9%
      • SPHINCTER DEFICIT 51%
    • Sensory symptoms 61%
      • Radicular 7%
      • Long tract 90%
    • Sphincter disturbance 50%

Radiology

A close-up of an x-ray AI-generated content may be incorrect.
 
S. N. Misra and H. W. Morgar Fig. 5. Case 2. Preoperative sagittal (left) and axial (center) MR images demonstrating a posterolateral intraspinal meningioma. Postoperative axial computerized tomography scan (right) illustrating the unilateral Al approach for the dura-splitting excision of the entire lesion.
Preoperative sagittal (left) and axial (center) MR images demonstrating a posterolateral intraspinal meningioma. Postoperative axial computerized tomography scan (right) illustrating the unilateral A1 approach for the dura-splitting excision of the entire lesion.

Management

Surgery

  • Aim
    • Dorsal approach via laminectomy/laminotomy ( may need additional pedicle/facet/partial vertebral body removal for ventral locations)
    • Complete excision of spinal meningioma, avoiding cord retraction
    • Coagulation of dural origin
    • Instrument spine if iatrogenic instability expected
    • Localisation – pre-op level marking, especially in thoracic spine
  • Adjuncts
    • IOM
      • SSEP, MEP & D-waves.
      • Anaesthetic concerns
    • Intra-op ultrasound
      • Helps in localization,
      • Determining extent
    • Dexamethasone
    • CUSA
    • Dural substitutes & sealents
  • Indications for instrumented stabilisation
    • B/L facetectomies
    • Cervico-thoracic & thoraco-lumbar junction
    • Multilevel cervical laminectomies in cervical spine
  • Outcomes
    • Complete resection achieved in majority (>80%)
    • Complications:
      • 3% to 15%.
      • Common
        • CSF leak
        • Wound related complications
    • Neurological status
      • Intact or improved in majority (>90%)
    • Recurrence
      • 0% to 17%.
      • Recurrence rate with complete excision is 7% with a minimum of 6 years follow-up
    • Recurrance is associated with
      • Younger patients
      • Cervical meningiomas
      • En plaque growth
      • Arachnoid scarring
      • Partial resection
  • Controversies
    • Post op RT
    • Ventral approach
    • Resection of dural origin & duraplasty : uncommon, can be done for dorsal meningiomas & not for the ventrolateral /ventral meningiomas
Close-up of a surgery AI-generated content may be incorrect.
 

Differential diagnosis

Meningioma - MR
Neural sheath tumours - MR
Plain:
• IDEM lesion (ID – expansion of dural sac, EM – compression of cord) 
• Epicentre – typically ventro-lateral or ventral
• Isointense on T2
• May show cord signal change
• Rare – ED & combined ID & ED lesion ( dumbbell appearance)
Gd:
• Uniformly enhancing
• Dural tail
• Rare – en plaque lesion
Plain:
• IDEM lesion (ID – expansion of dural sac, EM – compression of cord)
• Epicentre – typically dorso-lateral or dorsal
◦ Schwannoma comes from sensory (dorsal)
• Hyperintense on T2, maybe cystic
• May show cord signal change
• Typical - combined ID & ED lesion ( dumbbell appearance)
• Foraminal widening
Gd:
• Hypointense centre with Gd