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Management of Meningiomas
File 20: SPINAL MENINGIOMAS

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To the Introduction and Contents of Management of Cranial and Spinal Meningiomas

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by ROBERT G. OJEMANN, M.D.
Congress of Neurological Surgeons Honored Guest Presentation
Originally Published Clinical Neurosurgery, Volume 40, Chapter 17, Pages 321-383, 1992
Used with permission of the Congress of Neurological Surgeons.

HTML Editor: Stephen B. Tatter, M.D., Ph.D.


Disclaimer: The information and reference materials contained herein are intended solely to provide background information. They were written for an audience of physicians. They are in no way intended to constitute medical advise. For medical advise a physician must, of course, be consulted.

Contents


SPINAL MENINGIOMAS

(Meningioma Management, File 20)

Management

Meningiomas in the spinal canal are usually intradural and extramedullary. Combined intradural and extradural growth and entirely extradural growth have been reported in 3-10% of patients (28, 67). The extradural tumor may extend into the intervertebral foramen. The intradural tumors can occur at any location around the circumference of the spinal dura. Most tumors tend to be lateral to the spinal cord, with ventrolateral being the most common site. These tumors are most frequent in the thoracic region (36, 67, 68).

MRI usually gives all the information needed to plan a surgical procedure. Myelography with CT scan is usually not needed. Operation is indicated when there is pain or increasing neurological deficit. Radiation therapy has not been used.

I prefer the prone position for all spinal tumors, including those in the cervical region. It is important to localize the correct level by x-ray. The place of intraoperative spinal evoked potential monitoring has not been established. Generally, in these tumors this monitoring has not added useful infon-nation.

The key considerations in the operation include the following.

  1. Adequate exposure above and below the tumor and on the ipsilateral side is needed. Careful removal of laminae is important particularly when there is an indication that the tumor is calcified. This may be facilitated by drilling a groove at the lateral edge of the lamina on each side and then lifting the lamina up while the yellow ligament attachments are divided.
  2. The dura is opened laterally over the tumor.
  3. Internal and/or lateral decompression of the tumor is performed before trying to dissect the tumor away from the spinal cord.
  4. Division of the dentate ligament attachments and/or a posterior nerve root in the thoracic region may facilitate removal.
  5. When the tumor is posterior lateral, the dural attachment is excised and the defect is repaired with a piece of fascia. In the more common anterior lateral tumors, resection of dura may be difficult without risk of iroury to the ventral nerve roots or spinal cord. Solero et al. (68) report that when the dural base is cauteiized recurrence is rare.

Results

In this series there were 13 patients, six men and seven women, ranging in age from 32 to 91 years, with five over 70 years of age (Table 17.19). In II the tumor was entirely intradural, in one was intra- and extradural, and in one was extradural with extension into the intravertebral foramen. In 10 patients a total removal was done. One patient with a cervical extradural tumor probably has fragments of tumor left in the dura of the nerve root sleeves but the postoperative scans have been stable. Ten patients had a good result. One patient, age 80, had a progressive myelopathy. A radical subtotal removal was done, leaving tumor in the dura. The patient had an immediate good result but early in the postoperative period a middle cerebral embolus led to a permanent hemiplegia. One patient was paralyzed before operation and did not recover. The third patient with a poor result was first seen with a recurrent tumor involving several sites and the tumor was densely adherent in the spinal cord. He did not improve. There has been no recurrence in any of the other patients and a low recurrence rate is reported in the literature. There was one wound infection.

TABLE 17.19 Spinal Meningiomas
aRemoval bOutcome Complications Recurrence
T 10 Good 10 Middle
cerebral
embolus
1 1
RST 2 Fair 0
ST 2 Poor 3 (2)
aT, total removal
RST, radical subtotal removal
ST, subtotal removal
bGood, free of major neurological deficit
and able to return to previous activity level
Fair, independent but not able to return to full activity
because of new neurological deficit or significant
preoperative deficit that did not fully recover
Poor, dependent.
Excellent results have been reported by several neurosurgeons (36, 39, 68). Using microsurgical techniques, Solero et al. (68) reported that only one of 29 patients showed slight deterioration. Malik et al. (39) reported that only one of 25 patients in their series was slightly worse. Significant neurological improvement has been reported even in those who had a serious preoperative neurological disability (67). Reported postoperative complications related to the operation site have included neurological worsening, cerebrospinal fluid leak, arachnoiditis, meningitis, and wound infection (36).

The prognosis for extradural meningiomas, even when a subtotal removal has been done, is good. Solero et al. (68) did not find any progression in eight patients (four with total and four with subtotal removal) over 4-17 years.


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