File 20: SPINAL MENINGIOMAS
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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.
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
(Meningioma Management, File 20)
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
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.
- 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
- The dura is opened laterally over
- Internal and/or lateral decompression
of the tumor is performed before trying to dissect the tumor away
from the spinal cord.
- Division of the dentate ligament
attachments and/or a posterior nerve root in the thoracic region
may facilitate removal.
- 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.
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.
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
|TABLE 17.19 Spinal
aT, total removal
RST, radical subtotal removal
ST, subtotal removal
bGood, free of major
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
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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