Spinal meningiomas – Risks and potential of an increasing age at the time of surgery

Resection vs. coagulation of dural attachment in patients with spinal meningioma: an updated systematic review and meta-analysis

BACKGROUND

The Simpson grading scale assumes dural resection (grade I) is more effective against recurrence than coagulation (grade II). However, the results of recent studies have raised doubts about this effectiveness in spinal meningiomas. Therefore, we aimed to perform a meta-analysis comparing outcomes between Simpson grades I and II in spinal meningiomas.

METHODS

According to the PRISMA statement, we systematically searched PubMed, EMBASE, and Web of Science for studies involving patients with spinal meningiomas who underwent Simpson grades I, II, III, or IV. Outcomes were radiological tumor recurrence, postoperative neurological deficits, and procedure-related complications.

RESULTS

We included 54 studies with a total of 3334 patients. Simpson grades I, II, III, and IV were performed in 674 (20%), 2205 (66%), 254 (8%), and 201 (6%) patients, respectively. The follow-up ranged from 9 to 192 months, and 95.4% of all tumors were WHO grade 1. There was no difference in radiological tumor recurrence (OR 0.80, 95% CI: 0.46-1.36, P = 0.41; I2 = 0%), postoperative neurological deficits (OR 0.74, 95% CI: 0.32-1.75, P = 0.50; I2 = 0%) or procedure-related complications (OR 2.22, 95% CI: 0.80-6.13, P = 0.12; I2 = 3%) between Simpson grades I and II. Furthermore, no significant difference in postoperative neurological deficits or procedure-related complications was detected when comparing all Simpson's to each other. However, radiological tumor recurrences in Simpson I and II were significantly lower than in III and IV, with Simpson III outperforming IV (OR 0.19, 95% CI: 0.09-0.40, P < 0.01; I2 = 0%).

CONCLUSION

Simpson grade I is not more effective than grade II in any outcome, although both are superior to III and IV in tumor recurrence. Our results might suggest that dural coagulation is preferable over resection when the latter carries a higher risk of complications.

Risk factors for preoperative neurological impairment in patients with spinal meningioma: A retrospective multicenter study

BACKGROUND

Patients with spinal meningioma may present preoperatively with paralysis and sensory deficits. However, there is a paucity of detailed evaluations and a lack of consensus regarding imaging findings that are predictive of neurological symptoms in patients with spinal meningioma.

METHODS

Herein, a total of 55 patients who underwent surgical resection of spinal meningiomas in eight hospitals between 2011 and 2021 were enrolled. Patient characteristics, degree of muscle weakness, sensory disturbances, and the presence of bowel/bladder dysfunction (BBD) before surgical treatment were evaluated using medical records. Patients with American Spinal Injury Impairment Scale grades A-C and the presence of BBD were classified into the paralysis (+) group. Patients with sensory disturbances were assigned to the sensory disturbance (+) group. Based on magnetic resonance (MR) and computed tomography images, the tumor location was classified according to the spinal level and its attachment to the dura mater. To evaluate tumor size, the tumor occupation ratio (OR) was calculated using the area and distance measurement method in horizontal MR images, and the maximum length and area of the tumor in the sagittal plane were measured.

RESULTS

Of all patients, 85 % were women. The mean age of patients at surgery was 69.7 years. Twenty-eight (51 %) and 41 (75 %) patients were classified into the paralysis (+) and sensory disturbance (+) groups, respectively. The average tumor length and area in the sagittal plane were 19.6 mm and 203 mm2, respectively; OR-area and diameters were 70.3 % and 72.3 %, respectively. In univariate analyses, tumor length and area in the sagittal plane were significant risk factors for paralysis. OR-diameter, symptom duration, and a low MIB-1 index correlated with sensory disturbances. Multivariate logistic regression analysis demonstrated that the area and length of the tumor in the sagittal plane were significantly correlated with paralysis, whereas the OR-diameter and symptom duration significantly correlated with sensory disturbances. The cut-off values for the area and length of the tumor in the sagittal plane to predict paralysis were 243 mm2 and 20.1 mm, respectively.

CONCLUSIONS

Preoperative paralysis in patients with spinal meningiomas was significantly associated with sagittal tumor size than with high tumor occupancy in the horizontal plane. Sensory disturbances were associated with high occupancy in the horizontal plane. Patients with spinal meningiomas > 20 mm in length or 243 mm2 in area in the sagittal plane are at risk of developing paralysis and could be considered for surgery even in the absence of paralysis.

Timing of Resection of Spinal Meningiomas and Its Influence on Quality of Life and Treatment

BACKGROUND

The main treatment modality for spinal meningiomas (SM) is gross total resection (GTR). However, the optimal timing of surgery, especially in cases with absent or mild neurological symptoms, remains unclear. The aim of this study is to assess the impact of early-stage resection on neurological outcome, quality of life (QoL), and quality of care. The primary objective is a favorable neurological outcome (McCormick scale 1).

METHODS

We retrospectively analyzed data from patients who underwent operations for SM between 2011 and 2021. Patients with mild neurological symptoms preoperatively (McCormick scale 1 and 2) were compared to those with more severe neurological symptoms (McCormick scale 3-5). Disabilities and QoL were assessed according to validated questionnaires (SF-36, ODI, NDI).

RESULTS

Age, spinal cord edema, thoracic localization, and spinal canal occupancy ratio were associated with more severe neurological symptoms (all p < 0.05). Patients presenting with mild symptoms were associated with favorable neurological outcomes (OR: 14.778 (95%CI 3.918-55.746, p < 0.001)), which is associated with shorter hospitalization, better QoL, and fewer disabilities (p < 0.05). Quality of care was comparable in both cohorts.

CONCLUSIONS

Early surgical intervention for SM, before the development of severe neurological deficits, should be considered as it is associated with a favorable neurological outcome and quality of life.

A Retrospective Cohort Study Evaluating the Comparative Effectiveness of Unilateral Hemilaminectomy and Bilateral Laminectomy in the Resection of Spinal Meningiomas

BACKGROUND AND OBJECTIVES

The primary treatment modality for spinal meningiomas (SM) is surgical resection. In recent years, minimal invasive spine surgery has gained considerable popularity, attributing its growth to advancements in surgical technologies and improved training of surgeons. Nonetheless, the suitability and effectiveness of minimal invasive spine surgery for intradural spinal tumor resection remain a subject of debate. In this cohort study, we aimed to compare the extent of resection of the unilateral hemilaminectomy approach, a less invasive technique, with the more traditional and invasive bilateral laminectomy.

METHODS

We performed a retrospective cohort study including patients with SM who underwent surgery at our department between 1996 and 2020. Cohorts included patients who underwent tumor resection through bilateral laminectomy and patients who underwent a unilateral hemilaminectomy. The primary end point was extent of resection according to the Simpson classification.

RESULTS

Of 131 with SM, 36 had a bilateral laminectomy and 95 were operated through a unilateral hemilaminectomy. In both groups, gross total resection, Simpson grades 1 and 2, was achieved in 94.44% and 94.74%, respectively (P = .999). The neurological outcome was also comparable in both cohorts (P = .356). Both length of hospital stay and estimated blood loss were significantly lower in the unilateral cohort (P < .05).

CONCLUSION

The results of this study indicate that the unilateral hemilaminectomy yields comparable results in both oncological and neurological outcome when compared with the bilateral laminectomy. Thus, unilateral hemilaminectomy may serve as a viable and safe alternative for the surgical removal of SM.

Association of quantitative radiomic shape features with functional outcome after surgery for primary sporadic dorsal spinal meningiomas

Objective

Spinal meningiomas (SM) account for 25%-46% of all primary spinal tumors and show an excellent long-term disease control in case of complete resection. Therefore, the postoperative functional outcome is of high importance. To date, reports on dorsally located SM are scarce. Moreover, the impact of radiomics shape features on the functional outcome after surgery for primary dorsal SMs has not been analyzed yet.

Methods

We retrospectively performed an analysis of shape-based radiomic features in 3D slicer software and quantified the tumor volume, surface area, sphericity, surface area to volume ratio and tumor canal ratio. Subsequently, we evaluated the correlation between the radinomic parameters and the postoperative outcome according to Modified Japanese Orthopedic Association (mJOA) score.

Results

Between 2010 and 2022, we identified 24 Females and 2 Males operated on dorsal SMs in our institutional database. The most common SM localization was thoracic spine (n = 20), followed by cervical (n = 4), and lumbar (n = 2). The univariate analysis and the receiver operating characteristic (ROC) analysis showed a strong diagnostic performance of sphericity in the prediction of postoperative functional outcome based on mJOA score (AUC of 0.79, sphericity cut-of value 0.738; p = 0.01). Subsequently, the patients were divided into two groups (mJOA improved vs. mJOA stable/worsened). Patients with improved mJOA score showed significantly higher sphericity (0.79 ± 0.1 vs. 0.70 ± 1.0; p = 0.03). Finally, we divided the cohort based on sphericity (<0.738 and ≥0.738). The group with higher sphericity exhibited a significantly higher positive mJOA difference 3 months postoperatively (16.6 ± 1.4 vs. 14.8 ± 3.7; p = 0.03).

Conclusion

In our study investigating primary sporadic dorsal SMs, we demonstrated that a higher degree of sphericity may be a positive predictor of postoperative improvement, as indicated by the mJOA score.

Predictors of Neurological Worsening after Resection of Spinal Meningiomas

BACKGROUND

Due to the slow-growing nature of spinal meningiomas, they are mostly asymptomatic for a long time, and become symptomatic after the compression of the spinal cord or nerve roots. The aim of this study was to identify predictors for a poor clinical outcome after the surgical resection of spinal meningiomas and thereby to allow a preoperative identification of high-risk spinal meningiomas.

METHODS

Data acquisition was conducted as a single-center retrospective analysis. From 1 January 2004 to 31 December 2019, 121 patients who underwent surgical resection of a spinal meningioma were reviewed. Clinical and radiological data (such as tumor size, location, occupation ratio of the spinal canal, and the degree of spinal cord compression) were assessed. The functional clinical findings of the patients were recorded using the Karnofsky Performance Score, modified McCormick scale, and Frankel scale preoperatively, at discharge, and 3-6 months after surgery.

RESULTS

The mean patient age was 66 ± 13 years. A total of 104 (86%) patients were female and 17 (14%) were male. The thoracic spine (68%) was the most common location, followed by the cervical (29%) and lumbar (3%) spine. Preoperatively, 11.7% of patients were categorized as McCormick 1, 35.8% as 2, 39.2% as 3, 11.7% as 4, and 1.7% as 5. The neurological function of the patients with a functional deficit prior to surgery improved in 46% of the patients, remained unchanged in 52%, and worsened in 2% at discharge. At early follow-up, the proportions were 54%, 28%, and 5%, respectively. Preoperative Frankel scale was a significant predictor of a postoperative deterioration. Patients with Frankel score A to C preoperatively had a 9.2 times higher chance of clinical deterioration postoperatively (OR = 9.16). We found that the Frankel scale weakly correlated with the degree of spinal cord compression. In this study, other radiological parameters, such as the degree of cord compression and spinal canal occupation ratio, did not show a significant effect on the outcome.

CONCLUSIONS

Surgery of intraspinal meningiomas can be considered safe. Neurological function improves in a large proportion of patients after surgery. However, a relevant preoperative deficit according to the Frankel scale (grade A-C) was a significant predictor of a postoperative neurological deterioration.

Resection of Intramedullary Hemangioblastoma: Timing of Surgery and Its Impact on Neurological Outcome and Quality of Life

Background and Objectives: Spinal intramedullary hemangioblastomas (SIMH) are benign vascular lesions that are pathological hallmarks of von Hippel-Lindau disease (vHL) and constitute the third most common intramedullary neoplasm in adults. So far, maximal and safe resection is the first choice of treatment. However, as SIMH show no malignant transformation, it remains unclear whether surgical resection is beneficial for all patients. Materials and Methods: We retrospectively analyzed the surgical outcomes of 27 patients who were treated between 2014 and 2022 at our neurosurgical department and investigated potential risk factors that influence the surgical outcome. Pre- and postoperative neurological status were classified according to the McCormick scale. Furthermore, surgical quality indicators, such as length of hospital stay (LOS; days), 90-day readmissions, nosocomial infections, and potential risk factors that might influence the surgical outcome, such as tumor size and surgical approach, have been analyzed. In addition to that, patients were asked to fill out the EQ-5D-3L questionnaire to assess their quality of life after surgery. Results: Surgery on SIMH patients that display no or minor neurological deficits (McCormick scale I or II) is associated with a favorable postoperative outcome and overall higher quality of life compared to those patients that already suffer from severe neurological deficits (McCormick scale III or IV). Conclusion: Early surgical intervention prior to the development of severe neurological deficits may offer a better neurological outcome and quality of life.

The Role of Prolonged Bed Rest in Postoperative Cerebrospinal Fluid Leakage After Surgery of Intradural Pathology-A Retrospective Cohort Study

BACKGROUND

Postoperative cerebrospinal fluid leakage (CSFL) is a feared complication after surgery on intradural pathologies and may cause postoperative complications and subsequently higher treatment costs.

OBJECTIVE

To assess whether prolonged bed rest may lower the risk of CSFL.

METHODS

We performed a retrospective cohort study including patients with intradural pathologies who underwent surgery at our department between 2013 and 2021. Cohorts included patients who completed 3 days of postoperative bed rest and patients who were mobilized earlier. The primary end point was the occurrence of clinically proven CSFL.

RESULTS

Four hundred and thirty-three patients were included (female [51.7%], male [48.3%]) with a mean age of 48 years (SD ±20). Bed rest was ordered in 315 cases (72.7%). In 7 cases (N = 7/433, 1.6%), we identified a postoperative CSFL. Four of them (N = 4/118) did not preserve bed rest, showing no significant difference to the bed rest cohort (N = 3/315; P = .091). In univariate analysis, laminectomy (N = 4/61; odds ratio [OR] 8.632, 95% CI 1.883-39.573), expansion duraplasty (N = 6/70; OR 33.938, 95% CI 4.019-286.615), and recurrent surgery (N = 5/66; OR 14.959, 95% CI 2.838-78.838) were significant risk factors for developing CSFL. In multivariate analysis, expansion duraplasty was confirmed as independent risk factor (OR 33.937, 95% CI 4.018-286.615, P = .001). In addition, patients with CSFL had significant higher risk for meningitis (N = 3/7; 42.8%, P = .001).

CONCLUSION

Prolonged bed rest did not protect patients from developing CSFL after surgery on intradural pathologies. Avoiding laminectomy, large voids, and minimal invasive approaches may play a role in preventing CSFL. Furthermore, special caution is indicated if expansion duraplasty was done.

Current Knowledge on Spinal Meningiomas Epidemiology, Tumor Characteristics and Non-Surgical Treatment Options: A Systematic Review and Pooled Analysis (Part 1)

BACKGROUND

Spinal meningiomas are the most common primary intradural spinal tumors. Although they are a separate entity, a large portion of the knowledge on spinal meningiomas is based on findings in intracranial meningiomas. Therefore, a comprehensive review of all the literature on spinal meningiomas was performed.

METHODS

Electronic databases were searched for all studies on spinal meningiomas dating from 2000 and onward. Findings of matching studies were pooled to strengthen the current body of evidence.

RESULTS

A total of 104 studies were included. The majority of patients were female (72.83%), elderly (peak decade: seventh), and had a world health organization (WHO) grade 1 tumor (95.7%). Interestingly, the minority of pediatric patients had a male overrepresentation (62.0% vs. 27.17%) and higher-grade tumors (33.3% vs. 4.3%). Sensory and motor dysfunction and pain were the most common presenting symptoms. Despite a handful of studies reporting promising findings associated with the use of non-surgical treatment options, the literature still suffers from contradictory results and limitations of study designs.

CONCLUSIONS

Elderly females with WHO grade 1 tumors constituted the stereotypical type of patient. Compared to surgical alternatives, the evidence for the use of non-surgical treatments is still relatively weak.

Current Knowledge on Spinal Meningiomas-Surgical Treatment, Complications, and Outcomes: A Systematic Review and Meta-Analysis (Part 2)

Background: Most of the knowledge on spinal meningiomas is extrapolated from their intracranial counterparts, even though they are considered separate entities. This review aimed to systematically summarize studies covering different aspects of spinal meningiomas and their management. Methods: Databases were searched for all studies concerning spinal meningiomas dating from 2000 and onwards. When possible, a meta-analysis was performed. Results: Neurological outcomes of surgery were consistently favorable across studies, with a complication rate of 7.9% and 78.9% of the patients demonstrating good postoperative neurological function (McCormick score 1−2). The most relevant predictors of unfavorable outcomes were poor preoperative status, longer time from diagnosis to surgery, and surgery of recurrent tumors. The recurrence rate after surgery was estimated at 6%. Meta-analysis and/or survival analysis revealed that higher WHO grade (p < 0.001), higher Simpson grade (p < 0.001), ventral tumor location (p = 0.02), and male sex (p = 0.014) were all associated with higher odds of recurrence. However, the meta-analysis did not show any difference between Simpson grade 1 and grade 2 with respect to the odds of recurrence (p = 0.94). Surgery provided immediate and durable health-related quality-of-life improvement, as well as a high frequency of return to work. Conclusion: Spinal meningioma surgery is a relatively safe procedure with a low risk of tumor recurrence and high likelihood of favorable postoperative outcomes.

Surgical Treatment of Spinal Meningiomas in the Elderly (≥75 Years): Which Factors Affect the Neurological Outcome? An International Multicentric Study of 72 Cases

(1) Background: With the increasing life expectancy in the Western world, an increasing number of old patients presents with spinal meningioma. Considering the benign nature of these tumors, the functional outcome remains of great importance, since more people reach old age in general conditions of well-being and satisfactory autonomy. (2) Methods: We conducted an international multicenter retrospective study to investigate demographic, clinical and radiological data in a population of elderly patients (≥75 years of age) undergoing surgery for SM from January 2000 to December 2020 in four European referral centers. The aim was to identify prognostic and predictive factors for a good postoperative functional outcome. (3) Results: 72 patients were included in the study. Complete tumor resection (Simpson I or II) was achieved in 67 (95.7%) cases. Intraoperative complications were reported in 7 (9.9%) patients while postoperative complications were found in 12 (16.7%). An excellent general postoperative status (McCormick I and II) was achieved in 65.3%. Overall, surgical resection had a good impact on patients’ functional outcome (86.1% either showing an improvement or maintaining a good preoperative status). Uni- and multivariate analyses found that both age and preoperative modified McCormick independently correlated with relative outcome (coeff = −0.058, p = 0.0251; coeff = 0.597, p < 0.0001) and with postoperative status (coeff = 0.058, p = 0.02507; coeff = 0.402, p = 0.00027), respectively. (4) Conclusions: Age and preoperative modified McCormick were found to be independent prognostic factors. Nevertheless, advanced age (≥75), per se, did not seem to contraindicate surgery, even in those with severe preoperative neurological deficits. The functional results sustain the need for surgical resection of SM in the elderly.

Functional Outcome in Spinal Meningioma Surgery and Use of Intraoperative Neurophysiological Monitoring

Data on intraoperative neurophysiological monitoring (IOM) during spinal meningioma (SM) surgery are scarce. The aim of this study was to assess the role of IOM and its impact on post-operative functional outcome. Eighty-six consecutive surgically treated SM patients were included. We assessed pre and post-operative Modified McCormick Scale (mMCS), radiological and histopathological data and IOM findings. Degree of cord compression was associated with preoperative mMCS and existence of motor or sensory deficits (p < 0.001). IOM was used in 51 (59.3%) patients (IOM-group). Median pre and post-operative mMCS was II and I, respectively (p < 0.001). Fifty-seven (66.3%) patients showed an improvement of at least one grade in the mMCS one year after surgery. In the IOM group, only one patient had worsened neurological status, and this was correctly predicted by alterations in evoked potentials. Analysis of both groups found no significantly better neurological outcome in the IOM group, but IOM led to changes in surgical strategy in complex cases. Resection of SM is safe and leads to improved neurological outcome in most cases. Both complication and tumor recurrence rates were low. We recommend the use of IOM in surgically challenging cases, such as completely ossified or large ventrolateral SM.

Primary Benign Tumors of the Spinal Canal

Benign tumors that grow in the spinal canal are heterogeneous neoplasms with low incidence; from these, meningiomas and nerve sheath tumors (neurofibromas and schwannomas) account for 60%-70% of all primary spinal tumors. Benign spinal canal tumors provoke nonspecific clinical manifestations, mostly related to the affected level of the spinal cord. These tumors present a challenge for the patient and healthcare professionals, for they are often difficult to diagnose and the high frequency of posttreatment complications. In this review, we describe the epidemiology, risk factors, clinical features, diagnosis, histopathology, molecular biology, and treatment of extramedullary benign meningiomas, osteoid osteomas, osteoblastomas, aneurysmal bone cysts, osteochondromas, neurofibromas, giant cell tumors of the bone, eosinophilic granulomas, hemangiomas, lipomas, and schwannomas located in the spine, as well as possible future targets that could lead to an improvement in their management.

Recovery Potential of Spinal Meningioma Patients With Preoperative Loss of Walking Ability Following Surgery - A Retrospective Single-Center Study

Objective

Spinal meningiomas are neurosurgical rarities that manifest with progressive para- or tetraparesis. The effect of timing of surgery on the recovery after the loss of walking ability is poorly known. We studied the effect of timing of surgery on restoring walking ability in surgically-treated spinal meningioma patients.

Methods

Using electronic health records, we retrospectively identified ≥18-year-old patients operated on during 2010-2020. The patients were followed until 30th September 2020, death or emigration.

Results

We identified 108 patients (81% women) with operated spinal meningiomas. The mean age of the patients was 64 years (range 18-94). A gross-total resection was achieved in 101 (94%), and 21 (19%) patients suffered from perioperative complications. Of the 108 patients operated on, 49 (45%) could not walk without assistance prior to surgery. At the time of first postoperative visit (mean 3.1 months, range 1.3-13.1), 14 (58%) out of 24 patients operated on within 29 days and eight (40%) out of 20 patients operated on later than 29 days since the loss of walking ability without assistance, were able to walk without assistance. Also, three out of five paraplegic patients who underwent surgery later than 29 days after they lost the walking ability, were able to at least walk with assistance at first postoperative visit.

Conclusion

Early surgical treatment following the loss of walking ability restores walking ability in a substantial number of patients. However, even late surgery may restore walking ability.

Two out of three of octogenarians benefitted from delayed resection of spinal meningiomas

Background:

Can elderly patients with thoracic meningioma and severe paraparesis benefit from delayed surgery?

Case Description:

Two out of three octogenarians with severe preoperative paraparesis (all wheelchair-bound) were able to walk again following delayed (60–120 days from onset of deficit) surgical resection of thoracic spinal meningiomas.

Conclusion:

Two out of three octogenarians with thoracic meningiomas causing severe paraparesis benefitted from the delayed (i.e. from 60 to 289 days) surgical resection of their tumors.

Spinal Meningiomas: Influence of Cord Compression and Radiological Features on Preoperative Functional Status and Outcome

Simple Summary

Patients affected by spinal meningioma globally exhibit an excellent postoperative functional outcome despite tumor size and severity of spinal cord compression. This work aims to analyze the impact of tumor size and other radiological findings on clinical functional preoperative status and postoperative outcome. In this multicentric retrospective study involving 90 adult patients, we found that spinal cord and tumor occupancy as well as cord compression and tumor volume are correlated with low preoperative functional status. Higher tumor occupancy and tumor-canal volume ratio corresponded to lower postoperative neurological recovery. Cord re-expansion did not show any correlation with postoperative outcome, while preoperative signs of cord myelopathy were predictors of worse postoperative outcome. These findings suggest that these radiological features should be taken into consideration during preoperative counselling.

Abstract

Background: Radiological parameters predicting the postoperative neurological outcome after resection of a spinal meningioma (SM) are poorly studied, with controversial results. Methods: Observational multicenter cohort (2011–2018) of adult patients undergoing surgery for resection of SM. Tumor-canal volume ratio (TCR), the areas related to the cord and tumor occupancy at maximum compression, the presence of dural tail, calcifications, signs of myelopathy, and postoperative cord expansion were compared with the modified McCormick scale (mMCS) preoperative and at follow-up. Results: In the cohort (n = 90 patients), cord and tumor occupancy as well as cord compression and tumor volume showed a correlation with preoperative mMCS (p < 0.05, R −0.23; p < 0.001, R 0.35; p < 0.005, R −0.29; p < 0.001, R 0.42). Cord occupancy had a strong correlation with cord compression (p < 0.001, R 0.72). Tumor occupancy and TCR were correlated with relative outcome at follow-up (p < 0.005 R 0.3; p < 0.005 R 0.29). No correlation was found between cord re-expansion and clinical outcome at follow-up. Finally, a correlation was shown between preoperative signs of cord myelopathy and mMCS (p < 0.05 R 0.21) at follow-up. Conclusions: Larger tumors showed lower preoperative functional status and a worse clinical outcome. Moreover, preoperative T2 cord signal changes are correlated with a poorer outcome.

Clinical characteristics and long-term outcomes for patients who undergo cytoreductive surgery for thoracic meningiomas: a retrospective analysis

OBJECTIVE

Primary spinal meningiomas represent a rare indolent neoplasm usually situated in the intradural-extramedullary compartment. They have a predilection for afflicting the thoracic spine and most frequently present with sensory and/or motor symptoms. Resection is the first-line treatment for symptomatic tumors, whereas other clinical factors will determine the need for adjuvant therapy. In this study, the authors aimed to elucidate clinical presentation, functional outcomes, and long-term outcomes in this population in order to better equip clinicians with the tools to counsel their patients.

METHODS

This is a retrospective analysis of patients treated at the authors' institution between 1998 and 2018. All patients with thoracic meningiomas who underwent resection and completed at least one follow-up appointment were included. Multiple preoperative clinical variables, hospitalization details, and long-term outcomes were collected for the cohort.

RESULTS

Forty-six patients who underwent resection for thoracic meningiomas were included. The average age of the cohort was 59 years, and the median follow-up was 53 months. Persistent sensory and motor symptoms were present in 29 patients (63%). Fifteen lesions were ventrally positioned. There were 43 WHO grade I tumors, 2 WHO grade II tumors, and 1 WHO grade III tumor; the grade III tumor was the only case of recurrence. The median length of hospitalization was 4 days. Seventeen patients (37%) were discharged to rehabilitation facilities. Thirty patients (65.2%) experienced resolution or improvement of symptoms, and there were no deaths within 30 days of surgery. Only 1 patient developed painful kyphosis and was managed medically. Ventral tumor position, new postoperative deficits, and length of stay did not correlate with disposition to a facility. Age, ventral position, blood loss, and increasing WHO grade did not correlate with length of stay.

CONCLUSIONS

Outcomes are overall favorable for patients who undergo resection of thoracic meningiomas. Symptomatic patients often experience improvement, and patients generally do not require significant future operations. Tumors located ventrally, while anatomically challenging, do not necessarily herald a significantly worse prognosis or limit the extent of resection.

Differences and characteristics of symptoms by tumor location, size, and degree of spinal cord compression: a retrospective study on 53 surgically treated, symptomatic spinal meningiomas

OBJECTIVE

The differences in symptoms of spinal meningiomas have rarely been discussed from the perspective of tumor characteristics. The main purpose of this paper was to define the differences, if any, in symptoms in patients with spinal meningiomas with respect to tumor size, location, and degree of spinal cord compression. The authors also sought the threshold of spinal cord compression that causes motor weakness.

METHODS

The authors conducted a retrospective study of 53 cases of spinal meningiomas that were surgically treated from 2013 to 2018. Symptoms related to the tumor were classified as motor weakness, sensory disturbance, pain, and bowel/bladder dysfunction. Based on MR images, tumor location was classified by spinal level and by its attachment to the dura mater. Tumor dimensions were also measured. Occupation ratios of the tumors to the spinal canal and degree of spinal cord flattening were sought from the axial MR images that showed the highest degree of spinal cord compression.

RESULTS

Motor weakness and sensory disturbance were significantly more common in thoracic spine meningiomas than in cervical spine meningiomas (p < 0.001 and p = 0.013, respectively), while pain was more common in meningiomas at the craniovertebral junction (p < 0.001). The attachment, height, width, depth, and volume of the tumor showed no significant difference irrespective of the presence or absence of each symptom. In cases of motor weakness and sensory disturbance, occupation ratios and spinal cord flattening ratios were significantly larger. However, these ratios were significantly smaller in the presence of pain. Multivariate logistic regression analysis revealed that occupation ratio independently contributed to motor weakness (OR 1.14, p = 0.035) and pain (OR 0.925, p = 0.034). Receiver operating characteristic curve analysis suggested that occupation ratio with a value of 63.678% is the threshold for the tumor to cause motor weakness.

CONCLUSIONS

The study showed the difference in clinical presentation of spinal meningiomas by spinal level, occupation ratio, and spinal cord flattening ratio. An occupation ratio of approximately 64% could be utilized as the threshold value of tumor growth to cause motor weakness. Tumor growth in the cervical spine might cause pain symptoms before causing motor weakness. The relationship between the tumor and its symptomatology should be discussed with respect to tumor size relative to the surrounding spinal canal.

Spinal Clear Cell Meningiomas: Clinical Features and Factors Predicting Recurrence

OBJECTIVE

As a World Health Organization grade II tumor of the nervous system, clear cell meningioma (CCM) is an uncommon histologic variant of meningioma. Spinal CCMs are even rarer, with <100 spinal CCMs reported in the English literature. We present this study to characterize clinical manifestations of spinal CCMs and determine the factors predicting recurrence.

METHODS

A literature search was performed for relevant case reports and series in PubMed and Embase until September 1, 2019. These articles were reviewed to identify clinical features, treatment modalities, and prognosis of patients with spinal CCMs.

RESULTS

Eighty-four spinal CCMs were analyzed. Of these patients, 36 (42.9%) were young (age ≤18 years), and the mean age at resection was 24 years. Fifty-three patients (63.1%) were female and 31 (36.9%) were male. Most of the tumors (56/84, 66.7%) were located in the lumbar region. In 31 patients (36.9%) >2 segments in the craniocaudal direction were involved (number of involved segments ≥3 levels). Gross tumor resection was performed in 77 patients (91.7%). Twenty patients (23.8%) showed radiographic evidence of recurrence during follow-up. Recurrence-free survival at 1, 5, and 10 years after resection of spinal CCM was 87%, 71%, and 47%, respectively. Multivariate analysis showed that age ≤18 years (hazard ratio [HR], 3.64; P = 0.024), subtotal resection (HR, 3.43; P = 0.031), and segments involving ≥3 levels (HR, 5.66; P = 0.002) were associated with increased recurrence.

CONCLUSIONS

Spinal CCMs have their own unique clinical features compared with conventional spinal meningiomas and intracranial CCMs. Spinal CCMs have a predilection to affect younger patients, are prone to appear in the lumbar region, and have a high recurrence rate. Age ≤18 years, subtotal resection, and involvement of long segments (≥3 levels) are positive predictors of recurrence.

Spinal meningioma surgery in the elderly: who can benefit from it?

BACKGROUND

With increasing life expectancy and increasing demands on quality of life more spinal meningiomas will limit quality of life in elderly in the coming decades. We investigated whether elderly can improve neurologically and gain self-dependence postoperatively.

METHODS

Medical records of consecutive spinal meningioma patients from 2004-2015 were retrospectively analyzed. Age, gender, preoperative duration and quality of symptoms, pre- and postoperative McCormick score, Karnofsky Performance Status (KPS), American Society of Anesthesiologists Physical Status (ASA), modified Clinical Scoring System (mCSS) and tumor characteristics were included. Elderly were defined by ≥70 years.

RESULTS

One hundred and twenty-nine patients were included, of whom 44 were 70 years or older. Younger patients were significantly better preoperatively in McCormick, KPS, ASA and mCSS within the first postoperative year. Both younger and elderly patients improved significantly postoperatively in McCormick, KPS and mCSS. Surgical complication rate was similar for younger and elderly patients (5.9 vs. 6.8%). Systemic complication rate was higher in elderly (0 vs. 6.8%).

CONCLUSIONS

Surgery for spinal meningioma in elderly (KPS≥40 and ASA≤III) leads to a significant improvement of McCormick, KPS and mCSS postoperatively. This leads to a higher rate of self-dependency and thereby probably to an improvement of quality of life in elderly. However, special attention for systemic complications is necessary.