The surgical challenge of ossified ventrolateral spinal meningiomas: tricks and pearls for managing large ossified meningiomas of the thoracic spine

Transdural location as a predictor of recurrence in spinal cord meningiomas

Spinal cord meningiomas are typically benign, rare tumors that pose clinical challenges owing to their location and potential for spinal cord compression. This study aimed to assess the radiological features of spinal cord meningiomas and the key factors associated with their recurrence. We conducted a retrospective, single-institution study on 67 patients with pathologically confirmed spinal cord meningiomas who were surgically treated between January 2016 and December 2023. Radiological features, such as tumor size, en plaque growth, tumor signal intensity, and anatomical location, were assessed using preoperative magnetic resonance imaging. Clinical outcomes were evaluated using univariate and multivariate logistic regression analyses to identify risk factors for recurrence. Of the 67 patients, six (9.0 %) experienced a recurrence during a mean follow-up of 31.8 months. Results of univariate analysis suggested that a younger age, high World Health Organization grade, en plaque growth, and transdural location were significantly associated with tumor recurrence (p < 0.05). Multivariate analysis confirmed that a younger age (p = 0.027) and transdural growth (p = 0.006) were significant independent predictors of recurrence. Our study identified younger age and transdural tumor location as significant risk factors for spinal cord meningioma recurrence. A total resection is the primary surgical goal; however, tumors with complex anatomical presentations, especially those exhibiting transdural growth, pose significant challenges. The findings highlight the importance of developing tailored surgical approaches and intensifying postoperative surveillance in high-risk patients to reduce the recurrence likelihood.

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.

Rare dorsal ossified meningioma in an elderly female: a case report and comprehensive review of literature

Meningiomas, typically benign neoplasms originating in the central nervous system, display a predilection for female patients. Although they predominantly manifest within the cranial vault, ~25% of primary spinal neoplasms are attributed to these tumors. The occurrence of ossification in spinal meningiomas is an uncommon phenomenon, with scant documentation in medical literature. In this report, we detail the clinical journey of an octogenarian female patient afflicted with an ossified spinal meningioma, which was associated with left lower extremity weakness and reduced sensation. Diagnostic imaging, specifically magnetic resonance imaging, identified a mass exerting pressure on the spinal cord, necessitating its surgical removal. Subsequent histopathological examinations corroborated the initial diagnosis. Postoperative magnetic resonance imaging scans confirmed the absence of residual tumor tissue and ruled out recurrence. A comprehensive review of existing literature yielded 47 analogous cases, with a majority involving elderly female patients and the thoracic region of the spine being the most common site. The standard therapeutic approach is surgical intervention, which is often complicated by the tumor's tenacious adherence to surrounding structures and the potential for ensuing operative complications. This case highlights the exceptional nature of ossified spinal meningiomas and emphasizes the critical need for meticulous surgical management.

Spinal Meningiomas: A Comprehensive Review and Update on Advancements in Molecular Characterization, Diagnostics, Surgical Approach and Technology, and Alternative Therapies

Spinal meningiomas are the most common intradural, extramedullary tumor in adults, yet the least common entity when accounting for all meningiomas spanning the neuraxis. While traditionally considered a benign recapitulation of their intracranial counterpart, a paucity of knowledge exists regarding the differences between meningiomas arising from these two anatomic compartments in terms of histopathologic subtypes, molecular tumor biology, surgical principles, long-term functional outcomes, and recurrence rates. To date, advancements at the bench have largely been made for intracranial meningiomas, including the discovery of novel gene targets, DNA methylation profiles, integrated diagnoses, and alternative systemic therapies, with few exceptions reserved for spinal pathology. Likewise, evolving clinical research offers significant updates to our understanding of guiding surgical principles, intraoperative technology, and perioperative patient management for intracranial meningiomas. Nonetheless, spinal meningiomas are predominantly relegated to studies considering non-specific intradural extramedullary spinal tumors of all histopathologic types. The aim of this review is to comprehensively report updates in both basic science and clinical research regarding intraspinal meningiomas and to provide illustrative case examples thereof, thereby lending a better understanding of this heterogenous class of central nervous system tumors.

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.

Removal of Spinal Calcified Meningiomas With Piezosurgery: Technical Note on a New Application of a Known Device

BACKGROUND AND IMPORTANCE

Ossified spinal meningiomas are a rare form of spinal tumor. The removal in narrow surgical space is challenging because of their hard consistency and strong adhesion to the neural tissue. These meningiomas are often located in the upper thoracic spine, and sometimes, even the identification of the correct intraoperative level is difficult.

CLINICAL PRESENTATION

We describe the clinical findings, surgical strategies, and histological findings of a patient with a thoracic ossified meningioma.

DISCUSSION

We discuss the technical points, safety, and efficacy of the piezosurgery device in reducing the calcified mass.

CONCLUSION

The device has the potential to reduce the operating time and enhance surgical safety when removing ossified meningiomas.

Multiple ossified intracranial and spinal meningiomas: a rare case report and literature review

Ossified intracranial meningiomas (OIM) and ossified spinal meningiomas (OSM) are rare neoplasms of mesenchymal origin that predominantly manifest in the spinal cord and infrequently in the cranial region, accounting for ~0. 7-5.5% of all meningiomas. It is extremely rare to have multiple intracranial and spinal lesions accompanied by ossification. Herein, we report this rare case for the first time. A 34-year-old woman presented with paresthesia and limb weakness in the right lower limb and gradually worsened. Approximately half a year later, she could only walk with crutches. Magnetic resonance imaging of the brain and spinal cord showed multiple meningiomas, and histopathological examination confirmed multiple OIM and OSM (WHO grade 1). Multiple OIM and OSM are extremely rare with diverse imaging features, and it is easily confused with other tumors. Histopathological examination is the final diagnostic method.

An unusual presentation of ossified spinal meningioma: case report and literature review

Background

Spinal meningioma is a common intraspinal tumor, which mainly occurs in the thoracic spine. Ossified meningioma (OSM) is an extremely rare histological variant. Our article reports a rare patient with dorsal complete OSM and reviews this subject.

Case presentation

A 68-year-old woman presented with a one-year history of progressive weakness in both lower limbs with gait disturbance. Physical examination revealed hypoesthesia with a sensory level below T10. Babinski and pathological signs on both sides were weakly positive. Magnetic resonance imaging (MRI) showed a mass at the T10 to T11 level causing severe compression of the spinal cord. Computed tomography (CT) showed complete ossification of the mass. 18F-Fluoro-deoxy-glucose positron emission tomography CT (18F-FDG PET/CT) scan combined with MRI revealed that the mass was an intradural extramedullary high-density ossified nodule. The patient underwent a gross total resection of the mass and pathologic examination indicated that the mass was a meningioma with diffused psammomatous bodies.

Conclusion

We identified a rare case of dorsal complete OSM occurring in a 68-year-old woman. After complete surgical resection, although there were complications such as cerebral fluid leakage and fever, the patient finally recovered with a satisfactory result.

Postoperative neurological complications in intradural extramedullary tumors: A 10-year experience of a single center

BACKGROUND

Intradural extramedullary spinal cord tumors (IDEMs) cause neurological symptoms due to compression of the spinal cord and caudal nerves. The purpose of this study was to investigate the incidence of postoperative neurological complications after surgical resection of IDEM and to identify factors associated with such postoperative neurological complications.

METHODS

We retrospectively analyzed 85 patients who underwent tumor resection for IDEM between 2010 and 2020. We investigated the postoperative worsening of neurological disorders. The patients were divided into two groups: those with and without postoperative neurological complications. Patient demographic characteristics, tumor level, histological type, and surgery-related factors were also compared.

RESULTS

The mean age at the time of surgery was 57.4 years, and histological analysis revealed 45 cases of schwannoma, 34 cases of meningioma, three cases of myxopapillary ependymoma, one case of ependymoma, one case of hemangioblastoma and one case of lipoma. There were five cases (5.8%) of postoperative neurological complications, and four patients improved within 6 months after surgery, and one patient had residual worsening. There were no statistically significant differences in age, sex, tumor location, preoperative modified McCormick Scale grade, histology, tumor occupancy, or whether fixation was performed in the presence or absence of postoperative neurological complications. All four cases of meningioma with postoperative neurological complications had preoperative neuropathy and meningiomas were located in the anterior or lateral thoracic spine.

CONCLUSIONS

Neurological complications after surgical resection for IDEM occurred in 5.8% of patients. Meningiomas with postoperative neurological complications located anteriorly or laterally in the thoracic spine.

Calcified spinal meningiomas: a systematic review of clinical characteristics, treatment strategies, and outcomes

BACKGROUND

Calcified meningiomas involving the spine are rare but can pose significant surgical challenges. We systematically reviewed the literature on calcified spinal meningiomas.

METHODS

PubMed, EMBASE, Web-of-Science, and Scopus databases were searched to include studies reporting clinical data of patients with calcified spinal meningioma. Included articles were analyzed for symptoms, imaging, spine level of the tumor, tumor location relative to the spinal cord, calcification status, treatment regimen, recurrence, progression-free survival, and outcomes.

RESULTS

A total of 35 articles encompassing 94 patients were included. Most patients were female (90.4%), presenting with lower extremity weakness (44%) and/or lower extremity paresthesia (38.1%). Most calcified spinal meningiomas occurred in the thoracic spine (82%) and on the dorsal (33.3%) or ventral (27.2%) side relative to the spinal cord. Most tumors were intradural (87.2%). Histologically, most calcified spinal meningiomas were WHO grade I (97.4%) and psammomatous (50.7%). Most tumors demonstrated macroscopic calcification (48.9%). Most patients underwent gross total resection (91.5%) through a posterior approach (100%). Two patients (2.1%) received adjunctive radiotherapy. The most common treatment related complication was CSF leakage. Post-operatively, most patients demonstrated symptomatic improvement (75.5%) and 2 (2.1%) had local tumor recurrence.

CONCLUSIONS

Calcified spinal meningiomas are uncommon but benign entities. These neoplasms tend to adhere to surrounding tissues and nerves and, thus, can be surgically challenging to remove. In most patients, safe gross total resection remains the standard of care, but accurate surgical planning is necessary to reduce the risks of postoperative complications.

Multiple ossified spinal meningiomas in the thoracic spine: A case report and literature review

Background

Ossified spinal meningioma (OSM) is a rare form of a spinal tumor. The surgical strategies and pathologic findings related to OSM have been investigated in recent years. However, multiple OSMs are rarely reported. Here, we intend to present a rare case of multiple OSMs and review the relevant published literature.

Case Presentation

A 76-year-old woman experienced a progressive sensorimotor disturbance in her bilateral lower limbs for the past 2 years. She complained of inability to walk, urinary incontinence, and chronic constipation when referred to our hospital. A neurological examination revealed a diminished sensation below the bilateral T7, and her neurological status was Nurick Grade 6. Magnetic resonance imaging (MRI) revealed multiple intradural-extramedullary neoplasms at the T7-T11 level. Computed tomography (CT) scans showed five high-density masses of varying sizes in the spinal canal at the T7-T12 level. The patient underwent tumor resection through T7-T11 laminectomy. A histopathological examination revealed multiple OSMs.

Conclusion

We reported a rare case of multiple OSMs in an elderly patient. After one-stage complete resection, the patient recovered with satisfactory curative effect. Although elderly patients will face various postoperative complications due to their poor physical condition, we still recommend one-stage complete resection of multiple OSMs to reduce recurrence.

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.