Spinal meningiomas: surgical management and outcome

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TABLE 6 Functional outcomes after surgery for spinal meningiomas Outcome (%) Ambulatory (%) Im- Dete- Authors & Year proved Stable riorated Preop Postop Levy, et al., 1982 83 17 0 70 76 Solero, et al., 1989 53 37 10 70 92 Roux, et al., 1996 85 13 2 67 94 King, et al., 1998 95 1 4 74 97 Klekamp & Samii, 1999 NA NA NA 74 94 Gezen, et al., 2000 83 14 3 33 75 present study, 2003 92 0 8 68 96 tive bladder dysfunction exhibited normal function after surgery. Some patients suffered transient neurological worsening postoperatively, typically secondary to vasogenic edema or as a result of dissection, but function generally recovered after 6 months. 13,22,25 Surgical Complications Mortality and morbidity rates were low. In published studies, the mortality rate ranged from 0 to 3% (Table 7), and the cause of death was unrelated to the primary disease in all cases reviewed. Causes of death in the reviewed series included pulmonary embolism, aspiration pneumonia, stroke, and myocardial infarction. 12,13,16,25 The incidence of CSF leakage was low (0–4%). Tumor Recurrence Recurrence of spinal meningiomas was rare, and in most series the rate ranged from 1.3 to 6.4% (Table 7). 8,12,16,22,25 Ketter, et al., 11 reported that spinal meningiomas did not have the genetic abnormalities found in recurrent intracranial meningiomas, suggesting that they had a more indolent nature. The slow growth of spinal meningiomas and their presentation in patients at a late age contributed to the low recurrence rates. 12 In the reviewed series, recurrences occurred at 1 to 17 years (Table 7). In our series, one patient (4%) suffered a recurrence 2 years after subtotal resection of a large, infiltrative conus medullaris meningioma. Significantly higher recurrence rates were found in TABLE 7 Surgical morbidity and mortality and the rate/timing of recurrence* O. N. Gottfried, et al. cases involving en plaque or infiltrating meningiomas, tumors with arachnoid scarring, and in partially resected lesions. 13 Klekamp and Samii 13 stated that in patients in whom complete resection, was performed, 29.5% experienced a recurrance within 5 years of surgery, whereas in all patients with partially removed tumors the lesion had recurred by that time. In general, the course of a spinal meningioma appeared to be more benign than its intracranial counterpart. Mirimanoff, et al., 18 reported a recurrence rate of 13% at 10 years, which was far lower than those reported for convexity meningiomas (3 and 25% after 5 and 10 years, respectively) and parasagittal meningiomas (18 and 24% after 5 and 10 years). Unlike intracranial meningiomas, there was no correlation between recurrence and the resection of dural attachment. 8,12,13,25 Comparing radical dural resection and dural coagulation, Solero, et al., 25 reported recurrence rates of 8 and 5.6%, Levy, et al., 16 reported 4 and 0%, and Klekamp and Samii reported 31.3 and 26.1%, respectively. Cohen-Gadol, et al., 3 found that rates of recurrence and reoperation in patients younger than 50 years of age were higher than those in older patients because of a higher frequency of spinal meningiomas with cervical spine locations, extradural tumor extension, and en plaque growth, all of which made total resection more difficult. Deen, et al., 4 also reported a higher rate of recurrence (20%) in patients younger than 21 years of age. Adjunctive Radiotherapy Although the optimal treatment for primary spinal meningioma was total microsurgical resection, some authors advocated adjunctive radiotherapy in cases of recurrent tumors. 8,22 Its role as adjuvant therapy after subtotal resection was controversial because of the tumor’s typically indolent nature. 8,22 It has been indicated that radiotherapy should be considered after subtotal primary excision in cases of recurrent meningiomas, or as an alternative to surgery when the operative risk is too high because of comorbidities or tumor location. 8,18,22 Surgery for recurrent spinal meningiomas was performed before radiotherapy if the tumor was accessible. 8,18,22 Gezen, et al., 8 reported no recurrence in the two patients who underwent radiotherapy for recurrent spinal meningioma. Roux, et al., 22 also performed radiosurgery in two patients with recurrences, and the patients were stable at a follow-up examination Morbidity (%) Recurrence Mortality CSF Wound Mean Authors & Year (%) Leak Infection FU (mos) Incidence Timing (yrs) Levy, et al., 1982 1 3 1 84 3.1 8–16 Solero, et al., 1989 1 1 1 180 6.4 1–17 Roux, et al., 1996 0 0 1 28 3.7 2 King, et al., 1998 1 4 0 132† 1.3 14 Klekamp & Samii, 1999 2 4 1 20 14.7 NA Gezen, et al., 2000 3 3 6 108 5.6 5–8 present study, 2003 0 0 0 23 4.0 2 * FU = follow up. † Value represents the median number of follow-up months. 6 Neurosurg. Focus / Volume 14 / June, 2003
Spinal meningiomas after 5 years. In our series, the one patient in whom recurrence was demonstrated underwent radiotherapy, leading to decreased tumor size and stabilization of neurological function. Overall, one can anticipate that new radiosurgery techniques will be useful in the treatment of recurrent spinal meningiomas. CONCLUSIONS Surgery is the preferred treatment in cases of spinal meningiomas because of its associated excellent functional improvement and low recurrence rates. Radiosurgery should be considered for the exceptional case involving recurrent and symptomatic spinal meningiomas. Acknowledgments The author would like to thank Jenny Ridenour for her excellent technical assistance and Sacha Hwang for editorial assistance. References 1. Albanese V, Platania N: Spinal intradural extramedullary tumors. Personal experience. J Neurosurg Sci 46:18–24, 2002 2. Arslantas A, Artan S, Oner U, et al: Detection of chromosomal imbalances in spinal meningiomas by comparative genomic hybridization. Neurol Med Chir 43:12–19, 2003 3. Cohen-Gadol AA, Zikel OM, Koch CA, et al: Spinal meningiomas in patients younger than 50 years of age: a 21-year experience. J Neurosurg (Spine 3) 98:258–263, 2003 4. Deen HG Jr, Scheithauer BW, Ebersold MJ: Clinical and pathological study of meningiomas of the first two decades of life. J Neurosurg 56:317–322, 1982 5. Freidberg SR: Removal of an ossified ventral thoracic meningioma. Case report. J Neurosurg 37:728–730, 1972 6. Friedman WA, Chadwick GM, Verhoeven FJ, et al: Monitoring somatosensory evoked potentials during surgery for middle cerebral artery aneurysms. Neurosurgery 29:83–88, 1991 7. Friedman WA, Kaplan BL, Day AL, et al: Evoked potential monitoring during aneurysm operation: observations after fifty cases. Neurosurgery 20:678–687, 1987 8. Gezen F, Kahraman S, Canakci Z, et al: Review of 36 cases of spinal cord meningioma. Spine 25:727–731, 2000 9. Helseth A, Mork SJ: Primary intraspinal neoplasms in Norway, 1955 to 1986. A population-based survey of 467 patients. J Neurosurg 71:842–845, 1989 10. Jones SJ, Harrison R, Koh KF, et al: Motor evoked potential monitoring during spinal surgery: responses of distal limb muscles to transcranial cortical stimulation with pulse trains. Electroencephalogr Clin Neurophysiol 100:375–383, 1996 11. Ketter R, Henn W, Niedermayer I, et al: Predictive value of progression-associated chromosomal aberrations for the prognosis of meningiomas: a retrospective study of 198 cases. J Neurosurg 95:601–607, 2001 12. King AT, Sharr MM, Gullan RW, et al: Spinal meningiomas: a 20-year review Br J Neurosurg 12:521–526, 1998 13. Klekamp J, Samii M: Surgical results for spinal meningiomas. Surg Neurol 52:552–562, 1999 14. Kothbauer K, Deletis V, Epstein FJ: Intraoperative spinal cord monitoring for intramedullary surgery: an essential adjunct. Neurosurg. Focus / Volume 14 / June, 2003 Pediatr Neurosurg 26:247–254, 1997 15. Lesser RP, Raudzens P, Luders H, et al: Postoperative neurological deficits may occur despite unchanged intraoperative somatosensory evoked potentials. Ann Neurol 19:22–25, 1986 16. Levy WJ Jr, Bay J, Dohn D: Spinal cord meningioma. J Neurosurg 57:804–812, 1982 17. Mimatsu K, Kawakami N, Kato F, et al: Intraoperative ultrasonography of extramedullary spinal tumours. Neuroradiology 34:440–443, 1992 18. Mirimanoff RO, Dosoretz DE, Linggood RM, et al: Meningioma: analysis of recurrence and progression following neurosurgical resection. J Neurosurg 62:18–24, 1985 19. Mizoi K, Yoshimoto T: Permissible temporary occlusion time in aneurysm surgery as evaluated by evoked potential monitoring. Neurosurgery 33:434–440, 1993 20. Parisi JE, Mena H: Nonglial tumors, in Nelson JS, Parisi JE, Schochet SS Jr (eds): Principles and Practice of Neuropathology. St Louis: Mosby, 1993, pp 203–266 21. Pechstein U, Cedzich C, Nadstawek J, et al: Transcranial highfrequency repetitive electrical stimulation for recording myogenic motor evoked potentials with the patient under general anesthesia. Neurosurgery 39:335–344, 1996 22. Roux FX, Nataf F, Pinaudeau M, et al: Intraspinal meningiomas: review of 54 cases with discussion of poor prognosis factors and modern therapeutic management. Surg Neurol 46: 458–464, 1996 23. Saito T, Arizono T, Maeda T, et al: A novel technique for surgical resection of spinal meningioma. Spine 26:1805–1808, 2001 24. Schramm J, Koht A, Schmidt G, et al: Surgical and electrophysiological observations during clipping of 134 aneurysms with evoked potential monitoring. Neurosurgery 26:61–70, 1990 25. Solero CL, Fornari M, Giombini S, et al: Spinal meningiomas: review of 174 operated cases. Neurosurgery 25:153–160, 1989 26. Steinbok P, Cochrane DD, Poskitt K: Intramedullary spinal cord tumors in children. Neurosurg Clin N Am 3:931–945, 1992 27. Taniguchi M, Cedzich C, Schramm J: Modification of cortical stimulation for motor evoked potentials under general anesthesia: technical description. Neurosurgery 32:219–226, 1993 28. Wagner W, Peghini-Halbig L, Maurer JC, et al: Intraoperative SEP monitoring in neurosurgery around the brain stem and cervical spinal cord: differential recording of subcortical components. J Neurosurg 81:213–220, 1994 29. Whittle IR, Johnston IH, Besser M: Recording of spinal somatosensory evoked potentials for intraoperative spinal cord monitoring. J Neurosurg 64:601–612, 1986 30. Zhou HH, Mehta M, Leis AA: Spinal cord motoneuron excitability during isoflurane and nitrous oxide anesthesia. Anesthesiology 86:302–307, 1997 31. Zornow MH, Grafe MR, Tybor C, et al: Preservation of evoked potential in a case of anterior spinal artery syndrome. Electroencephalogr Clin Neurophysiol 77:137–139, 1990 Manuscript received April 16, 2003. Accepted in final form May 8, 2003. Address reprint requests to: Meic H. Schmidt, M.D., Department of Neurosurgery, University of Utah Medical Center, 30 North 1900 East, Suite 3B409, Salt Lake City, Utah 84132. email: Meic.Schmidt@hsc.utah.edu. 7
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