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Operative strategies in ventrally and ventrolaterally located spinal meningiomas and review of the literature

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Authors and Affiliations

  1. Department of Neurosurgery, University Hospital Essen, Essen, Germany

    Neriman Özkan, Philipp Dammann, Bixia Chen, Tobias Schoemberg, I. Erol Sandalcioglu & Ulrich Sure

  2. Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany

    Marc Schlamann

Authors
  1. Neriman Özkan
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  2. Philipp Dammann
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  3. Bixia Chen
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  4. Tobias Schoemberg
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  5. Marc Schlamann
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  6. I. Erol Sandalcioglu
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  7. Ulrich Sure
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Correspondence to Neriman Özkan.

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Comments

Hischam Bassiouni, Kaiserslautern, Germany

In this retrospective analysis, Dr Özkan and co-authors present their surgical strategy and clinical results in 55 patients treated microsurgically for a ventral/ventrolateral spinal meningioma over a 20-year period. The majority of tumors were located in the thoracic spine. Total resection, defined as Simpson grade II removal, was achieved in 96 % of the patients, although gross calcification prevented complete tumor resection in two cases. After a mean follow-up period of 33 months (range, 1–240 months), one tumor recurrence was displayed on MR imaging. Improvement of preexisting neurological deficits was observed in 84 % of the patients, and a permanent deterioration was observed in 9 % of the cases. No neurological improvement occurred in 7 % of the patients. Importantly, most patients unable to walk preoperatively regained this important function after surgery.

I share the authors’ experience that microsurgical resection of spinal meningioma is a very rewarding treatment in the majority of patients. Dramatic improvement of function particularly gait disturbance/re-ability to walk can be achieved even in long-standing cases. Also, bipolar coagulation of the dural tumor matrix, i.e., Simpson grade II resection, usually suffices to prevent tumor recurrence on long-term follow-up. In my experience, the dural attachment in the majority of tumors is lateralized to one side even in apparently ventrally located meningiomas. Therefore, complete resection is usually well feasible via a hemilaminectomy thus rendering laminectomy/laminoplasty unnecessary in most cases. This paper provides valuable data to the reader on functional results after state of the art microsurgical resection of spinal meningioma.

Alessandro Ducati, Torino, Italy

The Authors present their experience with the removal of ventrally and lateroventrally located spinal meningiomas: the series is consistent (55 patients out of 164 spinal meningiomas observed), even though it covers a long time span (20 years). The conclusion is that almost all the cases observed may be possibly removed via a posterior approach, in all its variants: laminectomy, hemilaminectomy with/without facetectomy, laminoplasty. Actually, surgery in one calcified meningioma is reported as particularly traumatic, and the patient worsened postoperatively. In the literature, very seldom has been reported an approach that is different from a posterior one, in thoracic meningiomas. Jenny et al. (1) reports on a case of transthoracic transvertebral approach to remove a calcified meningioma. Other reports of the literature (2) of anterior approaches for ventrally located lesions refer to schwannomas or neuoenteric cysts: in general, an anterior approach is suggested in cases with remarkable calcifications or, at the opposite, with bulky cystic components, and in general for recurrent tumors with significant arachnoidal scarring. The limit of this approach is the difficulty of closing the dura; however, since in the last years, we have learned how to treat this problem, particularly in anterior skull base surgery; I think that nowadays in very selected cases an anterior approach could be taken into consideration. Purely ventral meningiomas that are completely calcific should be evaluated in this possibility, balancing pros and cons. I think that even in these cases, a posterolateral with costotraversectomy approach could give sufficient space for a safe removal of the lesion; further possibilities are added by the use of surgical endoscope that can greatly help the exploration and the removal of tumors from the anterior spinal space, with a posterolateral approach.

The surgical strategy suggested and applied by the authors has been to expose the dura sufficiently to control both inferior and superior poles of the meningioma, to cut one or two dentate ligaments in order to allow a rotation without traction of the cord, and in selected cases, to associate a selective section of some dorsal roots as well (only at thoracic level). The cord was then gently rotated with traction stitches to allow a clear vision of the bulk of the tumor. Decompression, detachment, and coagulation of the dura to obtain a Simpson II removal have been carried out. Two cases operated with this technique, and without apparent intraoperative problems, deteriorated after surgery: there are no data concerning intraoperative monitoring in these patients, but it is possible that the rotation of the cord had been excessive for them, even though it has been similar to that well tolerated in different patients. This is the specific contribution of intraoperative monitoring for surgery that is to taylorize the surgical maneuvers. In other cases of postoperative deterioration, an extradural haematoma has been found: haemostasis is critical and not always easy to achieve in the extradural space. Some surgeons leave big fragments of gelfoam or of surgicel, but these may swell with blood and compress the cord after closure, particularly if a laminoplasty has been carried out. Therefore, before closure the surgical field must be perfectly clean, even in the presence of an increased vein pressure, that the anaesthesiologist may simulate with the Valsalva maneuver.

What is typical of this series, and in agreement with my personal observation, is that the diagnosis is rather late for this kind of lesions: 10 months in mean the length of preoperative symptoms (but up to 3 years) and almost one third of patients not able to walk, before surgery. It is really surprising how seldom the diagnosis is well timed, possibly because the symptoms are difficult to express in the beginning (sensory disturbance, not specific), and also because a thorough physical examination is seldom carried out both by family doctors and by neurologists referred to. The early diagnosis is particularly important because there is a direct relation between the pre- and postoperative clinical status, in this as in all other reports.

References

1. Jenny B, Rilliet B., May D., Pizzolato GP (2002) Transthoracic, transvertebral approach for resection of anteriorly located calcified meningioma. Case report. Neurochirurgie 48: 49–52

2. Dickman CA, Apfelbaum RI (1998) Thoracoscopic microsurgical excision of a thoracic schwannoma. Case report. J.Neurosurg. 88: 898–902

Uwe Spetzger, Karlsruhe, Germany

The paper details the surgical strategies in a total of 55 patients with ventrally and ventrolaterally located spinal meningiomas and evaluated the postoperative outcome retrospectively. Ventrally and ventrolaterally located meningiomas are less common compared to dorsally located ones, but these types of meningiomas are more challenging to remove. However, this retrospective study demonstrates that ventrally and ventrolaterally located meningiomas can be treated via posterior approaches with an appropriate long-term neurological outcome. A permanent postoperative neurological deterioration was seen in five patients (9.1 %). However, the neurological outcome was improved or equal in 90.9 % in the long-term follow-up.

A ventrolateral location of the meningioma was found in most of the patients (78.2 %) mainly treated by a laminectomy (76.4 %). Individually tailored different dorsal approaches to the spinal column were detailed, but a laminectomy was the usual approach for the microsurgical resection. Hemilaminectomies were done only in four cases (7.3 %), and laminoplasties were used in nine more recent cases (16.4 %) usually in the cervical spine. The high rate of laminectomies is explained by the location of the meningiomas, mainly in the thoracic spine. A laminectomy seemed useful especially if the dural attachment of the meningioma was unable to define exactly in the preoperative imaging and allows a slight rotation the spinal cord if necessary.

Remarkable is the relatively high rate of rhizotomies; this was performed in 18 patients (32.7 %), however, without any documented or mentioned complication related to this procedure. In total, seven patients (12.7 %) presented with calcified meningiomas. Calcification of the tumor was found as a risk factor for a higher surgical morbidity. All meningiomas were classified as grade I according to WHO classification. However, the figures were not high enough to evaluate the different histological subclasses and their influence to the surgical morbidity. Generally, this paper is relevant and helps us in our daily neurosurgical routine treating those types of meningiomas.

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Özkan, N., Dammann, P., Chen, B. et al. Operative strategies in ventrally and ventrolaterally located spinal meningiomas and review of the literature. Neurosurg Rev 36, 611–619 (2013). https://doi.org/10.1007/s10143-013-0462-1

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