Unusual clinical presentation of cervical extradural meningioma detected with neuromuscular ultrasound: A case report

Extradural meningiomas are rare in the cervical region. A total of 70-77% of reported cases have occurred in the thoracic region. Tumors that occur in the cervical region may invade the adjacent nerve root and brachial plexus. Typically, diagnoses of extradural meningioma are made after patients present with signs of myelopathy, such as progressive paresis and numbness. In the current study, a 64-year-old male patient presented with neck pain, numbness and mild weakness in the left hand over a 6-month period. The general neurological examination was unremarkable, except for mild grasping weakness on the left side. Needle electromyography revealed complex repetitive discharges in the left 5 and 6th cervical paraspinal muscles. Neuromuscular ultrasound revealed a lesion over the left 7th cervical root, which enabled the early detection of an extradural meningioma before notable focal neurological defects developed. The patient underwent a subtotal tumor excision, followed by radiotherapy for residual tumor. Histopathological examination confirmed atypical meningioma.

Epidemiology and survival of patients with spinal meningiomas: a large retrospective cohort study

INTRODUCTION

Spinal meningiomas (SMs) are relatively rare central nervous system tumors that usually trigger neurological symptoms. The prevalence of SMs is increasing with the aging of the global population. This study aimed to perform a systematic epidemiologic and survival prognostic analysis of SMs to evaluate their public health impact and to develop a novel method to estimate the overall survival at 3-year, 5-year, and 10-year in patients with SMs.

METHODS

Five thousand one hundred fifty eight patients with SMs were recruited from the Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2019. Firstly, descriptive analysis was performed on the epidemiology of SMs. Secondly, these individuals were randomly allocated to the training and validation sets in a ratio of 7:3. Kaplan-Meier method and Cox regression analysis were utilized in the training set to identify independent prognostic factors and to construct a nomogram for survival prognosis. Subsequently, the discriminative power, predictive performance, and clinical utility of the nomogram were evaluated by receiver operating characteristic curve and decision curve analysis. Finally, a mortality risk stratification system and a web-based dynamic nomogram were constructed to quantify the risk of mortality in patients with SMs.

RESULTS

The annual age-adjusted incidence rates of SMs increased steadily since 2004, reaching a rate of 0.40 cases per 100 000 population in 2019, with a female-to-male ratio of ~4:1. The age groups of 50-59, 60-69, and 70-79 years old were the most prevalent ages for SMs, accounting for 19.08, 24.93, and 23.32%, respectively. In addition, seven independent prognostic factors were identified to establish a prognostic nomogram for patients with SMs. The decision curve analysis and receiver operating characteristic curve indicated that the nomogram had high clinical utility and favorable accuracy. Moreover, the mortality risk stratification system effectively divided patients into low-risk, middle-risk, and high-risk subgroups.

CONCLUSIONS

SMs are relatively rare benign spinal tumors prevalent in the white elderly female population. Clinicians could use the nomogram to personalize the prediction of the overall survival probability of patients with SMs, categorize these patients into different mortality risk subgroups, and develop personalized decision-making plans. Moreover, the web-based dynamic nomogram could help to further promote clinical application and assist clinicians in providing personalized counseling, timely monitoring, and clinical assessment for patients.

Analysis of demographics and the impact of adjuvant radiotherapy on a nationwide cohort of patients with high-grade spinal meningiomas

Background

Although typically benign, 5% of spinal meningiomas (SMs) present with higher-grade features (World Health Organization grades 2 and 3). High-grade SMs are poorly studied and the role of adjuvant radiotherapy in their management remains controversial. We hence aimed to study the demographic characteristics of this rare tumor and investigate the outcomes associated with the use of surgery with adjuvant therapy in contrast to surgery alone.

Methods

The National Cancer Database was queried for patients with SMs from 2004 to 2017. Basic statistics were used to identify differences between low- and high-grade tumors in terms of baseline characteristics. Surgery with and without adjuvant radiotherapy were compared after (1:1) propensity-score matching. Kaplan-Meier survival analysis was conducted to study overall survival. All analyses were performed on R.

Results

A total of 13 184 patients diagnosed with SMs were included, of whom only 5% (n = 669) had high-grade SMs. Patients with high-grade SMs presented at a younger median age (57 years [IQR: 44-68] versus 65 years [54-75]; P < .001) and were more commonly males (33% vs 20%; P < .001). After propensity-score matching, survival analysis revealed similar overall survival outcomes in patients with high-grade SM undergoing both surgery and radiotherapy as compared to those only receiving surgery (P = .19).

Conclusions

This study reveals major demographic differences between high- and low-grade SMs. There were no benefits associated with the use of adjuvant radiotherapy. However, due to confounding, overall survival outcomes between patients receiving surgery alone and those receiving surgery with adjuvant radiotherapy are not causally interpretable.

Clinical diagnosis model of spinal meningiomas based on the surveillance, epidemiology, and end results database

Most spinal meningiomas (SM) are benign lesions of the thoracic spine and are usually treated surgically. This study aimed to explore treatment strategies and construct a nomogram for SM. Data on patients with SM from 2000 to 2019 were extracted from the Surveillance, Epidemiology, and End Results database. First, the distributional properties and characteristics of the patients were descriptively evaluated, and the patients were randomly divided into training and testing groups in a 6:4 ratio. Least absolute shrinkage and selection operator (LASSO) regression was used to screen the survival predictors. Kaplan-Meier curves explained survival probability by different variables. The nomogram was constructed based on the results of LASSO regression. The predictive power of the nomogram was identified using the concordance index, time-receiver operating characteristics, decision curve analysis, and calibration curves. We recruited 1,148 patients with SM. LASSO results for the training group showed that sex (coefficient, 0.004), age (coefficient, 0.034), surgery (coefficient, -0.474), tumor size (coefficient, 0.008), and marital status (coefficient, 0.335) were prognostic factors. The nomogram prognostic model showed good diagnostic ability in both the training and testing groups, with a C-index of 0.726, 95% (0.679, 0.773); 0.827, 95% (0.777, 0.877). The calibration and decision curves suggested that the prognostic model had better diagnostic performance and good clinical benefit. In the training and testing groups, the time-receiver operating characteristic curve showed that SM had moderate diagnostic ability at different times, and the survival rate of the high-risk group was significantly lower than that of the low-risk group (training group: p = 0.0071; testing group: p = 0.00013). Our nomogram prognostic model may have a crucial role in predicting the six-month, one-year, and two-year survival outcomes of patients with SM and may be useful for surgical clinicians to formulate treatment plans.

Spinal meningiomas, from biology to management - A literature review

Meningiomas arise from arachnoidal cap cells of the meninges, constituting the most common type of central nervous system tumors, and are considered benign tumors in most cases. Their incidence increases with age, and they mainly affect females, constituting 25-46% of primary spinal tumors. Spinal meningiomas could be detected incidentally or be unraveled by various neurological symptoms (e.g., back pain, sphincter dysfunction, sensorimotor deficits). The gold standard diagnostic modality for spinal meningiomas is Magnetic resonance imaging (MRI) which permits their classification into four categories based on their radiological appearance. According to the World Health Organization (WHO) classification, the majority of spinal meningiomas are grade 1. Nevertheless, they can be of higher grade (grades 2 and 3) with atypical or malignant histology and a more aggressive course. To date, surgery is the best treatment where the big majority of meningiomas can be cured. Advances in surgical techniques (ultrasonic dissection, microsurgery, intraoperative monitoring) increase the complete resection rate. Operated patients have a satisfactory prognosis, even in those with poor preoperative neurological status. Adjuvant therapy has a growing role in treating spinal meningiomas, mainly in the case of subtotal resection and tumor recurrence. The current paper reviews the fundamental epidemiological and clinical aspects of spinal meningiomas, their histological and genetic characteristics, and their management, including the various surgical novelties and techniques.

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.

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 and morbidity after microsurgical resection of spinal meningiomas

OBJECTIVE

The aim of this study was to evaluate functional outcome, surgical morbidity, and factors that affect outcomes of surgically treated patients.

METHODS

The authors retrospectively analyzed patients who underwent microsurgical resection for spinal meningiomas between 2009 and 2020. Patient data and potential variables were collected and evaluated consecutively. Functional outcomes were evaluated using univariate and multivariate analyses.

RESULTS

A total of 119 patients underwent microsurgical resection of spinal meningioma within the study period. After a mean follow-up of 25.4 ± 37.1 months, the rates of overall complication, tumor recurrence, and poor functional outcome were 9.2%, 7.6%, and 5%, respectively. Age, sex, revision surgery, and tumor recurrence were identified as independent predictors of poor functional outcome. Obesity and surgeon's experience had an impact on the complication rate, whereas extent of resection and tumor calcification affected the rate of tumor recurrence.

CONCLUSIONS

Microsurgical resection of spinal meningiomas remains safe. Nevertheless, some aspects, such as obesity and experience of the surgeons that result in a higher complication rate and ultimately affect clinical outcome, should be considered when performing surgery.

Nursing review of spinal meningiomas

Background

Spinal meningiomas are found in patients typically between the ages of 75 and 84: some report the average age to be 50. They occur with an incidence of approximately 1000 patients per year in the US, are mostly single (90%) rather than multiple (10%), and arise from the spinal meninges (arachnoid/dura). Tumors are typically posterior/posterolateral (70%) in location, leaving the remaining 30% in the anterior/anterolateral spinal canal. They produce symptoms and signs of radiculopathy (nerve root) and/or myelopathy (cord compression) depending on their site of origin.

Methods

Meningiomas may be single/sporadic (90%) or multifocal. They may arise primarily/spontaneously, can be radiation-induced, or associated with neurofibromatosis. They are found most frequently in females vs. males in up to a 3.4:1 ratio, occur predominantly in the thoracic spine. They are found in decreasing order in the cervical and lumbar spinal canals. The diagnosis of a meningioma is based on magnetic resonance (MR) studies, where tumors are isointense on T1 weighted MR, and hyperintense onf T2-weighted MR images; they also typically uniformly enhance with Gd-DTPA. On computed tomography (CT) examinations, they are usually characterized as calcified/hyperdense.

Results

The neurological deficits resulting from meningiomas and the rapidity of symptom/sign progression dictate whether they are treated surgically or nonsurgically. Management choices include; stereotactic radiation therapy only, and/or in combination with varied surgical resection techniques.

Conclusions

The majority of benign spinal cord tumors are meningiomas (40%) that are predominantly found in the thoracic spine in middle-aged females. Tumor levels (e.g. in descending order cervical, thoracic, lumbar), and their location (e.g. anterior/anterolateral 30%; dorsal/dorsolateral 70%) best determine whether nonoperative, operative, and/or operative intervention combined with routine vs. stereotactic radiosurgery are warranted.

Totally extradural spinal en plaque meningiomas - Diagnostic dilemmas and treatment strategies

Background:

Meningiomas are the second most common intraspinal tumors, constituting ~25% of all intraspinal tumors; however, in the context of extradural spinal lesions, the diagnosis of meningioma is an uncommon one. Purely extradural spinal meningiomas, especially of the en plaque variety, frequently mimic metastatic disease and may result in inadequate therapy.

Case Description:

We report two cases of totally extradural en-plaque meningiomas of the spine, one each in the cervical and dorsal spine. We present the significant diagnostic dilemmas posed by these cases and discuss the pathogenesis, treatment strategies, and long-term behavior of these uncommon lesions.

Conclusion:

Attention needs to be drawn to this dangerous preoperative and intraoperative misinterpretation. Intraoperative histopathology support for correct identification, gross total resection at surgery, inclusion of a durotomy to rule out intradural extension, and long-term follow-up are cornerstones for successful management of totally extradural en plaque spinal meningiomas.