Intradural Calcified Thoracic Meningioma
This 78-year-old woman presents with progressive gait difficulty over the past 8 years. She went from independent ambulation to requiring the use of a walker, and now has difficulty even with standing. Extensive workup eventually found an intradural lesion and she was referred for neurosurgical evaluation.
She is awake, alert, and oriented. Cranial nerves 2-12 are intact. Motor exam is 5/5 in the upper extremities. In her lower extremities, her hip flexors are 2/5, knee extensors 3/5, dorsiflexion and plantar flexion are each 3/5. She has increased reflexes and diminished proprioception in her lower extremities. She is unable to stand upright.
Figure 1: T2 sagittal image MRI shows a large intradural extramedullary mass causing severe compression of the upper thoracic spinal cord. The mass extends from the mid body of T1 through the upper portion of T3.
Intradural extramedullary calcified thoracic tumor, likely meningioma
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T1, T2, T3 laminectomy, T2 bipedicular decompression, resection of calcified intradural extramedullary tumor with microscopic dissection, placement of dural patch, T1-3 instrumented fusion.
Figure 8: Post-operative sagittal T2-weighted MRI demonstrates gross total resection.
At 5 months follow-up, the patient has had dramatic improvement of her ambulation. She still has some proprioception difficulties, but this is continually and progressively improving.
The authors present a case of a 78-year-old woman with significant thoracic myelopathy from spinal cord compression resulting from an intradural extramedullary spinal cord tumor, with imaging characteristics consistent with a meningioma.
The surgical goal in treatment of spinal meningiomas is the complete surgical removal while avoiding any permanent neurological sequelae. Paramount to the surgical management of these lesions is adequate exposure of the tumor. The demonstrated lesion has its cephalic end at the cervicothoracic junction and is very calcified, with significant mass effect on the spinal cord. Its diameter is essentially that of the spinal canal.
A generous laminectomy of T1, T2, and T3 with partial to complete removal of the T2 pedicles is necessary for several to:
• Maximize tumor exposure for optimal working channels in order to remove the lesion with the least amount of spinal cord manipulation; and
• Allow for an easier dural closure (most likely with a dural patch graft).
With the noted degree of calcification in this particular lesion, a marked level of adherence and interdigitation to the lateral or ventrolateral dura is to be expected. The dural attachment most likely will need to be resected with the tumor, hence the consideration of a patch graft, as well as possible insertion of an external lumbar spinal drain to aid dural patch incorporation and to prevent CSF fistula formation in the immediate post-operative period.
After ridged fixation in a head-holder device, intra-operative neurophysiologic monitoring with SSEP/MEP information, as well as standard microsurgical techniques would be useful, as this case will include microsurgical dissection of the tumor from the lateral surface of the upper thoracic spinal cord. Furthermore, given the location of the lesion, and the need for extensive bony removal, adjunctive instrumentation is a must in order to maintain alignment and prevent late-stage delayed instability.
With appropriate operative planning and meticulous intra-operative surgical techniques, complete removal of these lesions can be accomplished with minimal permanent morbidity to the patient.1
1. Sandalcioglu IE, Hunold A, Müller O, Bassiouni H, Stolke D, Asgari S. Spinal meningiomas: critical review of 131 surgically treated patients. Eur Spine J. 2008;17(8):1035-1041.
We would like to thank Dr. Frempong-Boadu for his thoughtful Discussion. We agree that appropriate surgical planning and meticulous surgical technique will lead to the best possible outcomes for patients with calcified thoracic meningiomas. We also add that calcified spinal meningiomas have a much higher morbidity rate upon resection, and a greater degree of canal stenosis appears to lead to poorer outcomes.1
1. Zhu Q, Qian M, Xiao J, Wu Z, Wang Y, Zhang J. Myelopathy due to calcified meningiomas of the thoracic spine: minimum 3-year follow-up after surgical treatment. J Neurosurg Spine. 2013;18(5):436-42.