Spinal meningiomas are the most common spinal tumors encountered in adults, and account for 6.5% of all craniospinal tumors. The treatment for these lesions is primarily surgical, but emerging modalities may include chemotherapy and radiosurgery. In this article, the current management of spinal meningiomas and the body of literature surrounding conventional treatment is reviewed and discussed.
Key points
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Spinal meningiomas are benign tumors that account for approximately 1.2% to 12.7% of all meningiomas and 25% of all spinal cord tumors.
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The treatment is surgical, with the primary goal to achieve complete tumor removal while minimizing neurologic dysfunction.
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Radiotherapy can be considered for recurrent for challenging surgical cases and for patients with higher-grade histopathology (World Health Organization grade II or III), but it remains an adjuvant therapy for spinal cord meningiomas.
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Emerging molecular and genetic targets may represent adjuvant treatment options for both surgical and nonsurgical treatment.
Video content accompanies this article at http://www.neurosurgery.theclinics.com
Introduction
Spinal meningiomas are the most common spinal tumors in adult patients, and they are typically managed with surgery to achieve a gross total resection when possible while minimizing neurologic dysfunction. The first case of successful surgical resection of a spinal meningioma was performed by Victor Horsley more than a century ago. Advances in surgical techniques and adjuvant treatment modalities have further improved the opportunities to achieve a cure.
Epidemiology
Intradural spinal tumors have an incidence of 64 per 100,000 person-years and account for 3% of primary central nervous system (CNS) tumors. Spinal meningiomas are intradural, extramedullary lesions ( Fig. 1 ) that arise from meningothelial arachnoid gap cells within the spinal dura mater. Spinal intradural-extramedullary tumors account for two-thirds of all intraspinal neoplasms, and spinal meningiomas are the second most common intradural spine tumor after neuromas. As the most common spinal tumor in adults, they account for up to 45% of intradural spinal tumors but only 6.5% of overall craniospinal tumors in adults. Intracranial meningiomas are much more prevalent than spinal meningiomas, which account for only 1.2% to 12.7% of all meningiomas and 25% of all spinal tumors.
The peak age of occurrence for spinal meningiomas is 40 to 70 years. Spinal meningiomas most commonly affect middle-aged women, with a greater disparity of women to men than is seen with intracranial meningiomas. In one series, the female:male ratio was as high as 4:1. This preponderance in women is thought to arise from tissue response to sex hormones and subsequent growth. Although the effect of sex hormones on meningiomas is suspected, several other receptor types may play a role in pathogenesis, including the following:
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Steroid receptors
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Peptidergic receptors
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Growth factor receptors
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Aminergic receptors
Most spinal meningiomas are histologically benign or World Health Organization (WHO) grade I; however, a small percentage are atypical (WHO grade II) or anaplastic (WHO grade III). The histologic subtypes are similar to those seen in cranial meningiomas, including the following:
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Meningothelial (WHO grade I)
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Metaplastic (WHO grade I)
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Psammomatous (WHO grade I)
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Transitional (mixed) (WHO grade I)
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Atypical (WHO grade II)
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Clear cell (WHO grade II)
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Anaplastic (WHO grade III).
The psammomatous (WHO grade I), meningothelial (WHO grade I), and transitional (WHO grade I) subtypes are the most common histologic subtypes seen in spinal meningiomas. Overall, spinal meningiomas show a lower recurrence rate than intracranial meningiomas. This is most likely a reflection of their less aggressive histopathology. When comparing the outcomes of surgical resection among the subtypes, patients with psammomatous pathology have been shown to have worse neurologic outcomes. Malignant transformation of spinal meningiomas, although rare, occurs in approximately 3% of cases.
Spinal meningiomas may present with or lead to acute or chronic spinal cord compression, neurologic dysfunction, and progressive myelopathy, depending on location. Because spinal meningiomas grow slowly, neurologic deficits are the result of significant spinal cord compression. Patients most commonly present with the following:
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Pain
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Sensory loss
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Weakness
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Sphincter disturbances
Although serious neurologic deficits may be a result of these tumors, surgical treatment is often curative, with few complications and rapid functional recovery. Advances in radiological and surgical technique (eg, MRI, neuromonitoring, intraoperative ultrasonography, microsurgery, and ultrasonic surgical aspirator) have resulted in earlier diagnosis and the ability to achieve gross total resection.
Patients with spinal meningioma can be assessed and graded on neurologic dysfunction using the McCormick scale ( Table 1 ).
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