What is the appropriate evaluation and management for a middle‑aged woman with a spinal meningioma presenting with slowly progressive back pain, sensory changes, and motor weakness?

Spinal Meningioma: Evaluation and Management

Initial Diagnostic Evaluation

MRI of the entire spine with and without IV contrast is the definitive imaging study for evaluating suspected spinal meningioma, demonstrating typical features including homogeneous dural-based enhancement, dural tail sign, and CSF cleft between tumor and spinal cord. 1

Key Imaging Characteristics

• Spinal meningiomas appear as well-circumscribed, intradural extramedullary masses with homogeneous contrast enhancement 1, 2
• The thoracic spine is the most common location (71.1% of cases), followed by cervical and lumbar regions 3
• MRI sensitivity ranges from 44-93% with specificity of 90-98% for diagnosing spinal cord compression 4
• Atypical presentations can mimic intramedullary tumors, particularly when the mass appears eccentric with ill-defined borders 5

Clinical Presentation to Assess

• Back pain (present in 57% of patients) is the most common presenting symptom 6
• Motor deficits occur in 47.5% of patients at presentation 6
• Sensory changes are present in 18% of cases 6
• Sphincter dysfunction occurs in 11.5% of patients 6
• Symptoms typically precede diagnosis by months to years, especially in elderly patients where age-related conditions can mask the tumor 2

Surgical Management

Complete surgical resection via microsurgical technique is the primary treatment of choice for spinal meningiomas, with preservation of neurological function taking priority over achieving Simpson grade I resection. 7, 3

Surgical Approach Selection

• Hemilaminectomy with preservation of the outer dural layer is preferred over traditional laminectomy, providing equivalent tumor removal rates while preserving spinal stability and improving postoperative recovery 2
• Image-guided neuronavigation should be utilized for surgical planning, particularly for tumors in unusual locations 1
• Complete resection (Simpson I-III) is achieved in 88.7% of cases 3
• Resection of the dural attachment is recommended to reduce recurrence risk 1

Preoperative Considerations

• For extremely large hemispheric tumors, preoperative angiography with possible embolization should be considered to minimize intraoperative blood loss 1
• Patients with pre-existing motor deficits have 5-fold increased odds of improved functional outcomes (OR=5; P=0.005) 6
• Pre-surgical myelopathy increases odds of favorable outcome by 3.5-fold (OR=3.5; P=0.026) 6

Postoperative Surveillance

MRI without and with IV contrast should be performed for postoperative surveillance, with imaging intervals determined by WHO grade: every 6-12 months for WHO grade I tumors and more frequently for WHO grade II/III tumors. 1

Expected Outcomes

• 79.1% of patients show functional improvement according to modified Rankin Scale following surgery 3
• 75.4% of patients either improve or remain functionally stable at 3-month follow-up 6
• Mortality from direct postoperative complications is 1.8% 3
• Common complications include CSF leakage and wound healing problems 3

Recurrence Monitoring

• Recurrence occurs in 7.2% of cases after intervals ranging from 0.7 to 13.8 years 3
• Patients with incomplete resections and pre-existing bladder/bowel dysfunction have higher recurrence rates 3
• Younger patients demonstrate higher recurrence rates 3
• Follow-up should extend beyond 2 years, as recurrences can occur 10-15 years after initial resection 3

Pathological Considerations

• WHO grade I meningiomas comprise 95.8% of spinal meningiomas, with WHO grade II representing only 4.2% of cases 3
• Psammomatous histological subtype is most common (42.8%) 3
• Female-to-male ratio is 5.15:1 3
• Mean age at presentation is 60.5 years (range 24-92 years) 6

Alternative Management for Non-Surgical Candidates

Stereotactic radiosurgery or fractionated radiotherapy may be considered for patients with significant medical comorbidities, aggressive or recurring tumors, or multiple lesions who are not surgical candidates. 7

• Standard radiotherapy regimens include 30 Gy in 10 fractions 4
• Stereotactic radiosurgery demonstrates 5-year progression-free survival rates of 86-99% for intracranial meningiomas 1
• Radiotherapy should be considered for WHO grade II/III tumors, multiple relapses, or contraindication to surgery 1

Critical Pitfalls to Avoid

• Do not delay surgical intervention in patients with progressive motor deficits, as pretreatment neurological status is the strongest predictor of postoperative functional outcome 4, 6
• Avoid prioritizing complete Simpson grade I resection over neurological preservation, as functional status takes precedence 3
• Do not discontinue surveillance after 2 years, as late recurrences beyond 10 years are documented 3
• Recognize that spinal meningiomas can present with atypical imaging features mimicking intramedullary tumors 5