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Spinal Meningioma

Summary

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  • Slow-growing, benign tumours arising from arachnoid cap cells of the spinal meninges
  • Most common intradural extramedullary spinal tumour in adults
  • Typically presents with gradual onset of neurological symptoms due to spinal cord compression

Pathophysiology

  • Arise from arachnoid cap cells in the spinal meninges
  • Most commonly occur in the thoracic spine (80%), followed by cervical and lumbar regions
  • Grow slowly, causing gradual compression of the spinal cord and nerve roots
  • WHO classification:
    • Grade I (benign): 90% of cases
    • Grade II (atypical): 5-7% of cases
    • Grade III (anaplastic): <1% of cases

Demographics

  • Peak incidence: 40-70 years of age
  • Female predominance (female:male ratio 3-4:1)
  • Account for 25-46% of primary spinal cord tumours in adults
  • Rare in children, comprising <5% of paediatric spinal tumours

Diagnosis

  • Clinical presentation:
    • Gradual onset of neurological symptoms
    • Local or radicular pain
    • Sensory disturbances
    • Motor weakness
    • Gait abnormalities
    • Sphincter dysfunction (in advanced cases)
  • Physical examination:
    • Sensory level deficit
    • Motor weakness below the level of the lesion
    • Hyperreflexia and spasticity
    • Positive Babinski sign

Imaging

  • MRI: imaging modality of choice
    • T1-weighted: iso- to hypointense relative to spinal cord
    • T2-weighted: iso- to hyperintense
    • Strong, homogeneous enhancement with gadolinium
    • "Dural tail" sign often present
    • May demonstrate calcifications (10-20% of cases)
  • CT:
    • Useful for detecting calcifications and bony changes
    • May show scalloping of adjacent vertebral bodies in long-standing cases
  • Plain radiographs:
    • Limited utility, may show bony erosion or widening of neural foramina

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  • A 60-year-old patient presented with low limb sensory disturbance.
  • MRI showed a hypointense lesion with a broad thecal base compressing the thoracic cord.

Treatment

  • Surgical resection: primary treatment modality
    • Goal: complete resection (Simpson Grade I or II)
    • Approach depends on tumour location and extent
  • Adjuvant radiation therapy:
    • Considered for subtotal resection, high-grade tumours, or recurrence
    • Stereotactic radiosurgery may be used for small, well-defined tumours
  • Follow-up:
    • Regular clinical and radiological follow-up to monitor for recurrence
    • Recurrence rates: 7-20% at 10 years for benign (WHO Grade 1) tumours
  • Prognosis:
    • Generally favourable with complete resection
    • Factors affecting outcome: extent of resection, tumour grade, patient age, and preoperative neurological status

Differential diagnosis

Differential Diagnosis Differentiating Feature
Schwannoma Typically eccentric to the spinal cord, often with "dural tail" sign absent
Neurofibroma Dumbbell-shaped expansion through neural foramen; "target sign" on T2; may be multiple
Metastatic tumour Often multiple lesions; may have associated bony involvement; more aggressive bone destruction
Ependymoma Intramedullary location; often with syringomyelia; "cap sign" haemosiderin on SWI
Astrocytoma Intramedullary location; poorly defined margins; irregular enhancement
Lymphoma Homogeneous epidural or intradural mass; restricted diffusion on DWI; may be multiple
Spinal epidural abscess Rim-enhancing collection; restricted diffusion in abscess; cord compression without intradural involvement
Herniated disc Typically at disc level, associated degenerative changes
Arachnoid cyst No enhancement, CSF-like signal on all sequences
Spinal arteriovenous malformation Flow voids on MRI, associated cord oedema