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B. MENINGIOMA

Ms. M-H.* is a 63 year old female with an 8 year history of progressive weakness of her lower extremities, leading to her inability to walk (spastic paraparesis) and sensory impairment to the T8 (Thoracic) level.

MRI and CT scans demonstrated a partially calcified, intradural tumor exerting considerable pressure upon and displacing the Spinal Cord at the T8 level. The calcification lay in the anterior (front) part of the tumor which, itself, occupied the anterior portion of the Spinal Canal. The presence of this calcification (bone) is a known occurrence in Meningiomas. Nevertheless, this rock hard lesion makes resection a formidable challenge.

THE TRADITONAL NEUROSURGICAL "LAMINECTOMY" IS NOT APPROPRIATE FOR A LESION IN THIS LOCATION SINCE IT WOULD REQUIRE RETRACTION OF THE SPINAL CORD IN ORDER TO GAIN ACCESS TO THE TUMOR. THIS WOULD PLACE THE SPINAL CORD AT GRAVE RISK.

THE CUSTOMARY SURGICAL APPROACH TO REMOVE THIS TUMOR REQUIRES A THORACOTOMY (OPENING OF THE CHEST WALL AND COLLAPSE OF ONE LUNG) AND REMOVAL OF THE VERTEBRAL BODIES IN FRONT OF THE TUMOR FOLLOWED BY RECONSTRUCTION OF THE SPINE WITH A BONE GRAFT, METAL PLATES AND SCREWS.

THIS IS THE FIRST REPORT OF A CALCIFIED INTRADURAL, ANTERIORLY LOCATED THORACIC LEVEL MENINGIOMA HAVING BEEN REMOVED USING A MINIMALLY INVASIVE TECHNIQUE.

Figure 1A (Left): MRI Scan (Sagittal View) The intraspinal tumor is located at the T7-8 level (Curved Arrow.)

Figure 1B (Center): MRI Scan (Gadolinium Enhanced Axial View-Same Patient) The tumor (oval shaped, "white" structure indicated by the Curved Arrow) displaces and compresses the Spinal Cord (Horizontal Arrow.)

Figure 1C (Right): CT Scan (Non-contrast-Axial View) The Calcified portion of the tumor appears as a "dense" white structure (Curved Arrow) in the anterior part of the Spinal Canal.


SURGICAL TREATMENT

A MINIMALLY INVASIVE (RIGHT-SIDED) APPROACH WAS USED TO PEFORM A MICROSURGICAL COSTO-TRANSVERSECTOMY (removal of the Head of a Rib and the Transverse Process of the Vertebra to which the Rib attaches) TOGETHER WITH A T7-T8 FACETECTOMY and BILATERAL LAMINECTOMY at T7 & T8 using a UNILATERAL (one sided) APPROACH. A COMPLETE RESECTION of the CALCIFIED MENINGIOMA WAS ACCOMPLISHED.

Figure 2A (Left): Operative Photo (Same Patient) A 4 centimeter long "X-tube" Minimally Invasive Retractor (Medtronic Sofamor-Danek, Inc., Memphis Tennessee) is in place at the T7-T8 level.

Figure 2B (Right): Operative Photo (Same Patient). A "Sonopet" OMNI Ultrasonic Aspirator (Synergeticstm, Inc., O'Fallon, Missouri) is used to remove the Meningioma WITHOUT ANY RETRACTION OR MANIPULATON OF THE SPINAL CORD.

Figure 3: Operative Photo. A Minimally Invasive (Unilateral Approach) Bilateral T7-T8 Laminectomy gave excellent exposure to this tumor. The Dura Mater (Vertical Arrows) was opened to expose the Meningioma (Curved Arrows) which had displaced and compressed the Spinal Cord (Oblique Arrows). Notice the Nerves leaving the Spinal Cord and draped over the Meningioma. (COMPARE THIS TO FIGURE 6)

Figure 4: Operative Photo (Same Patient) The Meningioma is being removed using the Sonopet OMNI Ultrasonic Aspirator (Horizontal Arrow). A small part of the tumor has been removed allowing us to see a portion of the anterior aspect of the Spinal Cord (Curved Arrow.)

Figure 5: Operative Photo. (Same Patient) After removing the greatest majority of the tumor, the calcified portion comes into view (Vertical Arrow). Notice how this calcified "mass" still indents the Spinal Cord (Curved Arrow.)

Figure 6: Operative Photo (Same Patient) The Meningioma with its calcified anterior portion has been completely removed. The Spinal Cord is well decompressed although it has not returned to its "normal" configuration at this early point. (COMPARE THIS TO FIGURE 3)

Figure 8: Operative Photo (Same Patient) The Dura Mater has been sutured closed creating a "water-tight" seal.

FOLLOW-UP

Ms. M-H. noticed improvement in leg function shortly after surgery. She began to walk several days post-operatively and continues to enjoy steady improvement to unassisted walking.

* Ms. M-H. wrote to us about this experience as follows: "My recovery has been far quicker and easier than I had expected. I left the hospital in less than a week and was living totally on my own and without physical therapy within another. Thank you and all of the hand-picked staff you assigned to my care."


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This page last edited on 2/19

All content ©2016 by Neurosurgical Consultants, P.A.
Author, Martin L. Lazar, MD, FACS
All Rights Reserved. See Usage Notices.