Elsevier

World Neurosurgery

Volume 135, March 2020, Pages e748-e753
World Neurosurgery

Original Article
Microsurgical Management of Ventral Intradural-Extramedullary Cervical Meningiomas: Technical Considerations and Outcomes

https://doi.org/10.1016/j.wneu.2019.12.145Get rights and content

Objective

Cervical meningiomas are uncommon intradural-extramedullary tumors that have a tendency to be situated anterior to the spinal cord. The optimal surgical corridor to reach purely ventral cervical meningiomas has not been established. This article presents a series of patients with ventral cervical meningiomas treated via 1 of 2 microneurosurgical approaches: the anterior approach with corpectomy and fusion or the posterolateral approach.

Methods

Eight patients who underwent surgical resection of solitary, histopathologically confirmed, intradural-extramedullary cervical meningiomas of purely ventral location were retrospectively examined. Preoperative and postoperative Nurick scores quantified the degree of ambulatory function. Patients were followed for an average of 2.1 years after surgery. Postoperative imaging was performed to determine the extent of resection and to assess for tumor recurrence.

Results

Two patients with lower cervical meningiomas underwent resection via an anterior approach with single-level corpectomy and fusion. Six patients were treated via a posterolateral approach including ipsilateral hemilaminectomy and partial facetectomy without fusion. No intraoperative or postoperative complications were observed. Gross total resection was achieved in 8 of 8 patients, although 1 patient exhibited tumor recurrence. Improvement in ambulatory function was observed in all patients.

Conclusions

Purely ventral cervical meningiomas are uncommon and pose unique technical challenges for neurosurgeons. We document favorable outcomes from 2 cases of lower cervical meningioma treated via an anterior approach and 6 cases of upper cervical tumors treated via a posterolateral approach. This series demonstrates operative considerations for effectively managing ventral cervical meningiomas.

Introduction

Spinal meningiomas are typically benign, slow-growing, intradural-extramedullary tumors that constitute 25%–46% of spinal cord neoplasms and approximately 1.2% of all meningiomas.1, 2, 3, 4 The thoracic spine is the most frequent location for spinal meningiomas, accounting for 75% of all cases.5,6 Cervical meningiomas are less common than tumors of other spine segments (approximately 15% of cases) and occur with a higher prevalence among patients <50 years old.7 The most effective treatment for spinal meningiomas is total surgical excision.

The surgical management of cervical meningiomas is dictated by tumor location. Compared with meningiomas of other spinal segments, cervical meningiomas have a greater tendency to be located anterior to the cord.3,5,7 Purely ventral cervical meningiomas present a unique surgical challenge for which limited data exist.7 In most cases, exposure of the ventral intradural space can be achieved through traditional posterior or posterolateral approaches. However, safe resection of purely ventral tumors with other complicating features (e.g., en plaque tumors, heavy calcifications, significant bilateral extension) may not be feasible through posterior avenues.8 Increasingly, reports have described the successful use of anterior cervical exposures to address ventral intradural-extramedullary lesions, including meningiomas,8, 9, 10, 11, 12 but the literature examining this approach is quite sparse.

The purpose of this retrospective study is to document our case series of 8 patients with purely ventral, intradural-extramedullary cervical meningiomas treated via 1 of 2 microneurosurgical approaches: the anterior approach with cervical corpectomy and instrumented fusion (2/8, 25%) or the posterolateral approach (6/8, 75%).The clinical characteristics, operative techniques, outcomes, and relevant literature are presented. In addition, a comprehensive review of similar reports to date in the English literature is provided.

Section snippets

Preoperative Assessment

Eight patients (3 men, 5 women; age range, 26–77 years) with a solitary, purely ventral, cervical meningioma who underwent surgery at the Department of Neurosurgery, Ankara University, between 2011 and 2019 were retrospectively studied. All consecutive tumors arising from C2-C7 were included in the study. Magnetic resonance imaging (MRI) of the cervical spine was performed in each case to anatomically characterize the lesion and surrounding tissues. T1-and T2-weighted images were evaluated for

Results

Clinical details of the study population are presented in Table 1. All patients had a purely ventral cervical meningioma involving the following levels: C2 (3/8, 37.5%), C3 (2/8, 25%), C6 (1/8, 12.5%), C7 (1/8, 12.5%). One patient harbored a multilevel tumor spanning C2-C5. The majority of patients (6/8, 75%) exhibited cord signal change on preoperative MRI. Nurick scores before surgery ranged from 1 to 4, with only 1 patient requiring assistance with gait. All patients presented with various

Discussion

Cervical meningiomas are rare lesions that occur disproportionately in patients <50 years old.7 The surgical approach to cervical meningiomas depends on the anatomic location of the lesion, which is typically classified as purely ventral (anterior), anterolateral, lateral, posterolateral, or purely posterior. Compared with tumors arising from the thoracic region, cervical meningiomas have a tendency to be located in a ventral position.3,5,7 Even when the physical characteristics of the tumor

Conclusions

The posterolateral approach is effective for treating upper cervical ventral meningiomas. Anterior corpectomy may be useful in cases of single-level, lower cervical tumors. Despite the challenging location of these tumors, the surgical results are satisfying.

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  • Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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