Spinal meningiomas are neurosurgical rarities that manifest with progressive paraor tetraparesis. The effect of timing of surgery on the recovery after the loss of walking ability is poorly known. We studied the effect of timing of surgery on restoring walking ability in surgically-treated spinal meningioma patients.
Using electronic health records, we retrospectively identified ≥ 18-year-old patients operated on during 2010–2020. The patients were followed until 30th September 2020, death or emigration.
We identified 108 patients (81% women) with operated spinal meningiomas. The mean age of the patients was 64 years (range, 18–94 years). A gross total resection was achieved in 101 (94%), and 21 patients (19%) suffered from perioperative complications. Of the 108 patients operated on, 49 (45%) could not walk without assistance prior to surgery. At the time of first postoperative visit (mean, 3.1 months; range, 1.3–13.1 months), 14 out of 24 patients (58%) operated on within 29 days and 8 out of 20 patients (40%) operated on later than 29 days since the loss of walking ability without assistance, were able to walk without assistance. Also, 3 out of 5 paraplegic patients who underwent surgery later than 29 days after they lost the walking ability, were able to at least walk with assistance at first postoperative visit.
Early surgical treatment following the loss of walking ability restores walking ability in a substantial number of patients. However, even late surgery may restore walking ability.
Spinal meningiomas are benign intradural but extramedullary tumors that are most often located in the thoracic spine [
The literature about the surgical treatment of spinal meningiomas is limited to a relatively small number of retrospective series. One of the largest retrospective series of 173 operated spinal meningiomas reported that 87% of the patients experienced postoperative functional improvement [
The Institutional Review Board of Helsinki University Hospital approved the data collection and study design (HUS/190/2021). According to Finnish legislation, obtaining informed consent from the patients was waived. We conducted the study in line with the Declaration of Helsinki [
Eighteen-year-old and older spinal meningioma patients, operated on between January 2010 and September 2020, were retrospectively identified from electronic health records. The catchment area of the department was around 2 million people during the study period. Patients with a comorbidity that prevented walking preoperatively were excluded.
Magnetic resonance images were reviewed by 2 study authors (VV, RH). We calculated the number of spinal meningiomas, and defined (based on gadolinium-enhanced T1-weighted images) the craniocaudal (cervical, thoracic, lumbar) and anteroposterior (anterior, lateral, posterior to spinal cord) location, and the maximum tumor diameter of the operated meningioma. The final diagnosis was based on the histology of the tumor.
The walking ability was classified (by surgeon) as normal (not assisted), para-/tetraparesis (capable of assisted walking/assisted walking with weakness in upper limbs), and para-/tetraplegia (not capable of assisted walking). The cause for the loss of walking ability was presumably muscle weakness, but due to the retrospective study design, this could not be confirmed. The time interval (days) from loss of walking ability to skin incision was calculated for these patients. Bladder function was divided into normal, mild dysfunction (difficulties in spontaneous urination), and severe dysfunction (including different urinary catheter types).
Only the patients with first-ever spinal meningioma surgery were included. Surgery was divided into 2 urgency categories: urgent (not booked in advance) and elective (booked in advance). The extent of the meningioma resection was classified according to its Simpson grade [
We collected data on walking ability and motor deficits at discharge, and at the first and last postoperative outpatient clinic visits. We also assessed the postoperative mortality rates and tumor recurrence rates during follow-up. Patient records were reviewed until the end of September 2020.
One hundred eight patients with spinal meningiomas requiring surgical treatment were identified (
Preoperative spinal magnetic resonance imaging (MRI) studies were available for all patients. The meningiomas were most often located in the thoracic region (78%,
The vast majority (91%) of the meningiomas were diagnosed after becoming symptomatic (
Of the 10 asymptomatic patients (9%) (
Of the 49 patients who could not walk without assistance, 24 (49%) were operated on urgently (all with thoracic meningiomas). The median interval from the preoperative loss of walking ability to surgery were 25 days (mean, 65 days; range, 1–365 days) for patients with thoracic meningiomas and 60 days (mean, 325 days; range, 18–1,440 days) for those with cervical. The median interval between the loss of ability to walk at all (13 patients with thoracic meningiomas) and surgery was 17 days (mean, 72 days; range, 3–365 days).
The surgeries were performed by 18 consultant neurosurgeons. Hemilaminectomy was the approach used in 104 surgeries (96%) (
Of the 10 patients whose motor function decreased perioperatively, 6 had been able to walk without assistance preoperatively but needed assistance with walking on discharge. In addition, 4 were capable of assisted walking preoperatively, but were not able to walk at all on discharge. Furthermore, 3 preoperatively paraparetic/-plegic patients and 1 independently walking patient, none of whom had a preoperative urinary catheter, needed catheters when they were transferred to other healthcare facilities. Of the 13 patients with preoperative complete loss of ability to walk, 5 were capable of assisted walking on discharge, whereas 3 had urinary catheters prior the surgery and 4 after.
Data on the first postoperative visit were available for 100 out of 108 patients (93%) (
Data on the last (other than the first) postoperative visit were available for 64 patients (59%) (
The data on the first postoperative visit were available for 44 of the 49 patients (90%) with preoperative loss of walking ability (
In this retrospective study of 108 patients with spinal meningiomas, we found that 49% of the patients with preoperative inability to walk without assistance, were able to walk independently at the first postoperative visit. Even 4 out of 12 preoperatively paraplegic patients (duration of paraplegia, 3–60 days) were able to walk without assistance. All 4 paraplegic patients who were operated within 8 days of the onset of paraplegia regained their capability for at least assisted walking at first postoperative visit. However, 3 out of 5 paraplegic patients who underwent surgery later than 29 days since the onset of paraplegia were capable of at least assisted walking at first postoperative visit. The longest interval between preoperative paraplegia and surgery, in a 77-year-old woman who regained the capability for assisted walking, was 365 days, suggesting that even late surgery for elderly paraplegic meningioma patients may be beneficial. A preoperative bladder dysfunction requiring urinary catheter was observed in 2 paraparetic and 3 paraplegic patients. All these patients got rid of the catheter at the first postoperative visit. Interestingly, bladder dysfunction also recovered among the paraplegic patients, whereas 3 of the 12 paraplegic patients did not regain their capability for assisted walking. This may suggest that bladder dysfunction has a better likelihood of recovery even after late surgery. Even though 6 patients had lost their walking ability and 4 patients their capability for spontaneous urination at surgery, they all fully recovered at the first postoperative visit. The preoperative percentual spinal canal obturation caused by meningioma was not associated with the outcome (results not shown).
Following surgery, an improvement of preoperative neurological deficits has been reported among the majority (85%–90%) of spinal meningioma and schwannoma patients in previous studies [
Our study has numerous limitations. Inherent to retrospective studies, reporting of neurological findings and surgical outcomes was not standardized and consistent. For similar reasons, comorbidities and minor perioperative complications were not systematically recorded. Given these shortcomings in reporting, we decided to focus on walking ability, which was well reported in the electronic health records. Moreover, this surrogate outcome measure is a meaningful outcome measure for patients. However, it may be that the loss of walking ability in some patients was caused by the loss of proprioception rather than muscle strength. Unfortunately, the duration in hours from the development of paresis/plegia to surgery could not be confirmed. However, it might be impossible to report the exact durations, since not even a prospective design is feasible for this patient group. In addition, no information about histopathological findings, e.g., WHO Grading, was collected as these were not consistently reported in the patient records. Postoperative MRI was not arranged routinely for all patients, which is why some asymptomatic tumor recurrencies may not have been diagnosed. Furthermore, this also prevented the analysis of T2 hyperintensity since the spinal cord is often flattened by meningioma in preoperative MRI studies. Finally, the mean overall follow-up of 57.1 months may be too short to report true recurrence rates.
Our study may also have a few strengths in comparison to previous studies [
As the spinal cord compression in spinal meningioma patients develops slowly, even somewhat delayed surgery may lead to significant functional improvements. New paraparesis or -plegia are rare events following spinal meningioma surgery.
The authors have nothing to disclose.
An author (VV) received research funding for the preparation of this manuscript from Neurocenter, Helsinki University Hospital.
Conceptualization: VV, MN, MK; Data curation: VV, RH; Formal analysis: VV, MK; Funding acquisition: VV; Methodology: VV, MN, MK; Project administration: VV, MN, MK; Visualization: VV, RH; Writing - original draft: VV; Writing - review & editing: VV, RH, MN, MK.
The postoperative walking ability among the patients with preoperative paraplegia and ability to walk independently at the first postoperative visit.
Patient and meningioma characteristics
Characteristic | Women (n = 87) | Men (n = 21) | Total (n = 108) | |
---|---|---|---|---|
Age (yr) | ||||
Mean | 62.4 | 68.1 | 63.5 | |
Median | 63.0 | 72.0 | 65.0 | |
Range | 18–94 | 41–84 | 18–94 | |
Cranio-caudal location | 87 (100) | 21 (100) | 108 (100) | |
Cervical spine | 16 (18) | 5 (24) | 21 (19) | |
Thoracic spine | 68 (78) | 16 (76) | 84 (78) | |
Lumbar spine | 3 (3) | 0 (0) | 3 (3) | |
Axial location |
85 (100) | 21 (100) | 106 (100) | |
Anterior to medulla/cauda | 15 (18) | 7 (33) | 22 (21) | |
Lateral | 38 (45) | 12 (57) | 50 (47) | |
Posterior | 32 (38) | 2 (10) | 34 (32) | |
Maximal tumor diameter (mm) | ||||
Mean | 19.0 | 22.9 | 19.7 | |
Median | 18.0 | 21.0 | 19.0 | |
Range | 5–44 | 13–40 | 5–44 | |
Functional status | ||||
Walking | 87 (100) | 21 (100) | 108 (100) | |
Independent walking | 48 (55) | 11 (52) | 59 (55) | |
Assisted walking | 27 (31) | 9 (43) | 36 (33) | |
Not able to walk | 12 (14) | 1 (5) | 13 (12) |
Values are presented as number (%) unless otherwise indicated.
Axial magnetic resonance images not available for 2 patients.
The characteristics of the patients capable of independent and assisted walking, and not able to walk
Characteristic | Walking without assistance | Walking with assistance | Not able to walk | ||
---|---|---|---|---|---|
Preoperatively | |||||
Sex | 59 (100) | 36 (100) | 13 (100) | ||
Female | 48 (81) | 27 (75) | 12 (92) | ||
Male | 11 (19) | 9 (25) | 1 (8) | ||
Craniocaudal location | 59 (100) | 36 (100) | 13 (100) | ||
Cervical | 16 (27) | 5 (14) | 0 (0) | ||
Thoracic | 41 (69) | 30 (83) | 13 (100) | ||
Lumbar | 2 (3) | 1 (3) | 0 (0) | ||
Interval: from paresis/plegia to surgery |
0 (0) | 35 (100) | 13 (100) | ||
≤ 29 days (n = 25) | 0 (0) | 17 (49) | 8 (62) | ||
> 29 days (n = 23) | 0 (0) | 18 (51) | 5 (38) | ||
First postoperative visit |
|||||
Sex | 78 (100) | 19 (100) | 3 (100) | ||
Female | 60 (78) | 18 (95) | 3 (100) | ||
Male | 18 (22) | 1 (5) | 0 (0) | ||
Craniocaudal location | 78 (100) | 19 (100) | 3 (100) | ||
Cervical | 18 (24) | 1 (5) | 0 (0) | ||
Thoracic | 58 (74) | 17 (89) | 3 (100) | ||
Lumbar | 2 (3) | 1 (5) | 0 (0) | ||
Interval: from paresis/plegia to surgery |
22 (100) | 19 (100) | 3 (100) | ||
≤ 29 days (n = 24) | 14 (64) | 9 (47) | 1 (33) | ||
> 29 days (n = 20) | 8 (36) | 10 (53) | 2 (67) | ||
Last postoperative visit |
|||||
Sex | 54 (100) | 8 (100) | 2 (100) | ||
Female | 43 (80) | 8 (100) | 2 (100) | ||
Male | 11 (20) | 0 (0) | 0 (0) | ||
Craniocaudal location | 54 (100) | 8 (100) | 2 (100) | ||
Cervical | 14 (26) | 0 (0) | 0 (0) | ||
Thoracic | 39 (72) | 7 (88) | 2 (100) | ||
Lumbar | 1 (2) | 1 (12) | 0 (0) | ||
Interval: from paresis/plegia to surgery |
18 (100) | 8 (100) | 2 (100) | ||
≤ 29 days (n = 16) | 12 (67) | 3 (38) | 1 (50) | ||
> 29 days (n = 12) | 6 (33) | 5 (63) | 1 (50) |
Values are presented as number (%).
Includes only the patients with preoperative paresis/plegia. Information about 1 preoperatively paraparetic patient missing.
Information on 8 patients missing.
Includes only the patients with preoperative paresis/plegia.
Information on 44 patients missing.
The characteristics of surgical treatment
Characteristic | Total |
---|---|
Indication for surgery | |
Symptomatic tumor | 98/108 (91) |
Radiological progression | 2/108 (2) |
Prophylactic | 8/108 (7) |
Approach | |
Hemilaminectomy | 104/108 (96) |
Laminectomy | 2/108 (2) |
Laminoplasty | 2/108 (2) |
Extent of resection | |
Gross total resection | 101/108 (94) |
Partial resection | 7/108 (6) |
Simpson grade | |
I | 10/108 (9) |
II | 73/108 (68) |
III | 18/108 (17) |
IV | 7/108 (6) |
Strategy with dural insertion |
|
Resection | 10/107 (9) |
Coagulation | 77/107 (72) |
No intervention | 20/107 (19) |
Intraoperative blood loss (mL) | |
Mean | 218 |
Median | 150 |
Range | 20–850 |
Skin-to-skin surgery time | |
Mean | 2 hr 58 min |
Median | 2 hr 47 min |
Range | 56 min–7 hr 7 min |
LOS (day) | |
Mean | 4.1 |
Median | 4.0 |
Range | 1–26 |
Major complications | 21/108 (19) |
Worsening of motor deficits | 10/108 (9) |
CSF leakage | 6/108 (6) |
New need for urinary catheter | 4/108 (4) |
Wound infection | 1/108 (1) |
Mortality |
|
30 Days | 1 (1) |
1 Year | 1 (1) |
Values are presented as number (%) unless otherwise indicated.
CSF, cerebrospinal fluid; LOS, length of hospital stay.
Information about the strategy with dural insertion was not reported in one patient.
Cause of death: unrelated malignancy.