Extradural spinal meningiomas

Report of four cases

JOHN A. CALOGERO:~M.D., ANn JOHN Moossr, M.D.

DepartmentsoJ Surgery (Section o/ Neurosurgery) and Pathology (Neuropathology)
Bowman Gray School oJ Medicine, Wake Forest University, and North Carolina
Baptist Hospital, Winston-Salem,North Carolina

Four patients with extradural spinal meningiomas are reported; one had
relapsing neurological deficits in two postpartal periods. In a bibliographic
review of 35 cases, nearly as many extradural spinal meningiomas occurred
in men as in women, five were in children, and three were lumbar or lum-
bosacral neoplasms in men.

KEY WORDS spinal tumors spinal meningiomas extradural spinal

meningiomas extradural spinal tumors pregnancy

S
PINAL MENINGIOMAS usually become
evident clinically as intradural, ex-
tramedullary neoplasms at the thoracic
level in middle-aged women. 4,7,16,2~ We are
reporting four patients with extradural spinal
meningiomas. These cases and those found
on bibliographic review represent interest-
ing variants of the more common in-
tradural spinal meningiomas.
Case Reports
Case 1
A 40-year-old woman had had progres-
sive paraparesis for 5 years, and for 1 year
had had left flank and thigh pain unrelieved
by a lumbar laminectomy. On admission to
the North Carolina Baptist Hospital she was
unable to walk, incontinent of urine and
feces, had hypalgesia below T-8, hyperactive
knee and ankle stretch reflexes, and extensor
plantar responses. A myelogram showed a
subarachnoid block at "I"-5. Laminectomy re-
vealed a red extradural tumor at T-4 com-
.pressing the dura on the left. It was removed
m pieces with its dural attachment; a pea-
sized intradural component was present. Sec-
tions stained with hematoxylin and eosin
showed a neoplasm composed of cells with
moderate cytoplasm and oval vesicular
nuclei, arranged in sheets and whorls. There
were small numbers of psammoma bodies
(Fig. 1). One year after surgery the patient
walked unsupported, and managed her home
without help.
Case 2
A 54-year-old man had had back pain ra-
diating down the back of his legs for 10
months and urinary incontinence for 4
months, which had not been relieved by re-
moval of a lumbar intervertebral disc at an-
other hospital. On admission, examination
showed the pain to be reproduced during
motion, back percussion, and leg-raising.
There was atrophy of the left anterior tibial
muscles, hypalgesia of S-2 and the lower sa-
cral segments, and absence of the left knee
and ankle reflexes. The plantar reflexes were
normal. The myelogram showed a complete
block at the L-5 vertebral body. Laminec-
tomy of L-3, -4, -5 revealed a red, beefy
mass in the extradural space at L-5 invading

442 ]. Neurosurg. / Volume 37 / October, 1972

Extradural spinal meningiomas
Fro. 1. Case 1. Photomicrograph of tumor section
showing cells in sheets and whorls, psammoma
bodies are present. H & E, 400.
Only sufficient tumor was removed to de-
compress the cord. Microscopic sections
showed plump cells with vesicular nuclei in
clusters and whorls with numerous psam-
moma bodies (Fig. 3). At a second opera-
tion the remainder of the neoplasm, its dural
attachment and a small intradural compo-
nent at the left T=9 nerve root exit were re-
moved. She rapidly regained normal neuro-
logical function.
Case 4
A 33-year-old man had had progressive
paraparesis for 2 years, with burning dy-
sesthesia below the umbilicus, and urinary
retention. Air myelography led to a laminec-
tomy at T-2, but the lesion was not found.
After a Pantopaque myelogram, laminec-
tomy revealed an extramedullary tumor with
large extradural and smaller intradural com-
ponents, communicating through the right T-
7 nerve root exit. Both parts of the tumor
were composed of polygonal cells, many in
whorls, with numerous psammoma bodies

through the posterior dura. A week later the

sacrum was unroofed in an attempt to re-
move the tumor totally. This failed because
the cauda equina was completely enmeshed
in tumor. The neoplasm was moderately cel-
lular. The cells had plump vesicular nuclei
and abundant cytoplasm, and were arranged
in clumps and cellular aggregates separated
by connective tissue and a moderate number
of blood vessels (Fig. 2). Telecobalt ther-
apy, 3500 R, was given to the region of the
tumor. Relief was minimal and transient,
and the patient died 3 years later of septice-
mia. Autopsy was not done.
Case 3
Two weeks postpartum a 28-year-old
woman noted weakness and unsteadiness of
gait which cleared after 3 months. Two
weeks after the birth of her next child it re-
curred, accompanied by numbness, pares-
thesia, and incontinence of urine. On admis-
sion, she had weakness of the legs, hypesthe-
sia below the umbilicus, hyperactive knee
and ankle reflexes, and extensor plantar re-
sponses. The myelogram showed a block at Fro. 2. Case 2. Photomicrograph of tumor show-
T-11. Laminectomy revealed a red-gray ing clumps of plump meningothelial cells in a vas-
sheet of extradural tumor from T-9 to T-11. cular stroma. H & E, 400.

J. Neurosurg. / Volume 37 / October, 1972 443


FIG. 3. Case 3. Photomicrograph of tumor section
showing dumps of meningothelial cells, whorls, and
psammoma bodies. H & E, x 400.
Fie. 4. Case 4. Photomicrographs of tumor at first operation showing sheets of polygonal cells, some
in whorls. Left: Intradural mass. H & E, 100. Center: Extradural mass. H & E,
ningioma removed from posterior mediastinum. H & E, 100
444
John A. Calogero and John Moossy
(Fig. 4). Recovery was rapid, and the pa-
tient remained well for 13 years until his
symptoms recurred and the tumor area was
again explored. In addition to constricting
arachnoiditis, there was a mass involving the
left T-7 spinal nerve just outside the interver-
tebral foramen. The nerve was sectioned.
Postoperatively he was permanently para-
plegic, with preserved dorsal column sensa-
tion. Later the mass was removed at thora-
cotomy; it appeared identical to the previ-
ously removed meningioma except for more
psammoma bodies.
Discussion
BibliographicReview
We reviewed the literature to find cases
similar to ours (Table 1 ); we included cases
of extradural spinal meningioma in which
the patient’s age, sex, and vertebral level of
tumor were known. Many tumors like our
own had minor intradural components. Re-
lying on histopathological descriptions and
published photographs, we have also omitted
several cases mentioned as extradural spinal
100. Right: Me-
t. Neurosurg. / Volume 37 / October, 1972
Extradural spinal meningiomas

TABLE 1
Summary of 35 cases of extraduralspinalmeningioma

Vertebral
Author, Year Age Sex Level Comment

Tissier (1898) 14 M C2-5

S6derbergh & Sundberg (1916) 59 M C3-4
Maas (1918) 54 F T4-6 autopsy 10 years postop" intradural meningioma
at same site
Naffziger & Brown (1933) 54 M T-8
60 F T-9
55 M C6-T2
34 F C7-T2
Enderle (1934) 44 M L3-4
Ingraham (1938) 10 F C1-5 multiple cutaneous neurofibromata, papilledema
of undetermined cause
Oddsson (1947) 32 M lumbosacral pelvic extension
Henschen (1955) 42 F C-5
17 F T-1
31 M "1"-5
Rand & Rand (1960) 8 F T-6
Haft & Shenkin (1963) 24 M T-7
Early & Sayers (1966) 14 M T-4
Soo (1966) 64 F T4-6
7 M C2-T1 later evidence of intracranial tumor
Pecker, et al. (1967) 29 F C2-C5
43 F C7-T1 onset of symptoms, age 43; surgery, age 67
65 F T4-6
Rath, et aL (1967) 20 F C3-6 also an intradural meningioma at T-10
Vakili (1967) 61 M T-1
Abbott, et al. (1968) 57 M T-4 tumor contained melanin
Hallpike & Stanley (1968) 33 M T-6 intrathoracic extension
Singh, et al. (1968) 35 F T-4 rapid postpartum onset
Fortuna, et al. (1969) 53 F T7-10
74 F T7-8
40 F T4-6
31 M "[1-2
Mittal, et aL (1970) 40 F T-12 papilledema, enlarged sella turcica
Calogero & Moossy (1972) 40 F T-4
54 M lumbosacral
29 F T9-11 rapid onset postpartal after spontaneous recovery
from previous similar paraparesis
33 M T-7 later developed meningioma of spinal nerve at
same level on opposite side

meningiomas because of our doubt as to the
correct diagnosis. ~,24,31
General Deductions
P r i m a r y t u m o r s in the spinal c a n a l are un-
c o m m o n . M e n i n g i o m a s p r o b a b l y o c c u r sec-
ond in f r e q u e n c y to n e u r i l e m o m a s 2 4 B o t h in
o u r series a n d others, 8 0 % of the patients
with spinal m e n i n g i o m a s have been w o m e n ,
a n d the age of the patients has a v e r a g e d 48
years.4,r,16,z0,34,38
Although many authors mention a definite
incidence of extradural spinal meningiomas,
the problem has received little emphasis. As
in our series Henschen 17 also had four extra-
dural tumors among 20 spinal meningiomas.
Most authors have reported a smaller propor-
tion of extradural meningiomas, and we be-
lieve the figure of about 15% by Sloof, e t al., 34
to be near the true incidence.
Many series and case reports were
searched to find the cases in Table 1. There-

1. Neurosurg. / Volume 37 / October, 1972 445


fore, conclusions based on this collection do
not have the significance of those based on
consecutive series. Nevertheless certain at-
tributes of this group are worth noting: 16 of
the 35 patients are male, an unusually large
number. The average age is 37 years while
Oddsson 25 found an average age of 48 in his
patients. Five of the listed patients are 14
years of age or less, yet meningiomas are
very rare m children. 1~176 Three pa-
tients had lumbar meningiomas, two of
which extended into the sacrum; this is a
rare site for meningiomas.4,1G,2~ 25,~4 These
variations from the behavior of the intradu-
ral spinal meningiomas must be confirmed
by a consecutive series large enough to have
statistical significance.
The appearance of meningiomas in the
extradural space of the spinal canal may be a
manifestation of the natural tendency of
these neoplasms to invade dura. The fre-
quent invasion of dural sinuses by meningio-
mas is well known22 Hassin 1~ showed that
arachnoid villi in the spinal canal are com-
monest at the nerve root exits. These should
be "favored seats of origin" for meningio-
mas, 5 but leave little intradural space for ex-
pansive growth. Invasion of the dura and
extradural tissues, like the invasion of fibrous
tissue by extraspinal peripheral meningiomas,
thus occurs. 14
Three patients in Table 1, and one men-
tioned by Pool, et al,27 had other nervous
system neoplasms associated with extradural
spinal meningioma. Whether our Case 4 had
two separate meningiomas is not clear. The
presence of multiple nervous system neo-
plasms suggests neurofibromatosis even
when skin lesions are lacking.
We suggest that spinal meningiomas may
be more invasive in young patients, in males,
and in those with a genetic predisposition to
form neoplasms, and thus appear in the ex-
tradural space.
Pregnancy and Meningiomas
It has been suggested that the rapid neu-
rological changes which sometimes occur in
menstruating or pregnant women harboring
meningiomas are due to alterations in the
water content of the tumor ceils, ~,~9 or to
vascular engorgement of the neoplasm. ~9 Al-
though these hypotheses are based primarily
on the histological appearance of the tumors,
446
John A. Calogero and John Moossy
the appearance of the tumor in our Case 3
(Fig. 3), removed after a rapid onset of
symptoms in the postpartal period, lends no
support to either theory.
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Partial support for this work came from USPHS
Neuropathology Training Grant NB-5643, and from
USPHS Oncology Training Grant 5T-12-CA 08037-
6.
Address reprint requests to: John A. Calogero,
M.D., 212 Ashley Street, Hartford, Connecticut
06105.
447