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57 Giant Cell Tumor
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advised. On the other hand, embolization itself can cause the shrinking/sclerotization of the tumor mass, so in spinal cases, where there is no instability or urgent
neurological symptom, embolization is the rst line of management. The effect of
the embolization should be follow-up by CT imaging studies, and the procedure can
be repeated several times. In case of a surgical treatment, preoperative embolization
(the day before the surgery) is strongly advised to reduce intraoperative blood loss.
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57.6.3 Denosumab
Denosumab is a human monoclonal antibody against osteoclast activator
RANKL. The inhibition of osteoclast activation via RANKL inhibition prevents
bone resorption. Denosumab is primarily used in the treatment of osteoporosis, but
a growing body of evidence shows its effect and safety in the management of
GCT.Calcium levels should be monitored and calcium/vitamin D supplementation
is advised during denosumab treatment. A dental checkup is also essential to screen
for osteonecrosis of the jaw. Stop of tumor growth and the sclerotization of the lytic
GCT mass can be seen on follow-up images as results of the treatment. “Standalone,” pre- and postoperative administration of denosumab can be supported in
spinal GCT after the individual evaluation of the situation, but the length of the
treatment is still an open question.
57.7 Expected Outcomes
The LR rate is about 20% to 30% in spinal GCT, especially in case of intralesional
resections. Functional outcome is strongly associated with biomechanical stability
and neurological function which can be compromised by surgical resection. Even in
huge tumors, denosumab treatment can stop the progression and improve function.
57.8 Potential Complications
Intralesional surgeries especially in sacral locations result in fatal intraoperative
blood loss. Spinal cord injury is a serious complication in thoracic/cervical GCT
resections. Denosumab treatment can have signicant side effects such as hypocalcemia or jaw osteonecrosis.
57.9 What Should Patient andFamily Know?
Patients and their families should understand that spinal GCT can be a lifethreatening condition especially if the management is not individually planned and
awed by reckless steps. The surgical treatment can result in massive blood loss and
serious complications, while inadequate surgery leads to LR, increasing morbidity,
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P. P. Varga and A. Lazary
and mortality. On the other hand, well-timed adjuvant therapies especially embolization and denosumab treatment increase the success of the management.
Further Readings
Boriani S, Cecchinato R, Cuzzocrea F, et al. Denosumab in the treatment of giant cell tumor
of the spine. Preliminary report, review of the literature and protocol proposal. Eur Spine
J. 2020;29(2):257–71.
Charest-Morin R, Fisher CG, Varga PP, etal. En bloc resection versus intralesional surgery in the
treatment of giant cell tumor of the spine. Spine (Phila Pa 1976). 2017;42(18):1383–90.
Puri A, Gupta SM, Gulia A, etal. Giant cell tumors of the sacrum: is non-operative treatment effec-
tive? Eur Spine J. 2021;30(10):2881–6.
Spinal Meningioma
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58
MarcelIvanov
58.1 Definition
The spinal meningiomas are usually well-dened, benign, and slow-growing tumors
with dural attachment. If untreated, they may cause signicant morbidity.
Meningiomas constitute approximately 30% of intradural extramedullary spinal
tumors. Their incidence is approximately 3:100,000 and they are more common in
women than in men (3:1).
The meningiomas are arising from the layers around the spinal cord (arachnoidal
cap cells).
Radiation and NF are recognized risk factors of meningiomas.
The meningiomas are located predominantly in the thoracic area (80%). The rest
are distributed in the cervical segment (15%) and less frequently in the lumbosacral
area (5%).
58.2 Natural History
Meningiomas are usually slow-growing tumors. The tumors tend to be diagnosed
between the fth and the seventh decade of life. Diagnosis of meningioma at an
earlier age suggests more aggressive tumor behavior which has an incidence of
<2% [1].
Supplementary Information The online version contains supplementary material available at
(https://doi.org/10.1007/978- 3- 030- 80356- 8_58).
M. Ivanov (*)
Department of Neurosurgery, Royal Hallamshire Hospital, Shefeld University,
Shefeld, UK
e-mail: m.ivanov@nhs.net
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_58
353
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Meningiomas may reach considerable size with severe radiological spinal cord
compression before becoming symptomatic.
Once the compression on the spinal cord and/or nerves becomes signicant, the
patients may present various degrees of sensory and motor dysfunction with progressive deterioration of balance and coordination, occasional falls. Occasionally,
the patients may describe vaguely localized pain in the spinal area, which is more
pronounced at night (Chap. 41).
In advanced stages, if untreated, the mobility may be lost, and the patients may
develop sphincter dysfunction.
M. Ivanov
58.3 Physical Examination
The clinical examination should look for signs of spinal cord/nerve compression. It
is essential to perform careful neurological examination with assessment of gait,
muscle power, tonus, reexes, proprioception, and sensation (Video 58.4).
Positive long tract signs with positive Romberg probe, brisk reexes, abnormal
proprioception, and clonus should be a strong indication for magnetic resonance
imaging (MRI) scan of the spine.
58.4 Imaging
MRI scan is the method of choice for the diagnosis of spinal meningiomas. On the
MRI scan, the meningiomas appear as well-dened intraspinal lesions isointense
with the spinal cord on T1- and T2-weighted images. They homogeneously enhance
contrast on T1WI with gadolinium.
The presence of dural tail with a wider dural base helps to differentiate meningiomas from the nerve sheath tumors [2] (Fig.58.1a). The MRI scan will conrm
the level and degree of spinal cord compression.
Computed tomography (CT) can help to assess tumor calcication (Fig.58.1b).
Myelo-CT can be an imaging alternative in cases when MRI is contraindicated.
58.5 Differential Diagnosis
Biopsy is important; the following conditions should be considered (Video 58.8):
• Nerve sheath tumors.
• Myxopapillary ependymoma.
• Dermoid/epidermoid tumors.
• Calcied thoracic disc herniation.
• Myelopathy of another cause.
58 Spinal Meningioma
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a
b
355
Fig. 58.1 (a) T1WI MRI with contrast. Spinal meningioma (*) located anterolateral to the spinal
cord (arrow). Tumor has a visible dural tail. (b) CT thoracic spine demonstrated a highly calcied
intradural tumor. This can be particularly challenging if located anterior to the spinal cord
58.6 Treatment Options
Surgery remains the mainstay of treatment of meningiomas and can be curative in
the vast majority of patients.
The surgery has two main goals:
1. Spinal cord decompression.
2. Prevention of tumor recurrence.
The patient is placed prone. Even if the tumor is located anterior to the spinal
cord, it still can be resected via the standard posterior approach. Either en bloc laminotomy using a craniotom (with the goal of its re-attachment after tumour is
removed - laminoplasty) or standard laminectomy is performed (Laminoplasty as
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described by Raimondi has the benet of lower risk of postoperative kyphosis comparing to laminectomy [3]. Laminotomy is the surgical removal and subsequent
reinsertion of laminae and spinous process; the term laminotomy is often incorrectly used to describe a partial laminectomy. A laminectomy is dened as complete
removal of the lamina.
Surgery of the tumors located anterior or anterolateral to the spinal cord (40%) is
usually more challenging due to narrow corridor and the potential need for gentle
manipulation of the spinal cord. This could be particularly challenging when the
tumor is calcied (Fig. 58.1b). Intraoperative neurophysiological monitoring is
helpful in cases when the spinal cord needs to be mobilized.
We recommend dural exposure of at least 5mm cranial and caudal to the tumor
poles. This can be conrmed with intraoperative ultrasound [4, 5] (Fig.58.2).
Under microscopic magnication, meticulous hemostasis is performed before
opening the dura. After midline dural opening, the dural edges are stitched laterally.
At this stage, the tumor should be visible (Fig.58.3).
In most cases, the spinal meningiomas are eshy, red-purple, sometimes brous,
and occasionally calcied tumors. There is normally a thin arachnoid layer between
the tumor and the neural structures, which prevents adherence to the spinal cord and
allows tumor mobilization and separation. Dissection of the tumor base with coagulation of the vessels helps to reduce the intraoperative bleeding.
By debulking the tumor (either with an ultrasonic aspirator or piecemeal
removal), the pressure on the spinal cord is decreased (Fig.58.3). It allows mobilization of the tumor capsule away from the spinal cord. If the tumor is located anteriorly, the dentate ligament can be divided, and the spinal cord can be gently rotated
laterally with the guidance of intraoperative neurophysiological monitoring.
M. Ivanov
*
Fig. 58.2 Intraoperative ultrasound can be helpful to conrm tumor location and adequate dural
exposure before opening the dura. The ultrasound demonstrates tumor (*) located anterolateral to
the spinal cord
*
58 Spinal Meningioma
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Fig. 58.3 Intraoperative
image– spinal
meningioma located
anterolateral to the spinal
cord. Surgical steps: view
after (a) dural opening, (b)
tumor debulking, (c) tumor
excised, and spinal cord
decompressed
357
After the tumor is removed and hemostasis achieved, the dura is inspected for
any residual which should be excised. The dural base is coagulated (Fig.58.3).
Dura is closed in a watertight fashion with non-resorbable stitches. When laminotomy is performed, posterior instrumented fusion is recommended; on the other
hand, in case of laminoplasty, the “posterior shutter” is placed back and xed with
stitches, and the patient is immobilized (cast) until fusion is achieved.
58.7 Expected Outcomes
Surgery for excision of spinal meningioma is usually a gratifying procedure with
generally good outcomes. Once the tumor is removed, the progressive neurological
decit is halted. Patients that had incomplete neurology before surgery will usually
notice some improvement or even return to normal. Most of the improvement will
happen within the rst 2 to 3 months from surgery, and usually by 12 months it will
reach a plateau.
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The risk of recurrence is generally low. However, it is possible, even after many
years; therefore, surveillance MRI is recommended. The proliferation index Ki-67
and the arachnoid invasion are the risk factors for recurrence of spinal meningiomas [6].
The postoperative outcome may be negatively inuenced by the anterior location
of the tumor with regard to the spinal cord, increased size, transdural expansion,
degree of spinal cord compression, calcication of the tumor, poor preoperative
neurological status, and aggressive histological status.
M. Ivanov
58.8 Potential Complications
Untreated patients can develop progressive neurological decit and potentially loss
of neurological function below the level of compression.
Surgical risks can be divided in:
• Intraoperative and early postoperative:
– Spinal cord or nerve injury.
– Bleeding.
– Infection—supercial or deep wound infection and meningitis.
– CSF leak.
– General/anesthetic risks.
• Delayed complications:
– Arachnoiditis.
– Tumor recurrence.
– Spinal deformity or possible osteoporotic fractures at the level of
laminectomy.
58.9 What Should Patient andFamily Know?
Tumors may be incidental ndings. If asymptomatic– they may stay dormant for
many years without obvious progression. Therefore, “watch and see” attitude is
acceptable in such cases, in particular in patients with low life expectancy.
Nevertheless, in most cases, the tumor will continue to slowly grow, and in
symptomatic patients with good life expectancy, it is recommended to excise the
tumor early.
Usually the tumor is benign, and in the vast majority the surgery is curative.
However, recurrence is possible; therefore, long-term MRI surveillance is
recommended.
58 Spinal Meningioma
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359
Further Readings
1. Kshettry VR, Hsieh JK, Ostrom QT, Kruchko C, Benzel EC, Barnholtz-Sloan JS.Descriptive
epidemiology of spinal meningiomas in the United States. Spine. 2015;40(15):E886–9.
2. Lee JH, Kim HS, Yoon YC, Cha MJ, Lee SH, Kim ES.Differentiating between spinal schwanno-
mas and meningiomas using MRI: a focus on cystic change. PLoS One. 2020;15(5):e0233623.
3. Raimondi AJ, Gutierrez FA, Di Rocco C.Laminotomy and total reconstruction of the posterior
spinal arch for spinal canal surgery in childhood. J Neurosurg. 1976;45(5):555–60.
4. Ivanov M, Wilkins S, Poeata I, Brodbelt A.Intraoperative ultrasound in neurosurgery—a prac-
tical guide. Br J Neurosurg. 2010;24(5):510–7.
5. Ivanov M, Budu A, Sims-Williams H, Poeata I.Using intraoperative ultrasonography for spinal
cord tumor surgery. World Neurosurg. 2017;97:104–11.
6. Maiuri F, Del Basso De Caro M, de Divitiis O, Guadagno E, Mariniello G.Recurrence of spinal
meningiomas: analysis of the risk factors. Br J Neurosurg. 2020;34:569–74.
Spinal Nerve Sheath Tumors (NST):
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Schwannoma andNeurofibroma
MarcelIvanov andIonPoeata
59.1 Definition
Spinal nerve sheath tumors, e.g., schwannomas and neurobromas, are slowgrowing, usually benign tumors, which arise from the nerve root (Figs. 59.1
and 59.2).
The tumors affect equally men and women. If untreated, they may reach a considerable size and may cause signicant morbidity.
Although in most of the cases solitary, they may be multiple and be part of more
complex conditions—neurobromatosis or schwannomatosis. These are separate
entities that are not discussed in this chapter.
NSTs are equally distributed along the entire spinal neuraxis. Of NSTs, 60% to
80% are intradural, 10% are both intradural and extradural, and occasionally NSTs
can be pure intramedullary or completely extradural or even extraspinal when they
can reach impressive size before being diagnosed (Fig.59.3).
Macroscopically schwannomas are more likely to grow on the periphery of the
nerve with the preservation of some neural laments which are displaced and remain
59
Supplementary Information The online version contains supplementary material available at
(https://doi.org/10.1007/978- 3- 030- 80356- 8_59).
M. Ivanov (*)
Department of Neurosurgery, Royal Hallamshire Hospital, Shefeld University,
Shefeld, UK
e-mail: m.ivanov@nhs.net
I. Poeata
Department of Neurosurgery, University of Medicine and Pharmacy “Gr. T.Popa”,
Iași, Romania
e-mail: ion.poeata@umasi.ro
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_59
361
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