Spinal meningioma surgical technique

• Predicting intraoperative meningioma consistency using features from standard MRI sequences: a preoperative evaluation
• Management of skull base meningiomas with extracranial extension: resection, recurrence, and prognostic factors
• Impact of tumor size and peritumoral edema on outcomes and complications in anterior midline skull base meningiomas
• Risk factors for postoperative thrombotic complications after meningioma resection: a retrospective single-center study in China
• Identification of intracranial solitary fibrous tumor and atypical meningioma by multi-parameter MRI-based radiomics model
• Effect of routine extradural optic canal decompression performed by skull base trained surgeons on visual outcomes in patients with anterior skull base meningiomas
• Patient nutritional status is associated with surgical site infections in meningioma patients undergoing craniotomy for tumor resection
• Radiation-induced cerebral cavernous malformations

1. Positioning of the Patient:

Cervical Spine: For cervical spinal tumors, the patient is typically positioned prone (face down) with the head secured in a Mayfield clampor with the neck slightly flexed using a specialized head holder to allow access to the posterior cervical spine.

Thoracic and Lumbar Spine: For thoracic spinal tumors and lumbar tumors, the patient is also positioned prone. Proper padding of pressure points and careful alignment of the spine are crucial to avoid pressure injuries and ensure optimal surgical access.

2. Incision and Exposure: Incision: A midline skin incision over the vertebrae corresponds to the tumor's level. The length of the incision depends on the size of the cancer and the number of levels involved.

Muscle Dissection: Paraspinal muscles are dissected away from the spinous processes and laminae to expose the posterior elements of the spine (lamina and facet joints).

3. Laminectomy, laminoplasty or hemilaminectomy:

Laminectomy: A laminectomy (removal of the lamina) or hemilaminectomy (removal of part of the lamina) is performed to expose the dura mater covering the spinal cord. The extent of bone removal is tailored to provide adequate access to the tumor while minimizing bone loss and preserving spinal stability.

Fluoroscopy: Intraoperative fluoroscopy may be used to confirm the correct spinal level.

4. Dural Opening: The dura mater is carefully incised with a scalpel or scissors. The incision is typically made over the tumor, extending adequately to provide a working space while minimizing exposure of the spinal cord.

5. Tumor Resection: Tumor Identification: The arachnoid membrane is carefully dissected to expose the tumor. Spinal meningiomas are usually well-circumscribed and have a clear plane between the tumor and the spinal cord or nerve roots. Debulking and Resection: The tumor is internally debulked using an ultrasonic aspirator or micro scissors to reduce its size, facilitating its complete removal. After debulking, the tumor capsule is dissected away from the spinal cord, nerve roots, and dura mater. This dissection requires careful handling and often the use of micro-dissectors and fine forceps under high magnification with a surgical microscope. Vascular Control: Small feeding arteries and draining veins are coagulated using bipolar cautery or surgical clips. 6. Hemostasis and Closure: Hemostasis: Meticulous hemostasis is achieved using bipolar coagulation, hemostatic agents (such as oxidized cellulose or fibrin glue), and irrigation to ensure a dry field. Dural Closure: The dura mater is closed watertight using fine sutures or a dural substitute if needed. Muscle and Skin Closure: Paraspinal muscles are reapproximated over the bone defect, and the fascia, subcutaneous tissue, and skin are closed in layers. 7. Postoperative Care: The patient is closely monitored in the postoperative period for any signs of neurological deficit, cerebrospinal fluid (CSF) leak, or infection. An MRI is usually obtained postoperatively to confirm the extent of tumor resection and to evaluate for any spinal cord or nerve root compression. Considerations for Minimally Invasive Surgery (MIS) In some cases, minimally invasive techniques may be employed, particularly for smaller tumors. These techniques involve the use of tubular retractors, endoscopic assistance, and smaller incisions, which can reduce recovery time and minimize muscle damage. However, the suitability of MIS depends on the tumor’s size, location, and the surgeon's experience.

Conclusion The surgical resection of a spinal meningioma requires careful preoperative planning, meticulous surgical technique, and a thorough understanding of spinal anatomy to achieve complete tumor removal while preserving neurological function. Advances in surgical techniques, intraoperative imaging, and neuromonitoring have significantly improved the safety and outcomes of these procedures.

After dural opening, a plane can be developed between the arachnoid and the tumor. The tumor is then internally debulked using suction, an ultrasonic surgical aspirator, microscissors, or laser.

After debulking, in the majority of cases the tumor can be rolled away from the spinal cord and toward its dural attachment.

The tumor is then removed from its dural attachment.

Simpson grade I is not more effective than grade II in any outcome, although both are superior to III and IV in tumor recurrence. Results might suggest that dural coagulation is preferable over resection when the latter carries a higher risk of complications ¹⁾

Dura with remaining tumor can be coagulated using bipolar cauterization or resected.

In the majority of cases, the dural attachment was cauterized rather than resected. The dural attachment was always cauterized in cases involving an anterior dural attachment. Additionally, in most cases the dura was closed primarily, compared with suturing in a graft, which was performed far less frequently

Saito et al. reported dura preservation technique to reduce the risk of CSF leakage, in which the meningioma together with the inner layer of the dura is removed and the outer layer is preserved for simple dural closure. The long-term outcomes with this technique have never been investigated ²⁾.

Another option was separation of the dura into an outer and inner layer and to resect the tumor with the inner layer, leaving the outer layer available for closure ³⁾.

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