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Epidemiology

Spinal meningiomas can occur at any age, but are most common between the 5th and 7th decades of life. It is also more common in women (75-85% of all spinal meningiomas) and in the thoracic spine (90% of all meningiomas).

Pathology

Meningiomas of the spine are thought to arise from the arachnoid cap cells of arachnoid villi (aka arachnoid granulations). Arachnoid villi in the spine are concentrated mainly over the nerve roots, and the meningiomas tend to rise more laterally. However, the origin of meningiomas is still controversial. It is thought that the ventral and dorsal spinal meningiomas might arise from fibroblast cells of the arachnoid or the pia mater.

Most spinal meningiomas belong to the psammomatous histological type.

Spinal and convexity meningiomas of ten have 22q deletions and/or NF2 mutations

Spinal meningiomas are associated with the following syndromes:

NF2
Familial clear cell meningioma syndrome
Multiple meningiomatosis

Clinical features

The symptoms include:

mild pain
insidious neurological deficit

Increasingly, many of the spinal meningiomas are incidentally found

Differential diagnosis

The differential diagnosis of intradural extramedullary spinal meningiomas is:

schwannoma
ependymomas, myxopapillary
lymphomas
metastases

However, meningiomas can be intradural with extradural extension, extradural, intramedullary, intraosseous or paraspinous.

Investigations

CT scan:

Calcification 1-5%
Rare for bone remodelling ( might occur in the foramina)
Strong contrast enhancement

MRI scan:

ventral or ventrolateral
non-contrast enhanced scans: isodense with the cord (T1 and T2)
uniformly contrast-enhancing
if calcified, it might not enhance
dural tail (58%)

	Meningioma	Schwannoma	Ependymomas	Mets	neurofibroma	lymphoma	chordoma	Haemangioma	paraganglioma	epidermoid	Arachnoid cysts
*epidemiology*				Multiple, history		Rare900			rare
			lumbar
*Dura based*	+	If large abuts dura	If large abuts dura
T1	Iso					solitary				low	Identical to CSF
T2	Iso	increased									Identical to CSF
*Contrast*	avid	variable	avid							No central enhancement
*Diffusion weights*
*cysts*
*Calcification*
*Haemorrhage*			yes
*Haemosiderin cap*			Yes

Feature	Meningioma	Schwannoma	Neurofibroma
Typical Location	Thoracic spine, intradural extramedullary	Lumbar spine, intradural/extradural	Cervical spine, intradural/extradural
Shape	Oval, sometimes with “ginkgo leaf” sign	Lobulated or dumbbell-shaped	Spindle-shaped, sometimes “target sign”
T2 MRI Signal	Iso- to hyperintense; less fluid signal	Hyperintense, often with cystic changes	Hyperintense, often with “target sign”
Enhancement Pattern	Diffuse, homogeneous; frequent dural tail	Rim or heterogeneous enhancement	Variable, less rim enhancement
Calcification (CT)	Common (up to 58%)	Rare	Rare
Dural Tail Sign	Common (up to 75%)	Rare	Rare
Neural Foraminal Ext.	Rare	Common (dumbbell shape)	Common
Cystic Change	Uncommon	Common (up to 96%)	Less common than schwannoma

(Table generated from Consensus AI)

Surgical Management

The following website includes operative videos which give an excellent outline of the surgical excision of spinal meningiomas:

Spinal Meningiomas