Spinal meningioma epidemiology

Spinal meningioma epidemiology

Because spinal meningiomas are infrequently encountered in any one center, a large portion of the literature relating to spinal meningiomas consists of case reports or case series 1)


In The Surveillance, Epidemiology and End Results, the age-adjusted incidence rate was 0.37 cases per 1,000,000 person-years between 2004 and 2016. Spinal meningiomas represented 4.25% of all meningiomas. A total of 4204 patients with spinal meningiomas were included in the study. Most of the patients were white and diagnosed at 60-69 years of age, and the female:male ratio was 4:1. Most of the tumors were benign and less than 3 cm in size. The most common pathological type was psammomatous meningioma. Surgery was the first choice of treatment for patients with spinal meningiomas. Male and pediatric patients were more vulnerable to borderline or malignant spinal meningiomas. Survival analysis showed that married, female, and younger patients with benign meningiomas had better overall survival than their counterparts 2).


Approximately 1000 spinal meningiomas were diagnosed in the United States per year, and the incidence was relatively stable. Advanced age, female sex, Asian Pacific Islander and Caucasian race, and Hispanic ethnicity were all associated with an increased incidence of spinal meningioma. The study of represents the most comprehensive evaluation of population-based descriptive epidemiology of spinal meningiomas in the United States to date 3).


Spinal meningiomas represent a significant fraction of all primary intradural spinal tumors and of all meningiomas. The results of a study of Westwick and Shamji established the association of lesion incidence and survival with sex, with a less frequent incidence in but greater mortality among males 4).

Meningiomas arising from the coverings of the spinal cord are one of the two most common intradural extramedullary spinal tumors, representing 25-30% of all such tumor5)

Amongst the intraspinal location, meningiomas account for 25% to 46% of primary spinal neoplasms, while the incidence of spinal meningiomas is 7.5% to 12.7% of all meningiomas

They have a peak incidence in the fifth and sixth decades. Interestingly, and unlike intracranial meningiomas, in the adult population, females are approximately ten times more commonly affected than males. In children, there does not appear to be a sex predilection.

There is an increased incidence of spinal meningiomas in patients with neurofibromatosis type 2 (NF2), and in fact in the paediatric population, meningiomas uncommonly occur outside of the setting of NF2.


Except in cases of neurofibromatosis, it is very rare for tumors of different pathological types to exist concurrently at the same spinal level, with only 9 cases reported to date, in which spinal meningioma was found with spinal schwannoma in 7 cases and with spinal neurofibroma in 2 cases 6).


2)

Cao Y, Jiang Y, Liu C, Jin R, Jin Z, Hong X, Zhao L, Zhao G, Wang Y. Epidemiology and survival of patients with spinal meningiomas: A SEER analysis. Eur J Surg Oncol. 2021 Jan 22:S0748-7983(21)00039-1. doi: 10.1016/j.ejso.2021.01.012. Epub ahead of print. PMID: 33546961.
3)

Kshettry VR, Hsieh JK, Ostrom QT, Kruchko C, Benzel EC, Barnholtz-Sloan JS. Descriptive Epidemiology of Spinal Meningiomas in the United States. Spine (Phila Pa 1976). 2015 Aug 1;40(15):E886-9. doi: 10.1097/BRS.0000000000000974. PMID: 25996535.
4)

Westwick HJ, Shamji MF. Effects of sex on the incidence and prognosis of spinal meningiomas: a Surveillance, Epidemiology, and End Results study. J Neurosurg Spine. 2015 Sep;23(3):368-73. doi: 10.3171/2014.12.SPINE14974. Epub 2015 May 29. PMID: 26023898.
5)

Osborn AG. Diagnostic neuroradiology. Mosby Inc. (1994) ISBN:0801674867.
6)

Zhan Z, Yan X, Nie W, Ding Y, Xu W, Huang H. Neurofibroma and Meningioma within a Single Dumbbell-Shaped Tumor at the Same Cervical Level without Neurofibromatosis: a Case Report and Literature Review. World Neurosurg. 2019 Jun 26. pii: S1878-8750(19)31788-7. doi: 10.1016/j.wneu.2019.06.142. [Epub ahead of print] PubMed PMID: 31254713.

Barricaid Annular Closing Device

Barricaid Annular Closing Device

https://www.barricaid.com

The bulk of the information regarding the use of annular closure devices in the prevention of recurrent herniation following lumbar discectomy comes from a randomized clinical trial (RCT) to evaluate the use of Barricaid device (Barricaid, Intrinsic Therapeutics, Inc, Woburn, MA) 1).

Previously reported long-term outcomes (3 years) of this RCT have shown a significant decrease in symptomatic reherniation (14.8 vs 29.5%) and reoperation (11 vs 19.3%) rates when compared with the control group 2).


Barricaid is designed to close large defects in the annulus, so to prevent recurrent disc herniation, while allowing the surgeon to preserve more of the patient’s lumbar disc.

The Barricaid Anular Closure device consists of a woven polyester occlusion component intended to block an anular defect, while anchored to the adjacent vertebral body by a titanium bone anchor.

Reinforcing the annulus fibrosus with Barricaid during lumbar discectomy may slow the progression of facet joint degeneration 3).


The polymer mesh is placed on the inner surface of the disc annulus, using the disc pressure to help seal the defect against leakage of the nucleus pulposus. Once wound dissection and (partial, hemilaminectomy has been done, discectomy is followed. However, aggressive nucleus removal has been shown to result in significant back pain and worsened clinical outcomes. After discectomy, the annular defect size is measured and the appropriately sized device is chosen. The titanium anchor is inserted into the bone (parallel to the surface of the endplate) and the mesh forms a barrier that blocks the defect.

The device provides permanent fixation through the bone anchorage and remains inside the disc. During the procedure, fluoroscopic guidance is required to ensure the appropriate location of the device.

Annular closure device insertion allows more nucleus to be left inside of the annulus and restores intra-discal pressure. Because only partial volume is removed from the intervertebral disc, this procedure can preserve disc height and motion and reduce facet degeneration


Patients with primary lumbar disc herniation show Endplate changes (EPC) in the corresponding segments. There is a significant increase in lesion number and size within 12 months after discectomy. This increase is significantly more pronounced in the annular closure device (ACD) group. The presence and growth of EPC are not correlated with low-back pain or ODI 4).

Study registration: ClinicalTrials.gov (https://clinicaltrials.gov): NCT03986580 5)

Barricaid Annular Closing Device case series.

Barricaid Annular Closing Device case reports.

Kurzbuch AR, Fournier JY, Tuleasca C. The annular closure device – panacea of lumbar disc herniation: how closed is closed enough for the intervertebral disc space? Acta Neurochir (Wien). 2021 Feb 19. doi: 10.1007/s00701-021-04764-9. Epub ahead of print. PMID: 33606100.


1)

Thomé C, Klassen PD, Bouma GJ, Kuršumović A, Fandino J, Barth M, Arts M, van den Brink W, Bostelmann R, Hegewald A, Heidecke V, Vajkoczy P, Fröhlich S, Wolfs J, Assaker R, Van de Kelft E, Köhler HP, Jadik S, Eustacchio S, Hes R, Martens F, Annular Closure RCT Study Group (2018) Annular closure in lumbar microdiscectomy for prevention of reherniation: a randomized clinical trial. Spine J 18(12):2278–2287
2)

Kienzler JC, Klassen PD, Miller LE, Assaker R, Heidecke V, Fröhlich S, Thomé C, Annular Closure RCT Study Group (2019) Three-year results from a randomized trial of lumbar discectomy with annulus fibrosus occlusion in patients at high risk for reherniation. Acta Neurochir 161(7):1389–1396
3)

Trummer M, Eustacchio S, Barth M, Klassen PD, Stein S. Protecting facet joints post-lumbar discectomy: Barricaid annular closure device reduces risk of facet degeneration. Clin Neurol Neurosurg. 2013 Aug;115(8):1440-5. doi: 10.1016/j.clineuro.2013.01.007. Epub 2013 Mar 6. PubMed PMID: 23473658.
4)

Barth M, Weiß C, Bouma GJ, Bostelmann R, Kursumovic A, Fandino J, Thomé C. Endplate changes after lumbar discectomy with and without implantation of an annular closure device. Acta Neurochir (Wien). 2018 Apr;160(4):855-862. doi: 10.1007/s00701-017-3463-y. Epub 2018 Feb 2. PMID: 29396603.
5)

Strenge KB, DiPaola CP, Miller LE, Hill CP, Whitmore RG. Multicenter study of lumbar discectomy with Barricaid annular closure device for prevention of lumbar disc reherniation in US patients: A historically controlled post-market study protocol. Medicine (Baltimore). 2019 Aug;98(35):e16953. doi: 10.1097/MD.0000000000016953. PMID: 31464935; PMCID: PMC6736093.

Anterior lumbar interbody fusion (ALIF)

Anterior lumbar interbody fusion (ALIF)

ALIF is an effective treatment for degenerative disc disease (with and without radiculopathy) and spondylolisthesis. Although results were promising for scoliosis, failed posterior fusion, and adjacent segment disease, further studies are necessary to establish the effectiveness of ALIF in these conditions 1).

Radiographic adjacent segment disease ASD is relatively common long-term finding associated with instrumented lumbar fusion. However, radiographic evidence of ASD does not necessarily correlate with a poor outcome. Results suggest that advanced age, anterior lumbar interbody fusion, and the restoration of the preoperative standing lumbar lordosis may have a protective effect against the development of ASD 2).

In degenerative disc disease, if conservative extensive care fails, anterior lumbar interbody fusion has proven to be an alternative form of surgical management.

Best for L5–1 (where the great vessels tend not to interfere with the access, and where every degree of correction produces a more significant amount of improvement in SVA than at other levels as a result of being at the lowest point in the spine).

Amount of lumbar lordosis that can be obtained (6º) 3)

Retroperitoneal usually through a Pfannenstiel’s abdominal incision.

Relatively contraindicated in males because of risk of retrograde ejaculation in 1–2% (as high as 45% in some reviews). Other risks: injury to great vessels, especially with calcified arteries, especially at L4–5. Bowel prep the day before surgery for complex cases.

Trendelenburg position, place the level of the iliac crests over the kidney rest, or use a sacral bump to increase lordosis. As a result of the bifurcation of the great vessels (aorta and inferior vena cava) which ranges from just above to just below the L4–5 disc space, this approach is best suited for access to L5–1. At L5–1, the anterior sacral artery runs down the midline of the VB and has to be sacrificed to do an ALIF.


Continuous wound infiltration with ropivacaine using an On-Q system may be effective for controlling postoperative pain after ALIF surgery 4).

see ALIF Cage

Anterior lumbar interbody fusion (ALIF) with percutaneous pedicle screw fixation (PPF) provides successful surgical outcomes to isthmic spondylolisthesis patients with indirect decompression through foraminal volume expansion. However, indirect decompression through ALIF followed by PPF may not obtain a successful surgical outcome in patients with isthmic spondylolisthesis accompanied by foraminal stenosis caused by a posterior osteophyte or foraminal sequestrated disc herniation. The microscopic anterior foraminal approach provides successful foraminal decompression. Combined with ALIF and PPF, this approach shows a good surgical outcome in patients with isthmic spondylolisthesis accompanied by foraminal stenosis caused by a posterior osteophyte or those with foraminal sequestrated disc herniation 5).

Posterior pedicle screw supplementation without posterolateral fusion improves the fusion rate of ALIF when using anterior cage and screw constructs 6).

The procedure is performed in close proximity to the large blood vessels.

Damage to these large blood vessels may result in excessive blood loss. Quoted rates in the medical literature put this risk at 1% to 15%, although this should be an uncommon complication in the hands of experienced vascular and spine surgeons.

Retrograde Ejaculation after ALIF Surgery

For males, another risk unique to this approach is that approaching the L5-S1 (lumbar segment 5 and sacral segment 1) disc space from the front has a risk of creating a condition known as retrograde ejaculation.

There are very small nerves directly over the disc interspace that control a valve that causes the ejaculate to be expelled outward during intercourse. By dissecting over the disc space, the nerves can stop working, and without this coordinating innervation to the valve, the ejaculate takes the path of least resistance, which is up into the bladder.

With retrograde ejaculation, the sensation of ejaculating is largely the same, but it makes conception very difficult (special harvesting techniques can be utilized). Fortunately, retrograde ejaculation happens in less than 1% of cases and tends to resolve over time (a few months to a year). This complication does not result in impotence as these nerves do not control erection.

Sixty-one patients who underwent ALIF surgery were enrolled. For thirty-one of them, a continuous local anesthetics infiltration system was used at the abdominal site. They collected data regarding the patients’ sleep quality; satisfaction with pain control after surgery; abilities to perform physical tasks and the additional application of opioids in the postoperative 48 hours.

The On-Q system group showed reduced visual analog scale scores for pain at the surgical site during rest and movement at 0, 12, 24, and 48 hours; and more were satisfied with pain control management at the first postoperative day (7.0 ± 1.2 vs. 6.0 ± 1.4; P = 0.003) and week (8.1 ± 1.6 vs. 7.0 ± 1.8; P = 0.010) than the control group. The number of additional patient-controlled analgesia (PCA) bolus and pethidine injections was lower in the On-Q group (PCA: 3.67 ± 1.35 vs. 4.60 ± 1.88; P = 0.049 and pethidine: 2.09 ± 1.07 vs. 2.73 ± 1.38; P = 0.032). Patients who used the On-Q system performed more diverse activity and achieved earlier ambulation than those in the control group.

Continuous wound infiltration with ropivacaine using an On-Q system may be effective for controlling postoperative pain after ALIF surgery 7).

2017

study retrospectively reviewed 82 patients who underwent MO-ALIF with self-anchored standalone cages (n = 42) or TLIF (n = 40) for the treatment of lumbar disc herniation between April 2013 and October 2014. Patient demographics, intraoperative parameters, and perioperative complications were collated. Clinical outcomes were evaluated using the visual analog scale (VAS) scoring, the Oswestry Disability Index (ODI) for pain in the leg and back, and radiological outcomes, including fusion, lumbar lordosis (LL), disc height (DH), and cage subsidence were evaluated at each follow-up for up to 2 years.

Patients who underwent TLIF had a significantly higher volume of blood loss (295.2 ± 81.4 vs. 57.0 ± 15.2 mL) and longer surgery time (130.7 ± 45.1 vs. 60.4 ± 20.8 min) than those who had MO-ALIF. Compared with baseline, both groups had significant improvements in the VAS and ODI scores and DH and LL postoperatively, though no significant difference was found between the two groups regarding these indexes. All patients reached solid fusion at the final follow-up in both groups. Three patients (3/42) with three levels (3/50) suffered from cage subsidence in the MO-ALIF group; meanwhile, no cage subsidence occurred in the TLIF group.

MO-ALIF with self-anchored stand-alone cages is a safe and effective treatment of lumbar disc herniation with less surgical trauma and similar clinical and radiological outcomes compared with TLIF 8).

2015

84 consecutive patients who underwent anterior lumbar interbody fusion from 2004 to 2009 were reviewed. The operative time, intraoperative blood loss, hospital stay, Oswestry Disability Index (ODI), visual analog scale (VAS) results, and complication rate were recorded separately.Medical indications were degenerative disc disease (73.8%), postdiscectomy disc disease (16.1%), and disc herniation (9.5%). Patients with severe spondylolysis or disc degeneration, with more than 3 or multilevel lesions, were excluded.The mean operative time was 124.5 ± 10.9 min (range 51-248 min), the mean intraoperative blood loss was 242.1 ± 27.7 mL (range 50-2700 mL), the mean hospital stay was 3.9 ± 1.1 days (range 3-6 days), the mean preoperative VAS score was 7.5 ± 1.4, and the mean preoperative ODI score was 60.0 ± 5.7. At the 1-year follow-up, the mean postoperative VAS score was 3.3 ± 1.3 and the mean postoperative ODI score was 13.6 ± 3.4 (P < 0.05). L4-L5 disc fusion led to better clinical results than 2-level L4-L5/L5-S1 disc fusion. Additionally, the 2-level fusion of L4-L5/L5-S1 had better clinical results than the L5-S1 disc fusion at both the 1 and 2-year postoperative follow-ups regarding the VAS score and the ODI score. The rate of complications was more frequent in the 2-level L4-L5/L5-S1 group (27.3%) (group C) than in the L4-L5 group (9.1%) (group A) and the L5-S1 group (12.5%) (group B). There was no difference between the L4-L5 group (9.1%) and the L5-S1 group (12.5%). A venous tear occurred during surgery and was successfully repaired in 6 of the 84 patients. Also, out of the 84 patients, 6 were found with pseudarthrosis during the follow-up, and these patients underwent a spinal fusion with instrumentation, with a posterior approach after a mean of 1 year. The complications secondary to the surgical approach were persistent abdominal pain (1/84, 1.2%) and wound dehiscence (1/84, 1.2%). Anterior lumbar interbody fusion for L4-L5 had better clinical results than the 2-segmental L4-L5/L5-S1 disc fusion, and the 2-segmental L4-L5/L5-S1 disc fusion had better clinical results than the L5-S1 disc fusion. Also, the 2-segmental L4-L5/L5-S1 disc fusion had a higher complication rate (27.3%), but there was no difference between the L4-L5 group (9.1%) and the L5-S1 group (12.5%) 9).


1)

Rao PJ, Loganathan A, Yeung V, Mobbs RJ. Outcomes of anterior lumbar interbody fusion surgery based on indication: a prospective study. Neurosurgery. 2015 Jan;76(1):7-24. doi: 10.1227/NEU.0000000000000561. PubMed PMID: 25255259.
2)

Min JH, Jang JS, Jung Bj, Lee HY, Choi WC, Shim CS, Choi G, Lee SH. The clinical characteristics and risk factors for the adjacent segment degeneration in instrumented lumbar fusion. J Spinal Disord Tech. 2008 Jul;21(5):305-9. doi: 10.1097/BSD.0b013e318142b960. PubMed PMID: 18600137.
3)

Hsieh PC, Koski TR, O’Shaughnessy B A, et al. Anterior lumbar interbody fusion in comparison with transforaminal lumbar interbody fusion: implications for the restoration of foraminal height, local disc angle, lumbar lordosis, and sagittal balance. J Neurosurg Spine. 2007; 7:379–386
4) , 7)

Lee SM, Yun DJ, Lee SH, Lee HC, Joeng KH. Continuous wound infiltration of ropivacaine for reducing of postoperative pain after anterior lumbar fusion surgery: a clinical retrospective comparative study. Korean J Pain. 2021 Apr 1;34(2):193-200. doi: 10.3344/kjp.2021.34.2.193. PMID: 33785671.
5)

Shin SH, Choi WG, Hwang BW, Tsang YS, Chung ER, Lee HC, Lee SJ, Lee SH. Microscopic anterior foraminal decompression combined with anterior lumbar interbody fusion. Spine J. 2013 Oct;13(10):1190-9. doi: 10.1016/j.spinee.2013.07.458. Epub 2013 Oct 2. PubMed PMID: 24094988.
6)

McCarthy MJ, Ng L, Vermeersch G, Chan D. A radiological comparison of anterior fusion rates in anterior lumbar interbody fusion. Global Spine J. 2012 Dec;2(4):195-206. doi: 10.1055/s-0032-1329892. Epub 2012 Nov 19. PubMed PMID: 24353968; PubMed Central PMCID: PMC3864421.
8)

Kuang L, Wang B, Lü G. Transforaminal Lumbar Interbody Fusion Versus Mini-open Anterior Lumbar Interbody Fusion With Oblique Self-anchored Stand-alone Cages for the Treatment of Lumbar Disc Herniation: A Retrospective Study With 2-year Follow-up. Spine (Phila Pa 1976). 2017 Nov 1;42(21):E1259-E1265. doi: 10.1097/BRS.0000000000002145. PubMed PMID: 28277385.
9)

Ni J, Fang X, Zhong W, Liu N, Wood KB. Anterior Lumbar Interbody Fusion for Degenerative Discogenic Low Back Pain: Evaluation of L4-S1 Fusion. Medicine (Baltimore). 2015 Oct;94(43):e1851. doi: 10.1097/MD.0000000000001851. PubMed PMID: 26512594.
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