A rare case report of extradural cervical spine meningioma

Parwej Ahmed; Rahul K Gupta; Azad Khan; Areeb A Siddiqui

doi:10.4103/jbjd.jbjd_3_23

CASE REPORTS

Year : 2023 | Volume : 38 | Issue : 1 | Page : 78-80

A rare case report of extradural cervical spine meningioma

Parwej Ahmed, Rahul K Gupta, Azad Khan, Areeb A Siddiqui
Department of Orthopaedics, Subharti Medical College, Meerut, Uttar Pradesh, India

Date of Submission	13-Jan-2023
Date of Acceptance	23-Jan-2023
Date of Web Publication	20-Apr-2023

Correspondence Address:
Areeb A Siddiqui
Department of Orthopaedics, Subharti Medical College, Flat Number 607, Durgabhagwati Residence, Subhartipuram, Meerut 250005, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbjd.jbjd_3_23

Abstract

Introduction: Extradural spinal meningiomas of the cervical spine are relatively uncommon. The vast majority of meningiomas develop in intracranial, intradural locations, and the majority of meningiomas affect the thoracic spine. History: A 39-year-old man presented with complaints of weakness in all four limbs for the last 8 months with bowel bladder involvement. Clinical Features: The patient had spastic quadriparesis with bowel and bladder involvement with planter extensors and the presence of patellar and ankle clonus. Investigation: Histopathopathology and immunohistochemical markers were sent and diagnosis of meningioma was made.

Keywords: Case report, cervical spine, meningioma

How to cite this article:
Ahmed P, Gupta RK, Khan A, Siddiqui AA. A rare case report of extradural cervical spine meningioma. J Bone Joint Dis 2023;38:78-80

How to cite this URL:
Ahmed P, Gupta RK, Khan A, Siddiqui AA. A rare case report of extradural cervical spine meningioma. J Bone Joint Dis [serial online] 2023 [cited 2023 Jun 7];38:78-80. Available from: http://www.jbjd.in/text.asp?2023/38/1/78/374425

Introduction

Meningiomas typically develop in intracranial or intradural regions. Meningioma accounts for approximately 38% of intradural spinal tumors and second most common intradural extramedullary tumors in adults.^[1],[2] In spine, the most common location of meningioma is thoracic spine.^[3] In this case report, we enlighten an extremely rare location of extradural meningioma in cervical spine.

Case Report

A 39-year-old man presented with complaints of weakness in bilateral upper limbs and lower limbs for the last 8 months. On examination, the patient had spastic quadriparesis with bowel and bladder involvement with planter extensors and presence of patellar and ankle clonus. The magnetic resonance imaging (MRI) of the cervical spine revealed evidence of an ill-defined long segment sheath-like soft-tissue intensity lesion, which appears slightly hyperintense on T1 and intermediate to isointense on T2 with homogenicity seen in right extradural space of cervical enhancement on post-contrast images spinal cord, extending from mid part of C3 vertebral body to upper margin of C6 vertebral body level. Medially, the lesion is encircling the right half of spinal cord and extending in anterior and posterior and right epidural space with intradural extension involving cervical spinal cord at C4–C6 vertebral level. Laterally, lesion is causing the widening of neural foramina at C4–C5 and C5–C6 levels and extension into extraforaminal region along the exiting nerve roots with widening of spinal canal causing encasement and narrowing of right vertebral artery and further anterolateral extension into upper neck region involving scalene muscles on right side [Figure 1]. Based on the radiological findings, differential diagnoses of neoplastic etiology (Neurogenic/Meningioma) granulomatous infective etiology was also considered. Based on the clinical and radiological findings, the patient underwent C3–C5 hemi-laminectomy exposing an entirely extradural mass adherent to the dura and ligamentum flavum. It was a brownish, nonsuckable, and moderately vascular mass. The intraoperatively biopsy specimen was taken and sent to the histopathological evaluation, and smears showed a meningioma (World health organisation grade 1) with mixed morphological pattern (meningothelial, psammomatous, and angiomatous, as shown in [Figure 2]). Immunohistochemistry markers were sent, which were (1) EMA strongly positive, (2) vimentin strongly positive in 60% tumor cells, and (3) s-100 strongly diffuse nuclear and cytoplasmic positivity in 50% tumor cells. Based on the above findings, a diagnosis of meningioma was made. The patient showed remarkable improvement in the motor symptoms, and bladder bowel control was gained gradually with almost full recovery in the postoperative follow-up course.

Figure 1: Sagittal, coronal, and axial images show signal abnormality from C3–C5 of posterior element with cord compression and edema

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Figure 2: Histopathology showing band of fibrous tissue with vascular channel, hyaline wall with mesothelial cell with psammoma bodies

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Discussion

Meningioma accounts for up to 38% of intradural spinal tumors and second most common intradural extramedullary tumors in adults. They usually rise from meningothelial arachnoid cells embedded in the dura.^[1],[2] The incidence of meningioma peaks between 50 and 65 years of age and is more common in females than in males^[4],[5] and is more common in the thoracic spine.^[3] Various subtypes of meningioma are seen, out of which psammomatous is most common, with rare exception of angioblastic and atypical subtype. Radiologically, plain films are usually normal, and calcification is very rare and may be present 1%–5% of cases. On MRI, most meningiomas appear isointense with the spinal cord on T1W and hyperintense on T2W image and show intense homogenous enhancement following contrast administration. Radiological features revealing lack of foraminal extension suggest a diagnosis of meningioma over schwannoma or neurofibromas. The latter two tumors show high signal intensity on T2W images and cystic changes with homogeneous enhancement.^[5] Chordoma is isotense to marrow on a T1W image.^[6] Surgical excision is the treatment of choice that depends on neurological symptoms, degree of neural compression, and age of patients. In this case report, patient presented with spastic quadriparesis with bowel and bladder involvement. Patient was evaluated clinicoradiologically, and patient underwent hemilamenectomy with complete excision of tumor and dural attachment was coagulated, postoperative period was uneventful, with a significant improvement in post-op 1week. As seen in literature, chances of recurrence of WHO grade 1 meningioma are very less.

Conclusion

Extradural meningioma is a very rare condition in cervical spine that is extremely rare. To the best of our knowledge, very few cases have been reported till date. Meningioma is difficult to diagnose as the feature overlaps with other extradural masses. Surgical excision is the treatment of choice. Radical excision is preferred as it prevents recurrence, if radical excision it not possible, one should go for subtotal resection. Prognosis of WHO grade 1 meningioma is good, and postoperative rehabilitation is of great importance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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