ACTA NEUROCHIRURGICA
Acta Neurochirurgica 46, 287--291 (1979)
9 by Springer-Verlag 1979
Neurosurgical Unit, Department of Surgery, University of Nigeria Teaching Hospital Enugu, Nigeria
Cauda Equina Epidural Meningioma By
S. C. Ohaegbulam With 2 Figures
Summary Spinal epidural meningiomas are rare. Also the location of meningiomas in the region of the cauda equina is uncommon. A case is presented in which a combination of both rare situations occured.
Case Report History: A 39-year-old business man was seen at the neurosurgical clinic of the University of Nigeria Teaching Hospital complaining of difficulty in walking, low back pain, penile pains, and sexual impotence. About one year before his admission the patient experienced numbness in the left leg of insidious onset, and this later spread to the right leg. Gradually, the backs of the thinghs, penis, and saddle area also became numb. After six months his gait became abnormal as he developed bilateral drop foot. In a few months, he could not walk without support. At the time of his hospitalisation, he was bedridden, and even with support standing was difficult. At about the same time of the onset, he experienced weak penile erection which progressed to complete impotence six months later. At night there was severe burning pain in the saddle area. He had had occasional low back ache since the onset of the illness, but the pain had gradually worsened and for three months before admission it had been associated with bilateral sciatica which was more severe in the left lower limb. There was no evidence of sphincter involvement. Examination: With the exception of obesity, abnormal signs were found only in the lower extremities. There was wasting of the calf muscles bilaterally. Lower limb weakness was confined to the ankles and toes where the power was grade 2. There was marked hypoesthesia of L~ to S5 dermatomes of varying degrees. Saddle anaethesia was very prominent. Vibration sense was diminished up to the level of the anterior superior iliac spines. Joint position sense was lost in both feet. Knee jerks were deminished, ankle jerks were absent, and plantar responses were flexor. Straight leg raising was reduced to 60 ~ on both sides by pain. 0001-6268/79/0046/0287/$
01.00
288
S.C. Ohaegbulam:
Investigation: The cs~ was normal with a protein content of 40rag~ Myelogram showed a block at the level of LjL~ (Fig. i). Operation: Laminectomy of L8 arid L~ was performed. A well circumscribed extradural turnout was found at the level of L~/4 antero-lateral to the dural tube. Complete removal was achieved. The postoperative course was uneventful.
Fig. 1. Myeiogram. PA view showing a block of the lower border of L3 vertebra. Note the irregular nature of the Myodit column
Pathology: The excised specimen consisted of irregular pieces of brown tissue. Microscopic examination showed the tumour to consist of sheets of oval ceils with oval nuclei. There were areas of mitosis in the sections. The diagnosis of meningotheliai meningioma was made (Fig. 2). Follow up: There was definite improvement objectively and subjectively within a few days after the operation. In three weeks he was walking welI, and was discharged home. He has been followed up for over two years, and has remained neurologically intact with normal sexual ability, and only complains of occasional mild low backache.
Cauda Equina Epidural Meningioma
289
Fig. 2. Photomicrograph of the epiduraI cauda equina meningioma. The sheets of oval cells are characteristic of meningothelial meningiorna. Haematoxylin and Eosin Discussion
Meningiomas are now known to arise from the endothelium which lines the leptomeningeal spaces in the case of spinal canal meningiomas, and the tela choroidea and choroid plexus in intraventricular meningiomas. It is also known that sequestrated clumps of arachnoid cells occur in the dura mater, and are probably the cells of origin of those meningiomas which are so attached to the dura that they appear to be arising from it. Elsberg (1933, 1941) and Rasmussen (1940) pointed out that spinal epidural meningiomas arise from the points of emergence of nerve roots where the arachnoid membrane is in contact with the dura mater. Haft and Shenkin (1963) made a similar observation in the case they reported. It is interesting that the case here reported also showed the same characteristic. The anatomical distribution of spinal meningiomas has been
290
S.C. Ohaegbulam:
analysed by several authors (Elsberg 1941, Northfield 1973). They show a predilection for the dorsal spine, which appears to be out of proportion to the length of that portion of the vertebral column. In the series reported by Elsberg, out of 73 spinal meningiomas, 4 were lumbar, 10 cervical, and 59 thoracic. None occurred in the cauda equina region. The occurrence of cauda equina meningioma is extremely rare. Spinal primary epidural meningiomas are also rare. Elsberg (1941) reported 4 cases in a series of 73 spinal meningiomas. Mullan and Evans (1957), and Shenkin (1945) reviewed spinal epidural tumours and found no meningiomas in their 50 and 40 cases respectively. Rasmussen et al. (1940) reviewed 557 spinal tumours. They found no primary epidural meningiorna, although 10 cases (7% were both intradural and extradural. Haft and Shenkin (1963) reported a case of dorsal epidural meningioma in a 24-year-old male. They reviewed the literature, and noted that there were only 13 examples out of 367 spinal meningiomas and 7 examples out of 371 extradural tumours of the spine. No cauda equina epidural meningioma was listed in that review. The clinical symptomatology of spinal meningioma is not so characteristic as to distinguish it from schwannoma or other tumours. However, when chronic spinal cord compression is seen in a patient over 35-40 years of age, a shrewd guess of meningioma may be made, especially if the compression is in the dorsal region of the cord. Epidural meningioma has no additional clinical characteristic. Because of the rarity of epidural cauda equina meningioma preoperative diagnosis is unlikely. Even myelography may not clinch the diagnosis. Acknowledgement
The author is grateful to Dr. (Mrs.) A. Suseelan, Consultant in Morbid Anatomy, for reporting on the excised specimen, and to Mr. A. Brooks for the photographs. References
I. Bull, J. W. D., Spinal meningiomas and neurofibromas. Acta Radiol. (Stockholm) 40 (1953), 283--300. 2. Elsberg, C. A., Concerning the Clinical and diagnosis of extramedullary meningeal and perineural fibroblastomas of the spinal cord. Bull. Neurological Institute New York 3 (1933), 124--137. 3. Elsberg, C. A., Surgicat diseases of the spinal cord, membranes and nerve roots. Symptoms, diagnosis and treatment, viii, p. 598. New York: P. B. Hoeber, Inc. 1941. 4. Haft, H., Shenkin, H. A., Spinal epidural meningioma. Case report. J. Neurosurg. 20 (1963), 801--804.
Cauda Equina Epidural Meningioma
291
5. Mullah, J., Evans, J. P., Neoplastic diseases of the spinal extradural space. A review of fity cases. Arch. Surg. (Chicago) 74 (1957), 900--907. 6. NorthfieId, D. W. C., Spinal cord compression. In: The surgery of the central nervous system, 1st Ed. p. 671. London: Blackwell. 1973. 7. Rasmussen, T. B., Kernohan, J. W., Adson, A. W., Pathological classification, with surgical consideration of intraspinal tumours. Ann. Surg. 111 (1940), 513--530. 8. Shenkin, H. A., Horn, R. C., Jr., Grant, F. C., Lesions of the spinal epidural space producing cord compression. Arch. Surg. (Chicago) 51 (1945), 125--146. Author's address: Dr. S. C. Ohaegbulam, Neurosurgical Unit, Department of Surgery, University of Nigeria Teaching Hospital, Enugu, Nigeria.
Acta Neurochirurgica 46, 287--291 (1979)
9 by Springer-Verlag 1979
Neurosurgical Unit, Department of Surgery, University of Nigeria Teaching Hospital Enugu, Nigeria
Cauda Equina Epidural Meningioma By
S. C. Ohaegbulam With 2 Figures
Summary Spinal epidural meningiomas are rare. Also the location of meningiomas in the region of the cauda equina is uncommon. A case is presented in which a combination of both rare situations occured.
Case Report History: A 39-year-old business man was seen at the neurosurgical clinic of the University of Nigeria Teaching Hospital complaining of difficulty in walking, low back pain, penile pains, and sexual impotence. About one year before his admission the patient experienced numbness in the left leg of insidious onset, and this later spread to the right leg. Gradually, the backs of the thinghs, penis, and saddle area also became numb. After six months his gait became abnormal as he developed bilateral drop foot. In a few months, he could not walk without support. At the time of his hospitalisation, he was bedridden, and even with support standing was difficult. At about the same time of the onset, he experienced weak penile erection which progressed to complete impotence six months later. At night there was severe burning pain in the saddle area. He had had occasional low back ache since the onset of the illness, but the pain had gradually worsened and for three months before admission it had been associated with bilateral sciatica which was more severe in the left lower limb. There was no evidence of sphincter involvement. Examination: With the exception of obesity, abnormal signs were found only in the lower extremities. There was wasting of the calf muscles bilaterally. Lower limb weakness was confined to the ankles and toes where the power was grade 2. There was marked hypoesthesia of L~ to S5 dermatomes of varying degrees. Saddle anaethesia was very prominent. Vibration sense was diminished up to the level of the anterior superior iliac spines. Joint position sense was lost in both feet. Knee jerks were deminished, ankle jerks were absent, and plantar responses were flexor. Straight leg raising was reduced to 60 ~ on both sides by pain. 0001-6268/79/0046/0287/$
01.00
288
S.C. Ohaegbulam:
Investigation: The cs~ was normal with a protein content of 40rag~ Myelogram showed a block at the level of LjL~ (Fig. i). Operation: Laminectomy of L8 arid L~ was performed. A well circumscribed extradural turnout was found at the level of L~/4 antero-lateral to the dural tube. Complete removal was achieved. The postoperative course was uneventful.
Fig. 1. Myeiogram. PA view showing a block of the lower border of L3 vertebra. Note the irregular nature of the Myodit column
Pathology: The excised specimen consisted of irregular pieces of brown tissue. Microscopic examination showed the tumour to consist of sheets of oval ceils with oval nuclei. There were areas of mitosis in the sections. The diagnosis of meningotheliai meningioma was made (Fig. 2). Follow up: There was definite improvement objectively and subjectively within a few days after the operation. In three weeks he was walking welI, and was discharged home. He has been followed up for over two years, and has remained neurologically intact with normal sexual ability, and only complains of occasional mild low backache.
Cauda Equina Epidural Meningioma
289
Fig. 2. Photomicrograph of the epiduraI cauda equina meningioma. The sheets of oval cells are characteristic of meningothelial meningiorna. Haematoxylin and Eosin Discussion
Meningiomas are now known to arise from the endothelium which lines the leptomeningeal spaces in the case of spinal canal meningiomas, and the tela choroidea and choroid plexus in intraventricular meningiomas. It is also known that sequestrated clumps of arachnoid cells occur in the dura mater, and are probably the cells of origin of those meningiomas which are so attached to the dura that they appear to be arising from it. Elsberg (1933, 1941) and Rasmussen (1940) pointed out that spinal epidural meningiomas arise from the points of emergence of nerve roots where the arachnoid membrane is in contact with the dura mater. Haft and Shenkin (1963) made a similar observation in the case they reported. It is interesting that the case here reported also showed the same characteristic. The anatomical distribution of spinal meningiomas has been
290
S.C. Ohaegbulam:
analysed by several authors (Elsberg 1941, Northfield 1973). They show a predilection for the dorsal spine, which appears to be out of proportion to the length of that portion of the vertebral column. In the series reported by Elsberg, out of 73 spinal meningiomas, 4 were lumbar, 10 cervical, and 59 thoracic. None occurred in the cauda equina region. The occurrence of cauda equina meningioma is extremely rare. Spinal primary epidural meningiomas are also rare. Elsberg (1941) reported 4 cases in a series of 73 spinal meningiomas. Mullan and Evans (1957), and Shenkin (1945) reviewed spinal epidural tumours and found no meningiomas in their 50 and 40 cases respectively. Rasmussen et al. (1940) reviewed 557 spinal tumours. They found no primary epidural meningiorna, although 10 cases (7% were both intradural and extradural. Haft and Shenkin (1963) reported a case of dorsal epidural meningioma in a 24-year-old male. They reviewed the literature, and noted that there were only 13 examples out of 367 spinal meningiomas and 7 examples out of 371 extradural tumours of the spine. No cauda equina epidural meningioma was listed in that review. The clinical symptomatology of spinal meningioma is not so characteristic as to distinguish it from schwannoma or other tumours. However, when chronic spinal cord compression is seen in a patient over 35-40 years of age, a shrewd guess of meningioma may be made, especially if the compression is in the dorsal region of the cord. Epidural meningioma has no additional clinical characteristic. Because of the rarity of epidural cauda equina meningioma preoperative diagnosis is unlikely. Even myelography may not clinch the diagnosis. Acknowledgement
The author is grateful to Dr. (Mrs.) A. Suseelan, Consultant in Morbid Anatomy, for reporting on the excised specimen, and to Mr. A. Brooks for the photographs. References
I. Bull, J. W. D., Spinal meningiomas and neurofibromas. Acta Radiol. (Stockholm) 40 (1953), 283--300. 2. Elsberg, C. A., Concerning the Clinical and diagnosis of extramedullary meningeal and perineural fibroblastomas of the spinal cord. Bull. Neurological Institute New York 3 (1933), 124--137. 3. Elsberg, C. A., Surgicat diseases of the spinal cord, membranes and nerve roots. Symptoms, diagnosis and treatment, viii, p. 598. New York: P. B. Hoeber, Inc. 1941. 4. Haft, H., Shenkin, H. A., Spinal epidural meningioma. Case report. J. Neurosurg. 20 (1963), 801--804.
Cauda Equina Epidural Meningioma
291
5. Mullah, J., Evans, J. P., Neoplastic diseases of the spinal extradural space. A review of fity cases. Arch. Surg. (Chicago) 74 (1957), 900--907. 6. NorthfieId, D. W. C., Spinal cord compression. In: The surgery of the central nervous system, 1st Ed. p. 671. London: Blackwell. 1973. 7. Rasmussen, T. B., Kernohan, J. W., Adson, A. W., Pathological classification, with surgical consideration of intraspinal tumours. Ann. Surg. 111 (1940), 513--530. 8. Shenkin, H. A., Horn, R. C., Jr., Grant, F. C., Lesions of the spinal epidural space producing cord compression. Arch. Surg. (Chicago) 51 (1945), 125--146. Author's address: Dr. S. C. Ohaegbulam, Neurosurgical Unit, Department of Surgery, University of Nigeria Teaching Hospital, Enugu, Nigeria.
