CHAPTER
142
Intradural, Extramedullary
Spinal Tumors
BACKGROUND
OVERVIEW
Since the development of routine successful surgery for intra-
dural, extramedullary spinal tumors following the pioneering
work by Frazier,5 Elsberg,4 and Cushing,2 removal of these
tumors has been considered to be among the most rewarding
operations in neurosurgery. Although tumors in the intradural
extramedullary location encompass a range of histologies, they
are almost always benign and well encapsulated and, as such,
are typically amenable to surgical cure. Usually, improvement
in neurological symptoms rapidly follows the decompression of
neural elements from tumor removal. Given a common thera-
peutic goal of gross-total macroscopic resection (GTMR)
regardless of histological type, the traditional categorization
based on anatomy rather than histology is still an appropriate
paradigm for treatment of this group of tumors. Moreover, an
anatomic understanding of their relationship to meningeal lay-
ers and neural elements forms the basis of useful principles to
effect their safe removal.
EPIDEMIOLOGY
Intradural extramedullary tumors by definition form outside
of the spinal cord and inside its dural coverings and arise from
the range of tissues within that anatomic space: nerves and
nerve roots (neurofibromas, schwannomas, and paragan-
gliomas), arachnoid and dura (arachnoid cysts, meningiomas),
blood vessels (hemangioblastomas), and ectopic tissues (der-
moids, epidermoids, lipomas, teratomas, ependymomas,
metastases). In adults, the vast majority of intradural extramed-
ullary tumors are nerve sheath tumors, meningiomas, or
ependymomas of the filum terminale. In children, menin-
giomas and schwannomas are extremely rare and are sup-
planted in their rank of incidence by ectopic lesions associated
with dysembryogenesis.
PRESENTATION
The most common presenting symptom of an intradural,
extramedullary tumor is pain. In the case of nerve sheath
tumors,13,23,24 the pattern is often dermatomal, reflecting
LWBK836_Ch142_p1535-1543.indd 1535
Alfred T. Ogden
Paul C. McCormick
direct involvement of the nerve root of origin or compression
of an adjacent nerve root. Lesions that cause symptoms by
spinal cord compression, such as meningiomas,12,14,15,25 or
that indirectly involve multiple nerve roots, such as myxopap-
illary ependymomas,26 induce a pain syndrome that is more
central, dull, and nonspecific, akin to that generated by
intramedullary lesions. In cases of spinal cord compression,
pain is likely to be accompanied by neurological symptoms. In
general, neurological symptoms will occur in a dermatomal
pattern, a spinal pattern, or some combination, depending on
the pathoanatomical relationships of the tumor. The classic
syndrome of stepwise progression through segmental, hemi-
cord, and transverse cord dysfunction is seldom seen today
because of earlier diagnoses enabled by physician awareness
and the widespread availability of magnetic resonance imag-
ing (MRI).
PREOPERATIVE EVALUATION AND IMAGING
Complete imaging is an important prerequisite to developing a
coherent operative plan. A contrast-enhanced MRI is an essen-
tial starting point. The vast majority of intradural, extramedul-
lary lesions, including nerve sheath tumors, meningiomas, and
ependymomas, have similar imaging characteristics on MRI,
appearing hypointense to isointense to neural tissue on
T1-weighted sequences and enhancing homogenously after
contrast administration. Despite these commonalities, distin-
guishing features can sometimes be gleaned that may suggest
certain histopathologies (Fig. 142.1). A close association with
the dura or the presence of a dural tail suggests a meningioma.
A dumbbell-shaped lesion traversing a neural foramen suggests
nerve sheath origin. For nerve sheath tumors with extensive
extraforaminal components, computed tomography (CT) and
plain X-rays may be required to evaluate the extent of bony
destruction and the potential for postresection instability.
When MRI is ambiguous in defining whether the intracanalicu-
lar portion of a dumbbell tumor is intradural, CT myelography
can be revealing. Lack of contrast enhancement is suggestive of
rarer lesions such as dermoid/epidermoids, cavernous malfor-
mations, and arachnoid cysts. Fat-suppressed MR sequences
can help to distinguish between intralesional lipid content,
hemorrhage, and cyst fluid.
1535
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 1536 Section XIII Tumor and Osteomyelitis
Intradural Extramedullary Tumors: Algorithm of preoperative imaging
Contrast-enhancing lesion
Dural base/tail Dumbbell
Meningioma Clear intradural
component
Schwannoma
Meningioma Nerve sheath tumor
Filum ependymoma
Hemangioblastoma
Metastasis
Large extraforaminal component
With extensive bony erosion
CT, upright X-rays to assess
Need for stabilization
Figure 142.1. Flow chart illustrating likely histological diagnoses of intradural extramedullary spinal
tumors based on imaging characteristics on contrast-enhanced magnetic resonance imagining. CT com-
puted tomography.
CLASSIFICATIONS, INDICATIONS,
AND CONTRAINDICATIONS
NERVE SHEATH TUMORS
Nerve sheath tumors arise from supporting cells adjacent to
neurons within spinal roots and nerves. Schwannomas account
for around 85% of these tumors and are the most common of
all intradural, extramedullary spinal tumors.24 They arise from
myelin-producing Schwann cells and grow tangentially to nerve
fibers in two characteristic collagen fiber bundling patterns:
Antoni A and Antoni B. Neurofibromas, which account for
around 15% of nerve sheath tumors,23 lack this histological
organization, consisting of fibrous cell bundles admixed with
nerve fibers. There is still debate over their cell of origin.
The typical nerve sheath tumor occurs sporadically and
presents in the fourth decade of life without apparent predilec-
tion for gender or spinal level.23,24 Because of associations with
neurofibromatosis (NF), however, any patient presenting with a
nerve sheath tumor should be examined for the stigmata of NF
and counseled regarding this potential diagnosis. Neurofibromas
are associated with neurofibromatosis type 1 (NF 1), whereas
schwannomas are associated with neurofibromatosis type 2
(NF 2). Multiple neurofibromas or schwannomas are pathog-
nomonic for their respective NF subtypes.
Approximately 3% of peripheral nerve sheath tumors
exhibit gross or microscopic evidence of invasiveness and a
high mitotic index. Such tumors are lumped into the classifica-
tion of malignant nerve sheath tumor (MNST) regardless of
their other histological features. MNSTs are associated with NF
LWBK836_Ch142_p1535-1543.indd 1536
Non-enhancing lesion
Unclear intradural +Fat-suppression -Fat-suppression
Component
Consider Dermoid Cavernous malformation
CT myelogram Epidermoid Arachnoid cyst
Lipoma
1 and are more common in patients with plexiform neurofibro-
mas and a history of irradiation. Very rarely do they involve the
spine.7
The treatment of choice for nerve sheath tumors is surgical
excision. Surgery is indicated for any symptomatic lesion and/
or lesions exhibiting spinal cord compression on MRI. Since
these are slow-growing tumors, small, incidentally discovered
lesions can be followed with serial imaging studies until growth
is documented or until symptoms occur. Although a likely strat-
egy for patients with NF and multiple lesions, observation of
sporadic lesions carries the risk attendant to any presumed
diagnosis. In particular, the inability to distinguish conclusively
on MRI between nerve sheath tumors and filum ependymomas,
which are likely better served by early surgical intervention,
makes the removal of all lesions associated with lumbar nerve
roots imperative. The decision to operate must, of course, be
weighed against the general health and age of the patient, as
these may be relative contraindications to surgery.
In rare cases of MNSTs affecting the spine, surgery is still
indicated but must be performed with the goal of achieving
wide surgical margins and a follow-up plan for adjuvant ther-
apy. Malignant degeneration of nerve sheath tumors is not
uncommon in the NF population and must be considered in
any lesion that demonstrates rapid growth on sequential
imaging.
MENINGIOMAS
Meningiomas are the second most common intradural,
extramedullary spinal tumor. The incidence of meningiomas
8/26/11 2:17:22 PM

peaks between the ages of 50 and 65, they are seen four to nine
times more frequently in women as in men,14,15 and they are
most common in thoracic spine.25 Meningiomas arise from
cells within the arachnoid villi and usually have dural attach-
ments. The increased density of arachnoid villi near dural root
sleeves may partially explain the lateral position of most men-
ingiomas, although dorsal and ventral lesions occur as well.
Several histological subtypes are seen in the spinal cord, psam-
momatous being the most common. With the rare exceptions
of angioblastic and atypical subtypes (which tend to occur in
younger patients), histological variation has no bearing on
treatment or prognosis. Surgical excision is the treatment of
choice, although, like nerve sheath tumors, meningiomas are
generally slow-growing lesions, making the decision to operate
a balance between the extent of neurological symptoms, the
degree of radiographic neural compression, and the age and
overall health of the patient.
EPENDYMOMAS
Ependymomas are seen in association with the lumbosacral
nerve roots either as intramedullary ependymomas of the conus
or extramedullary ependymomas of the filum. Only the latter
are considered here. Filum ependymomas are thought to arise
from ectopic rests of ependyma and can be of any histological
subtype. Still, the overwhelming majority of filum ependymo-
mas are of the myxopapillary subtype, which rarely occurs
outside of this location. Although frequently adherent to lum-
bosacral nerve roots, myxopapillary ependymomas are usually
separated from the conus by a margin of normal filum. As such,
they are true extramedullary lesions.
Although schwannomas and meningiomas are very rare in
children and young adults, around 20% of myxopapillary
ependymomas occur in the first two decades of life; the overall
mean age of presentation is in the mid-thirties.26 Because of
their potential to metastasize along cerebrospinal fluid (CSF)
spaces, their lack of true encapsulation, and their unpredict-
able growth rate, filum ependymomas should be removed in a
timely manner. With gross-total resection, cure rates for all spi-
nal ependymomas range from 91% to 100%.21 Myxopapillary
ependymomas are associated with higher rates of both subtotal
resection and recurrence compared to other ependymoma
subtypes, however, because of their immediate access to the
lumbar cistern and their tendency to adhere to lumbosacral
nerve roots.1,26,27
CONGENITAL TUMORS
Dermoids, epidermoids, lipomas, and teratomas are thought to
be congenital lesions resulting from errors in the cleavage
between neural ectoderm and cutaneous ectoderm that occurs
between the third and fifth week postconception. Rarely, iatro-
genic transplantation of epidermal cells after lumbar puncture
or myelomeningocele repair lead to tumor formation as well.
These tumors are typically discovered in childhood, occur pre-
dominately in the lumbosacral region, and may be seen in asso-
ciation with spinal dysraphisms such as dermal sinus tracts,
tethered cords, and split cord malformations. The incidence of
dermoids and epidermoids decreases dramatically with increas-
ing age, and they are very rarely diagnosed in adulthood. Such
lesions account for 5% to 17% of all spinal tumors in surgical
series of pediatric patients with spinal tumors.17 As slow-growing,
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Chapter 142 Intradural, Extramedullary Spinal Tumors 1537
benign lesions that have presumably existed since birth, the
role for surgical resection, particularly in adults, should be
heavily influenced by the presence and progression of neuro-
logical symptoms. In adults, incidentally discovered lesions may
not require treatment.
In the face of progressive symptoms, surgery is indicated.
Operative planning must take into account any dysraphism
present as well as mass resection. Although benign, these
tumors are often densely adherent to neural structures and
complete surgical excision without neurological injury is seem-
ingly impossible. In such cases, complete tumor removal is nei-
ther safe nor necessary for excellent long-term outcomes.17
OTHERS
Hemangioblastomas can be entirely extramedullary; indeed,
extramedullary hemangioblastomas comprise up to 30% all
hemangioblastomas found in patients with von HippelLindau
disease.16 Lacking the appropriate milieu to generate charac-
teristic intramedullary cysts, these tumors can masquerade as a
lumbar nerve root schwannoma on MRI. Other histological
subtypes in the intradural extramedullary compartment are
rare. Paragangliomas and systemic metastases, particularly mel-
anoma, can occur in association with nerve roots and can also
be indistinguishable from more common pathology on preop-
erative imaging.
OPERATIVE TECHNIQUE
APPROACHES
Overview
In our experience, the majority of intradural, extramedullary
tumors can be removed through a standard dorsal midline
approach. The midline posterior approach provides the most
familiar approach to normal neural anatomy prior to tumor
resection and affords the earliest opportunity to decompress
the spinal cord. This approach is advised for all tumors in the
lumbar region and thoracic or cervical tumors lying dorsal or
dorsolateral to the spinal cord. Ventrolateral and ventral tumors
can often be accessed dorsally as well, provided that a sufficient
surgical corridor exists. Often this corridor has been made by
the tumor itself, as the slow growth of an eccentrically located
tumor has gradually pushed the spinal cord to one side. Small
thoracic lesions without sufficient lateral displacement of the
spinal cord are sometimes better resected via a lateral approach
such as the retropleural approach. Purely ventral lesions of the
cervical and high thoracic cord may require anterior approaches.
Supra-axial lesions that cannot be managed from a dorsal
approach may require far lateral or transoral exposures.
Dorsal Midline Approach
This approach was described originally by Gowers and Horsley
who, in 1887, described the first successful removal of an intra-
dural extramedullary tumor.6 Refinements of this technique
include the use of the operating microscope and microsurgical
techniques, advances in anesthesia, and the advent of neuro-
physiological monitoring. We use a standard operating table
with the patient prone on a Wilson frame or cushioned bol-
sters. A Mayfield head holder is used for lesions above T5. After
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 1538 Section XIII Tumor and Osteomyelitis
standard intubation, an arterial line and Foley catheter are
placed, and a monitoring array with MEP, SSEP, nerve stimula-
tion, and free running EMG capabilities is applied.
Preoperative antibiotics and steroids are given. After stan-
dard prepping and draping, a midline incision is made and a
subperiosteal dissection of the soft tissues off of the spinous
processes and lamina is performed. Localization is confirmed
with a portable X-ray or fluoroscopy. A laminectomy is per-
formed with its width and laterality tailored to tumor anatomy.
Sometimes a unilateral partial facetectomy is necessary to
obtain adequate exposure, particularly for access to lateral or
ventrolateral lesions. Dural exposure proceeds with meticulous
cauterization of epidural vessels and bone waxing. Complete
hemostasis is required prior to durotomy to maintain a clean
intradural operative field. Ultrasonic confirmation of tumor
location is useful at this point to define the limits of the dural
opening. We have observed lumbar lesions to shift position
relative to preoperative imaging.
Other Approaches
Other approaches may be either desired or necessary as a pri-
mary or adjunct exposure. The lateral extracavitary approach is
useful for dumbbell tumors from T4 to L5 with extensive extra-
foraminal extension.18 We prefer this to retroperitoneal and
retropleural approaches because it reduces the likelihood of
CSF fistulae to the peritoneal or pleural spaces. For cervical and
high thoracic lesions with large extraspinal components, we opt
for a staged operation, where the intradural portion of the
tumor is resected first along with accessible portions of the
extraforaminal component. With the spinal cord decompressed,
there is ample time to allow the dural and fascial planes to heal
prior to the excision of the extraforaminal residua, which can
be pursued through an anterior or a transaxillary approach.
A C
B D
LWBK836_Ch142_p1535-1543.indd 1538
Purely ventral meningiomas and nerve sheath tumors of the ros-
tral spine, between C3 and T2, can be resected using a standard
anterior cervical approach and corpectomy.20 Ventral supra-
axial tumors may require lateral skull base approaches. Purely
ventral meningiomas from T2 to T4 may require open thoracic
exposures such as the trapdoor approach.19
INTRADURAL COMPONENT
A straight midline durotomy is usually adequate and is conve-
nient to close; paramedian or curvilinear incisions can be help-
ful in come cases, however. The arachnoid is preserved during
durotomy to prevent bleeding from epidural veins induced by
a loss of adjacent CSF pressure and to preserve the tumors
relationship to this meningeal layer. The dura is tented over a
quarter-inch cottonoid lining the epidural space at the limits of
the laminectomy and secured to the paravertebral muscles with
4.0 silk sutures.
At this point, the tumors relationship to the arachnoid is
explored. Intradural nerve sheath tumors and ependymomas
will lie within the arachnoid (Fig. 142.2A and C) and can often
be distinguished prior to resection based on association with
the filum or an individual nerve root. Nerve root stimulation is
often a useful adjunct to confirm visual assessments and to
assess the functionality of nerve roots. Meningiomas will usually
be separated from the neural elements by a clear arachnoid
plane (Fig. 142.2B and D).
The arachnoid overlying the exposed tumor capsule is dis-
sected free, and the exposed tumor capsule is cauterized. This
begins to interrupt the tumors blood supply and shrink down
the tumor mass. While small tumors may be removed en bloc,
larger tumors require internal debulking prior to dissection of
the capsule from neural elements. Debulking is usually best
achieved with an ultrasonic aspirator. From the dorsal approach,
Figure 142.2. Sagittal contrast-
enhanced MRIs of a filum
ependymoma (A) and a lumbar menin-
gioma (B) and the corresponding
intraoperative images of each. The
ependymoma, (e) is found inside the
arachnoid originating from the filum
terminale (yellow arrows) (C). The men-
ingioma (m) is attached to the dura
(d) and is separated from the nerve
roots (nr) by an arachnoid layer (D).
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 Chapter 142 Intradural, Extramedullary Spinal Tumors 1539

TABLE 142.1

Relationship to Relationship to Spinal Nonfunctional Neural

Type Dura Canal Origin Element Surgical Plan
I Intradural Intraspinal Dorsal or ventral Dorsal or ventral nerve Sacrifice nerve root of
nerve root root of origin origin, spare paired
nerve root
II Intradural with Extraspinal extension Dorsal or ventral Entire nerve root Sacrifice entire nerve
extradural via nerve root sleeve nerve root (anterograde spread root/spinal nerve
component to spinal nerve)
III Extradural Paraspinal extension Proximal spinal Fascicle of origin Isolate tumor from
(foraminal) nerve fascicle spinal nerve
IVa Extradural Paraspinal with Proximal spinal Fascicle of origin Isolate tumor from
intraspinal extension nerve fascicle spinal nerve
IVb (NF-2) Intradural Paraspinal with Proximal spinal Entire nerve root Sacrifice entire spinal
extension intraspinal extension nerve fascicle (retrograde spread to nerve and nerve
dorsal and ventral roots
spinal nerve roots)

unilateral sectioning of the dentate ligament and gentle rota-
tion of the spinal cord to achieve adequate exposure may facili-
tate excision of lateral lesions. Dissection of the tumor from
neural elements is usually straightforward, alternating with seg-
mental cauterization of the tumor capsule and division of feed-
ing vessels. Rarely is the blood supply of the tumor and spinal
cord shared. Removal of each of the main histological types is
nuanced at this point and bears special consideration.
Filum ependymomas should ideally be resected en bloc, as
there is some evidence that piecemeal resection of ependymo-
mas increases recurrence rates.26,27 The tumor is carefully freed
from adjacent nerve roots, and the filum is identified visually
and tested with a neurostimulator. The filum is cauterized
above and below the tumor and divided, and the tumor is care-
fully rotated out of the canal. En bloc resection is often not
possible to achieve safely in larger tumors for various reasons.
The tumor may lack sufficient internal integrity and fall apart
with even gentle manipulation. The tumor may be simply too
large to tease out without putting unacceptable amounts of
traction on overlying nerve roots. The tumor may be hopelessly
stuck to nerve roots; in such cases, subtotal resection is prefer-
able to over-manipulation.
Successful meningioma surgery is facilitated by maintenance
of an arachnoid plane. If preserved, it will effectively guide the
surgeon between tumor and spinal cord and aid in the dissec-
tion of nerve roots off of the tumor capsule. When the tumor
resection is near completion, a decision must be made regard-
ing the tumors dural attachment. Resection of associated dura
followed by patch-grafting of the dural defect is perhaps desir-
able, but may be difficult or impossible to achieve in a water-
tight fashion for tumors with lateral or anterior attachments.
The availability of numerous dural substitutes and caulking
agents gives the surgeon many unproven options to aid closure.
Whether dural resection reduces recurrence rates over dural
cauterization or split thickness resection is debatable and must
be weighed against the perceived likelihood and morbidity of a
CSF leak.
Nerve sheath tumors often require sacrifice of the nerve
root of origin in order to be removed. Often this requires the
sacrifice of a spinal nerve or nerve root. Surgical series have
reported permanent loss of function after nerve root section-
ing in 2% to 4% of patients with nerve sheath tumors. Notably,
all patients in these series with postoperative deficits had cervi-
cal schwannomas.11,13,23,24
A theoretical framework for determining whether the surgi-
cal goals should include preservation of the nerve or nerve root
of origin lies in ascertaining the segment of the nervenerve
root complex from which the tumor arises (Table 142.1). The
anatomical transition from spinal nerve root to spinal nerve is
characterized by a separate entry of dorsal and ventral roots
into the dural root sleeve (Fig. 142.3A) and the merging of
these nerve roots just distal to the dorsal root ganglion (Fig.
142.3B). At the ultrastructural level, a thinning of the dural
sleeve into epineurium and the separation of nerve fibers into
fascicles by perineurium characterize this transition. Tumors
can arise anywhere along this segment, and surgical resection is
nuanced according to this site of origin and subsequent growth
pattern.
Type I tumors are termed intradural, intraspinal (Fig. 142.4).
They arise from a dorsal or ventral nerve root lacking epineu-
rium or perineurium. In such cases, the nerve root of origin
(usually dorsal) is inseparable from tumor, nonfunctional, and
unsalvageable. It may, however, be distinguishable from its
paired nerve root (usually ventral) within a common arachnoid
sheath. The paired nerve root may be functional and should, if
possible, be identified and spared. This may not be feasible
with larger tumors. Type II tumors are intradural with extraspi-
nal extension through the root sleeve (Fig. 142.5). These
tumors invade the extraspinal peripheral nerve, entailing inti-
macy with fibers originating from both the nerve root of origin
and its paired nerve root. Thus root preservation is not neces-
sary or possible, regardless of tumor size. Type III tumors arise
from an extradural proximal spinal nerve and grow away from
the spinal canal into the paraspinal space (Fig. 142.6). As such,
they are really peripheral nerve tumors for which the fascicle of
origin can be isolated from the rest of the spinal nerve. Type IV
tumors arise from the proximal spinal nerve as well but grow
into the spinal canal where they remain extradural (IVa)
(Fig. 142.7) or invade through the root sleeve to become intra-
dural (IVb). In the first case, resection should follow the princi-
ples of peripheral nerve tumor surgery in which the tumor can
and should be isolated from undiseased fascicles. In the second
case, which has only been seen in patients with NF-2, the tumor
has invaded the intradural space growing into both dorsal and

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 1540 Section XIII Tumor and Osteomyelitis

Figure 142.3. Cadaver dissection of

a cervical nerve root. Separate entry of
dorsal (dr) and ventral (vr) nerve roots
into the dural sleeve are seen (A). Dor-
sal and ventral nerve roots merge after
A B
the dorsal root ganglion (drg) (B).

ventral nerve roots. In such cases, neither nerve root can be
spared.
CLOSURE AND RECONSTRUCTION
After the tumor is removed and hemostasis is achieved, the suba-
rachnoid space is copiously irrigated with warm saline and the
dura is closed primarily with a running locked 4.0 silk suture.
The muscle is loosely approximated with a running 0 absorbable
monofilament synthetic suture (Biosyn) and the dorsal fascia
closed with interrupted 0 absorbable braided synthetic suture
(Vicryl) in a watertight fashion. The skin is closed with a subcu-
taneous 2-0 absorbable braided synthetic suture followed by a
running 3-0 monofilament nylon suture for skin closure.
Occasionally the combination of bone exposure and bone
erosion caused by nerve sheath tumors causes instability that

A B C

D E

Figure 142.4. Type I Schwannoma. Contrast-enhanced T1-weighted MRI shows a lesion consistent with
an entirely intradural schwannoma at the level of C5 (A and B). Type I tumors arise from a single root (usu-
ally dorsal) and the paired root is associated but not invaded by tumor (C). Intraoperative images (D and E)
show that it is sometimes possible to save the paired nerve root (pnr).

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 Chapter 142 Intradural, Extramedullary Spinal Tumors 1541

A B

Figure 142.5. Type II Schwannoma. Type II tumors arise for a single nerve root but grow through the
neural foramen and invade the peripheral spinal nerve (A). After extension through the neural foramen
(nf), the peripheral portion of this tumor (t) is intimate with fibers from both dorsal and ventral nerve roots;
therefore, both nerve roots can be sacrificed (black arrow) (B).

should be addressed in the same operation as tumor removal. POSTOPERATIVE MANAGEMENT

Cases in which the entire lateral mass at a cervical level or the
entire facet complex at the thoracolumbar junction has been
destroyed are obvious examples that demand immediate stabi-
lization after tumor resection. Most cases are less clear-cut and
require an individualized assessment that takes into account
the patients age, the innate flexibility of the patients spine,
and the patients activity level. Relative instability can often be
addressed at a later date without any serious consequences.
We typically require patients to remain level in bed for 36 to 48
hours after surgery with routine spinal drainage reserved for
patients with anterior approaches only. All patients are ordered
for lower extremity sequential compression devices, incentive
spirometry, Foley catheters, and patient-controlled analgesia
(PCA). During this time, patients are permitted to lie on their side
or stomach and may elevate their upper bodies 10 to 15 degrees

A B

C D

Figure 142.6. Type III Schwannoma. Type III tumors arise from a single fascicle within the extradural
proximal spinal nerve and grow radially into the paraspinal space (A and B). The anatomic separation of fas-
cicles by perineurium permits tumor dissection that preserves other fascicles within the nerve of origin. The
tumor (t) is shelled out of peripheral nerve (n), which is distended but functional (C and D).

LWBK836_Ch142_p1535-1543.indd 1541 8/26/11 2:17:32 PM

 1542 Section XIII Tumor and Osteomyelitis
A B
C D
for meals. Patients are mobilized on postoperative day 2 and
are discharged between postoperative days 3 and 5.
COMPLICATIONS
Serious peri-operative complications such as a major postop-
erative neurological deficit, postoperative hematoma, or
thromboembolus from activity restriction are exceedingly rare.
A mild exacerbation of preexisting neurological deficits is
unusual and typically resolves in the immediate postoperative
period. Dysesthesias after nerve root sacrifice can be nettle-
some and may theoretically be avoided in extraforaminal
tumor surgery by root sectioning proximal to the dorsal root
ganglion. A variety of medications including anticonvulsants
and tricyclics may be effective in dealing with this neuropathic
pain syndrome. A CSF leak or pseudomeningocele can occur
in the immediate postoperative period or in a delayed fashion.
A CSF leak can often be remedied by wound oversewing with
or without spinal drainage. Pseudomeningoceles sometimes
respond to CT-guided percutaneous drainage with or without
spinal drainage. Both CSF leak and pseudomeningocele may
require reoperation, however, as can infections, which occur at
a rate similar to that of other noninstrumented spine cases.
Laminectomy carries a delayed risk of spinal instability in the
cervical, lumbar, and thoracolumbar spine that is related to
the number of levels exposed and to the extent of facetec-
tomy.10,22 Although the degree of bony sacrifice should be
minimized, especially outside of the middle and upper tho-
racic spine, it should never compromise the exposure needed
to remove the tumor safely.
LWBK836_Ch142_p1535-1543.indd 1542
Figure 142.7. Type IVa Schwan-
noma. Type IVa tumors arise from the
extradural proximal peripheral nerve
as well, but growth into the spinal
canal, causing neural compression (A
and B). Type IVa tumors (t) remain
extradural (d) and are thus separated
from the nerve roots and spinal cord
(C and D).
OUTCOMES AND FOLLOW-UP
Overall, the outcomes from intradural extramedullary tumors
are excellent. Most patients experience an improvement in
functional status and long-term remission after gross macro-
scopic resection without any adjuvant therapy. Neurological
deficits often resolve partially or completely in the immediate
postoperative period, with further progress made with physical
and occupational therapy in the months following surgery.
For nerve sheath tumors, pain is the symptom that most con-
sistently responds to surgery followed by weakness and then by
sensory loss.11,13,23,24 Although gross-total resection results in a
cure for most patients, precise recurrence rates after surgery
are difficult to assess because of a lack of studies with long-term
follow-up. One population study from Finland found a 10.7%
5-year recurrence rate in sporadic cases of spinal schwannoma
and a 39.2% 5-year recurrence rate in patients with NF-2.13
These relatively high numbers, in conjunction with the authors
observation of recurrences in cases of complete tumor resec-
tion and transection of the offending nerve root, dictate that
all patients should be followed with postoperative serial MRIs
for several years.
Outcome after meningioma surgery is linked to the patients
preoperative neurological condition. Although surgery can
exacerbate presenting symptoms, such setbacks are usually
temporary and respond to therapy. Surgical series report sig-
nificant and often dramatic recovery of neurological function
in most patients. For example, 80% to 90% of nonambulatory
patients are reported to regain the ability to walk after menin-
gioma removal12,14,15,25 and one series reported complete neu-
rological recovery in 46% of paraplegic patients.8
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The likelihood of recurrence of spinal meningiomas is
closely tied to the macroscopic extent of resection, with GTMR
the goal of surgery. Surgical series report recurrence rates of
totally resected meningiomas at 1.3%,12 6%,25 and 29.5%13 with
average follow-up periods ranging from 5 to 15 years. Rates of
GTMR are reported from 89% to 98% with subtotal resection
associated with recurrent tumors, arachnoid scarring, en plaque
morphology, malignant histological features, and anterior loca-
tion.12,14,15,25 As with nerve sheath tumors, postoperative serial
radiographic imaging is required for several years.
Although the vast majority of filum ependymomas are histo-
logically benign, their lack of encapsulation and propensity for
seeding through CSF reduces overall rates of real and perceived
GTMR. Although true rates of GTMR are difficult to assess in
the literature, en bloc resections of small tumors carry the
greatest likelihood of achieving this surgical goal. One series of
77 myxopapillary ependymomas found a recurrence rate of
10% following en bloc tumor removal versus 19% with piece-
meal or subtotal resection.
ADJUVANT THERAPY
Conventional radiation is an option for recurrent, dissemi-
nated, or subtotally resected tumors but has never proven to be
a replacement for surgery. Its benefit in the treatment of
ependymomas is debatable, although it is routinely used in an
adjuvant role in cases of anaplasia, radiographic residual tumor,
recurrence after resection, or disseminated tumor.9 Radiosur-
gery is now widely available for the spine, although the majority
of experience lies in the treatment of metastatic disease. Reports
of the radiosurgical treatment of benign intradural extramed-
ullary tumors exist, with mixed results.3 Clinical studies to date
have focused on determining the effects of collateral radiation
exposure of the spinal cord and nerve roots. While excessive
toxicity to neural tissues has been avoided over the short-term,
long-term effects are as yet unknown.
CONCLUSION
Intradural, extramedullary tumors encompass a range of path-
ological types, the majority of which are benign and amenable
to surgical resection. The majority of these tumors can be
removed through a standard dorsal, midline approach, and
the application of standard microsurgical techniques. GTMR
results in long-term recurrence-free survival in the great major-
ity of cases without the need for adjuvant therapy. Improve-
ment in functional status, through pain relief and/or recovery
of neurological function, is the norm following surgery. Patients
LWBK836_Ch142_p1535-1543.indd 1543
Chapter 142 Intradural, Extramedullary Spinal Tumors 1543
must be followed with serial imaging for several years to identify
recurrences regardless of the surgeons confidence in the
extent of resection.
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