Surgical resection of a T9-T11 thoracic extradural meningioma: 2D operative video

A 39-year-old female presented with worsening right lower extremity (RLE) weakness, gait imbalance, and bowel/bladder incontinence. She exhibited 3/5 strength throughout the RLE, hyperreflexia with clonus in the bilateral lower extremities, and a T10 sensory level to pin appreciation. The magnetic resonance imaging (MRI) revealed a homogenously enhancing mass extending from T9-T11 into the retropleural compartment, causing severe spinal cord displacement.

This high-definition operative video details key steps, including the T9-T11 laminectomy, T8-T12 freehand pedicle screw placement, right T10 pediculectomy, right T9/10 and T10/11 facetectomy, tumor resection, and intradural exploration for excision of a meningioma. Crucial maneuvers warranted due to the challenges of an adherent tumor included: spinal cord rotation using a 2/0 silk tie, applying traction/counter-traction using tumor stitches, and using cottonoids to avoid pleural violation. Critical maneuvers regarding the utilization of instrumentation, sacrificing nerve roots, and performing intradural exploration are discussed. We used a 5 mm coarse diamond drill to create bilateral laminar troughs and used Kerrison rongeurs to complete an en bloc T9-T11 laminectomy. A 5 mm coarse diamond drill was also used to perform the facetectomy, which allowed us to follow the tumor foraminally/extraforaminally. For fine drilling medial to the pedicles, we switched to a 3 mm matchstick diamond bit that enabled us to safely effect bony removal without violating the medial wall and mistakenly extending into the canal and damaging the cord/dura. After resecting the epidural and foraminal components of the tumor, we carefully dissected and removed the remaining tumor within the retropleural space. The effort made to achieve a gross total resection was to mitigate the chances of tumor recurrence, given the complex multi-compartmental nature of this unusually situated meningioma. We determined that a posterior approach gave us the best chance to safely explore both the intra- and extra-dural compartments, as well as extend into the retropleural space as needed. Notably, the patient preoperatively was severely paraparetic, and our operative approach enabled us to perform what we determined to be the safest approach to effect maximal tumor resection. We additionally utilized intraoperative ultrasound to confirm adequate cord decompression following tumor excision. The subsequent post-operative MRI did establish that gross total tumor excision had been achieved.

Postoperatively, the patient experienced immediate improvement in RLE weakness (3/5 preoperatively to 5/5 postoperatively). At 1.5-year follow-up, her neurological recovery was complete; bilateral lower extremity strength was normal, and we saw full resolution of her preoperative neurogenic bowel/bladder. Her only residual complaint is some numbness along the right T10 dermatome. This operative video underscores crucial considerations in the surgical management of a combined extradural/extrapleural meningioma at the T9-T11 level.