title: Surgical management of spinal meningiomas: A retrospective case analysis based on preoperative surgical grade.
abstract: BACKGROUND
  Although spinal meningiomas respond favorably to surgical excision, their surgical management is impacted by several factors. This study utilized a surgery-based grading system to discuss the optimal surgical strategy.
  
  
  METHODS
  Twenty-three consecutive patients who underwent surgery for spinal meningiomas were included in this retrospective study. The patients' neurological condition was assessed using the modified McCormick functional schema (mMFS) and sensory pain scale (SPS), and tumor removal was assessed using Simpson grade. Major factors contributing to surgical difficulty included; tumor size, extent/severity of cord compression, location of tumor attachment, spinal level, and anatomical relationships plus tumor extending in a dumbbell shape and local postoperative recurrence.
  
  
  RESULTS
  Fifteen cases were classified as ventral attachment (65.2%). There were two dumbbell-shaped tumors and three local recurrences at the primary site. Simpson grade 1 or 2 resections were performed in 18 of 20 cases (90%) with preoperative surgical grades 0 to 3. Simpson grade 4 resections were achieved in all three cases with preoperative surgical grades 4 to 5. Overall neurological assessment after surgery revealed the satisfactory or acceptable recovery on mMFS and SPS analysis.
  
  
  CONCLUSIONS
  Lower preoperative grade yielded better results, while the higher the preoperative grade, the more likely tumor was insufficiently removed. A preoperative surgical grading system appeared to be helpful when considering the surgical strategy. Ventral meningiomas could be safely resected via the posterolateral or lateral approach using technical modifications. Recurrent tumors, especially with ventral attachment, were hard to resolve, and primary surgery appears to be important.
authors.affiliation: Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
authors.forename: Hironori
authors.initials: H
authors.lastname: Arima
authors.affiliation: Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
authors.forename: Toshihiro
authors.initials: T
authors.lastname: Takami
authors.affiliation: Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
authors.forename: Toru
authors.initials: T
authors.lastname: Yamagata
authors.affiliation: Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
authors.forename: Kentaro
authors.initials: K
authors.lastname: Naito
authors.affiliation: Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
authors.forename: Junya
authors.initials: J
authors.lastname: Abe
authors.affiliation: Department of Neurosurgery, Spine Center, Tsukazaki Hospital, Hyogo, Japan.
authors.forename: Nobuyuki
authors.initials: N
authors.lastname: Shimokawa
authors.affiliation: Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
authors.forename: Kenji
authors.initials: K
authors.lastname: Ohata
keywords: Recurrence; spinal extramedullary tumor; spinal meningioma; surgical outcome; ventral attachment