Spinal meningioma is an intradural extramedullary benign tumor arising from arachnoid cap cells (meningothelial cells). It constitutes 25-30% of all spinal tumors and 40-50% of intradural extramedullary tumors. It is 4-9 times more common in women, partially explained by hormone receptor positivity (estrogen, progesterone) — acceleration during pregnancy has been reported. The thoracic region is the most common location (80%), cervical (15%) and lumbar (5%) are rare. Dorsolateral position is most common, and frequent occurrence at the foramen magnum should be remembered for craniospinal junction tumors. WHO Grade I meningiomas constitute >90% and surgical resection is curative. Slow growth causes progressive myelopathy — symptoms may take years to manifest. On MRI, T1 isointense, T2 isointense to mildly hyperintense signal, intense homogeneous enhancement, and dural tail sign are characteristic. Calcification is seen in 25% and detected on CT — calcified meningiomas may appear T2 hypointense on MRI.
Age Range
40-80
Peak Age
60
Gender
Female predominant
Prevalence
Uncommon
Spinal meningioma arises from neoplastic proliferation of cap cells (arachnoid meningothelial cells) in the outer layer of the arachnoid membrane. These cells normally concentrate at arachnoid granulations and nerve root exit zones — explaining the dural-related and dorsolateral predilection. The tumor forms broad-based adhesion with the dura and grows extra-axially — displacing but not invading the spinal cord. Psammoma bodies (concentric calcification lamellae) are histological features causing calcification on CT. Intense homogeneous enhancement reflects the rich vascular network — high vascularity and wide extracellular space facilitate gadolinium accumulation. The dural tail sign reflects reactive vascular congestion and meningothelial proliferation along the dura extending from tumor base — dural tail area does not always contain tumor cells, sometimes only reactive changes.
Enhancement along the dura extending from tumor base is the classic finding of meningioma. The enhancing dural tail tapers as it extends from the tumor. In 60% it contains only reactive vascular congestion, 40% have microscopic tumor spread. Specificity is not 100% — dural metastasis, lymphoma, and postoperative changes may also show dural tail.
Intense and homogeneous enhancement on contrast-enhanced MRI is the most characteristic finding of spinal meningioma. Enhancement along the dura extending from tumor base (dural tail sign) accompanies. Enhancement is generally homogeneous — necrosis or cystic degeneration is rare, an important distinguishing feature from schwannoma.
Report Sentence
Intradural extramedullary mass showing intense homogeneous enhancement and dural tail sign, consistent with spinal meningioma.
T2 signal isointense or mildly hyperintense relative to cord is typical of meningioma. Calcified meningioma may show T2 hypointense areas. This signal characteristic differs from schwannoma's marked T2 hyperintensity and is an important differential diagnostic clue.
Report Sentence
Intradural extramedullary mass showing T2 signal isointense to cord, favoring meningioma.
Calcification is seen in 25% on CT — pathological correlate of psammoma bodies. Broad dural base and well-defined intraspinal mass may be seen on CT. Due to lower soft tissue contrast than MRI, CT alone is not diagnostic but is superior to MRI for calcification detection.
Report Sentence
Calcified intraspinal mass with broad dural base on CT, consistent with spinal meningioma.
T1 signal isointense to cord is typical of meningioma. Signal similar to cord reflects meningioma's homogeneous cellular structure. Schwannoma shows more variable T1 hypointense to isointense signal.
Report Sentence
Intradural extramedullary mass isointense to cord on T1.
CSF space (CSF cleft/cap sign) is seen between mass and cord in intradural extramedullary lesions. This finding indicates the mass is intradural but extramedullary — a critical clue for differentiating from intramedullary masses. T2 hyperintense CSF signal appears as a crescent around the mass.
Report Sentence
T2 hyperintense CSF space (CSF cap sign) between mass and cord, supporting intradural extramedullary location.
Criteria
WHO Grade I, lobular pattern, indistinct cell borders, whorl structures
Distinct Features
Most common histological type; typical homogeneous enhancement and T2 isointensity; less calcification; excellent prognosis
Criteria
WHO Grade I, abundant psammoma bodies (calcification), fibrous stroma
Distinct Features
Prominent calcification — hyperdense on CT; T2 hypointense areas on MRI; more common in spinal meningioma than other locations; hard consistency during surgery
Criteria
Increased mitotic activity (≥4 mitoses/10 HPF) or 3+ atypical features
Distinct Features
Rare in spinal location (5%); more heterogeneous enhancement, more prominent peritumoral edema, increased recurrence risk (30-40%); adjuvant radiotherapy should be considered
Distinguishing Feature
Schwannoma shows marked T2 hyperintensity (myxoid stroma), heterogeneous enhancement (cystic degeneration), capsule, and foraminal extension (dumbbell). Meningioma shows T2 isointensity, homogeneous enhancement, dural tail, and broad dural base — cystic degeneration is rare.
Distinguishing Feature
Metastasis is usually multiple, irregularly marginated, and associated with bone destruction. Epidural metastasis is accompanied by vertebral body involvement and cortical destruction. Meningioma is intradural extramedullary, solitary, well-defined, and does not cause bone destruction.
Distinguishing Feature
Meningioma may show calcification (25%) on CT, calcification is rare in schwannoma. Neural foramen widening (remodeling) is a typical CT finding in schwannoma, not seen in meningioma.
Urgency
routineManagement
surgicalBiopsy
Not NeededFollow-up
12-monthSpinal meningioma is a WHO Grade I benign tumor and surgical resection is the standard treatment. Simpson Grade I-II resection is curative with 5-10% recurrence. Calcified meningiomas may be more adherent to cord. In NF2 patients, genetic counseling is recommended. In elderly patients with comorbidities, surveillance may be considered for small asymptomatic lesions. Radiotherapy should be considered for atypical (Grade II) or post-subtotal resection recurrence.
Spinal meningioma is a benign (WHO Grade I) tumor and surgical resection is curative. It grows slowly and may cause progressive myelopathy. Simpson Grade I-II resection (gross total + dural base coagulation) is the standard treatment. Recurrence rate is low (5-10%). Calcified meningiomas may be more adherent to the cord. Multiple spinal meningiomas may be seen in NF2 patients.