Previously Recorded: Thursday, Nov. 14 | 3:30-4:30 ET
Leading Experts in Spinal Neurosurgery, Physiatry and Radiology discuss an In-Depth Case Study on the Discovery of a Complex Spinal Meningioma, and the Treatment Plan that Reversed Paraparesis.
Event Summary
In a recent webinar, esteemed experts Dr. Robert Rothrock, Dr. Richard Morgan and Dr. Kevin Abrams presented together on a complex spinal meningioma case that changed a patient’s life forever. The patient had seen several specialists and was feeling hopeless, until the multidisciplinary team at Baptist Health Miami Neuroscience Institute worked together to discover and remove an undetected meningioma that had left her bedbound.
This session provided valuable insights from three leading authorities in spine tumors, physical medicine & rehabilitation and radiology, covering cutting-edge techniques, the latest research and advancements, and the importance of interdisciplinary cooperation.
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Meet the Experts
Good afternoon, everyone. Thank you so much for joining us. Uh I'm joined today by two amazing physicians and our Baptist community to discuss what hopefully will be an interesting case and discussion for everyone. We're just having a conversation amongst colleagues here and today we're here to speak about an amazing patient, uh Tanya Salinas. So Tanya is a 50 year old woman who came to us and we're gonna talk about how and, and with what condition but really in a bad place having been in, as you can see from these pictures, a very active 50 year old, really young spirited and wonderful woman who really over the course of a year rapidly started losing her ability to walk. Just want to take a minute to, to thank everyone uh here at Baptist to help care for her. And I really hope that today is inspiring to everybody who's joining us and to whether you're a physician or you're yourself a patient, whatever context, whether you're watching this live now. And thank you for uh for joining us or, or a future uh uh person watching this, you know, thank you for participating. I just want to take a minute just to add that. If you want to ask any questions, you will have an opportunity at the end of today's webinar to do that. What I'd like to do now is to hand it over to, to Doctor Richard Morgan, who's one of our outstanding physiatrists and physical and rehabilitation of physicians. Really to give some context about how this patient came to be in the state. She is and what she looked like. So when uh Tanya first came to my office, she'd uh previously seen a few other specialists. Um She had progressive numbness and tingling in her, in her feet, legs and progressive weakness in her lower extremities as well. Um This was affecting her ability to walk. She was previously very active actually before these symptoms started. Um she was on a uh a vacation in, in Europe and hiking all throughout Europe. Uh So this was um um really affecting her, her life. Um And she had undergone an extensive work work up before she came to my office. Um seeing a few other specialists. So she, she was really frustrated, um really concerned and, and scared about what was happening. Um And so we uh we started off by repeating some of the MRI S that she already uh completed before. Um We really didn't get any additional answers. Um And that's when we took another route and um went down a, a few, we, we uh ordered a few diagnostic tests that weren't done before, including ac T myelogram. And that's the point when we discovered that she had a, a large uh meningioma and the thoracic spine causing a thoracic myeloma uh myelopathy. Um So, Doctor Morgan, um can you just speak a little bit about some of her history? What, why was this a difficult case to diagnose? Um you know, she wasn't uh when she came, even to see you, she had quite an extensive medical history. Maybe you could just talk about some of what had been done. Yup. So, uh when, when she was younger, she had juvenile idiopathic scoliosis. Um and uh she underwent an extensive surgical procedure with a fusion throughout essentially her entire spine with Harrington rods. This was a difficult case because those Harrington rods created a lot of artifact when we ordered the imaging studies, um that included the MRI in particular. And so we really couldn't see exactly what was going on inside the thoracic spine because of that artifact. Um And so when we got the CT myelogram, we'll, we'll delve into this a little bit more later. But uh when we order that CT myelogram, that's when we really uh were able to, to figure out that she had a large meningioma in the thoracic spine causing cord compression. I guess we'll speak a little bit about your physical exam and some of the other uh guidelines. But you know what, what set off your spidey sense, you know, in this case, what made you think, you know, because this patient had seen a few other doctors, a few other neurosurgeons actually. And she was told, sort of, you know, we don't know what's wrong. Go see someone else. Uh, what made you say or think, you know, something's wrong and, and we need to do more. Well, um, she came into my office two times before we really were able to pinpoint exactly what was going on. Um The first time she came in, she had numbness and tingling in the, in the lower extremities and mild weakness throughout the lower extremities as well. The next time she came in, she was wearing knee braces, ankle braces and she was using a, uh, a cane. Uh And so within a very short period of time, you, we were able to see that these symptoms were, um progressing pretty rapidly. Um Each time she came in, I did a very detailed exam and, uh that exam really pointed me into the direction as to, um, uh, that, that this was occurring within the thoracic spine. Um, and I'll go into that a little bit more detail as far as the, the, the, the physical exam uh in a few minutes here. Um So, uh I'm gonna go into some of the background information on uh thoracic myelopathy. Um It is relatively uncommon. It's very uncommon because, uh, this part of the spine has, um, a lot of biomechanical stability and that's because of the ribs, the ribs are art, they articulate with the sternum as well as the vertebra. So that uh it's very rare to see degenerative changes causing myelopathy in this area. Um And so because it's rare, um there really hasn't been a whole lot of research on this area as far as incidents and prevalence of thoracic myelopathy in the community. Um Thoracic disc herniation as an example, um really only occurs about 4% of the time out of all disc herniations within the thoracic spine. Um Metastatic disease, we're talking about uh meningioma and, and tumors in the thoracic spine. Um But metastatic disease accounts for most of the the masses and tumors within the thoracic spine area. And that's because there's a um an abundance of, of vasculature in that area and it's a relatively large uh spinal canal. Now, one thing I do want to point out is um and this is really relevant for, for this case, in particular, the the duration uh from symptoms onset to surgery is approximately 17 months. And that's because uh these symptoms are the the initial uh um symptoms are, are uh non-specific, they're very subtle and, and they progress with time. So it's really hard to pinpoint exactly what is causing these symptoms until they get to a point where they're severe. Um And so this is, this is an article that I wanted to, to highlight. Um and it's a, it's a really good article um from a, a group in Japan and it's on the clinical features of thoracic myelopathy. So, uh I'm gonna, I'm gonna use this, this article to uh discuss some of the common present uh presenting symptoms in thoracic myelopathy. Um This symptom uh This uh this study is a retrospective study um reviewing uh a lot of patients with thoracic myelopathy and they were able to pinpoint some of the most common presenting symptoms. Um uh s some of the, the, the, the symptoms of thoracic myelopathy include gate abnormalities, difficulty with balance, weakness, numbness, tingling in the lower extremities, bowel and bladder dysfunction, uh back pain, lower extremity pain. Um But the two most common in particular are gate disturbances and uh leg numbness. And that's what we, what we, what we noticed uh was the, those were the main concerns of Tanya. When she came to our clinic, it was numbness in the lower extremities, weakness in the lower extremities. So, her symptoms really um correlate with the findings from this study. Um some of the, the clinical uh uh exam findings um and some of the, the, the highlights of the, the physical exam and thoracic myelopathy is the gate assessment, uh motor strength testing, sensory testing. Uh We wanna include the thoracic derma toes as well, um reflexes, um and upper motor neuron findings. So, uh in a, in a classic case of thoracic myelopathy, there's no upper motor neuron findings in the upper extremities, whereas there will be upper motor neuron findings in the lower extremities. Um And the most common based on the study that II I went over in a few slides ago, based on that study, most common upper motor neuron finding in these patients is ankle clonus. And that happens in about 68% of cases. Yeah. The only, the only other thing to add is that, that's a pretty late stage finding in myelopathy. So once you've gotten to that point and some of the, the reflexes that we're, we're gonna go through now and exam findings just in the next two minutes, you know, that's pretty advanced stage. We ideally want to catch this before that stage. Yeah. And just, um, going back to the amount of time that it takes from the initial onset to surgery. It's about 17 months. So, um, that, that, uh, that finding from the study, the, the, the ankle clonus that, uh, that, that correlates with the amount of time that it takes to really identify this, this, um, this issue and, and take this the patient to surgery. So, um, it's a late, late exam finding. So, um, these are a few photos demonstrating the exam findings that, that we look for in a patient with, uh, with thoracic myelopathy. Um That's um upgoing Babinsky, we would want to check for a Hoffman sign that's on the right side. We wouldn't expect to necessarily find a Hoffman sign in these patients because that's in the upper extremities. So, um, I think maybe skip the video, um, just for the sake of time. But, but that basically how would you describe Clonus to someone who's not doing a detailed neuro exam? Generally speaking. Um, so Clonus, um, you would s bring the, the foot up in dorsiflexion rapidly and then the foot will continue to go in dorsiflexion. Uh Usually we're looking for more than three beats. So that foot will go into dorsiflexion repetitively more than three times. Right. Mhm. And we can skip over this. This is uh this is just um a table demonstrating the the different lower motor neurons signs and uh upper motor neurons signs uh which are relevant to patients with thoracic myelopathy. So, so just to summarize quickly, I mean, basically, this patient in, in your words, had a really profound case of thoracic myelopathy you were concerned, but we couldn't visualize, literally, couldn't see into the canal, one of the paradoxes of the modern era uh of spine surgery, spinal assessment. And actually, uh I'm gonna introduce now, Dr Abrams to my other son and let him drive the slides here. But you know that now can you reach there Dr Abrams? So, so, you know, nowadays, uh this is what we call, I guess an old school technique, but there is a reason that we still need these techniques just like really importantly, you know, doctor Morgan's physical exam in this case, really highlighted something that somehow no one else had seen before and, and then the mission became to figure out. Ok. Well, why? Right, because, you know, for the viewers and, and participants, the, the whole issue at hand is these were levels that had already been, you know, theoretically treated, right? So we're dealing with few segments that really should be treated. So why, why should there be a problem? Right. Exactly. So, so maybe you could just take us through. This is Dr Kevin Abrams, our director of Neurology and who really saved the day in this case. Well, thank you. And um no, it's a pleasure to be here and uh speak with both of these gentlemen that we coordinate care on uh very frequently. And I remember getting the call from Doctor Morgan on this patient saying that he needed a uh CT myelogram on the patient. So, before I ever say, OK, let's go ahead and do it, I always want to look at the uh imaging that the patient has already had and let me go back one side. This is actually the X rays. Uh these are scoliosis series x rays of uh Tanya. And you can see she has extensive metallic hardware. She has these long rods, laminar hooks and in the lumbar spine, she has these trans particular screws. What you don't see here also is that when they put in all this metal, they also put in bone graft to fuse because eventually the metal can fatigue and fracture, which makes doing a myelogram that much more difficult. So she did have an MRI. And unfortunately, all that dark area in here is all metal artifact from the patient's hardware. So we could not see in her spinal canal in the area of interest at all. So what's next? Well, the answer is let's try and do ac T myelogram. So what are the indications? Well, one of the indications is patient is unable to undergo an MRI due to unsafe implants such as legacy pacemakers. Sometimes patient has ferromagnetic material could be in their eyes uh or near their eyes. So you don't want uh to potentially damage vision, nondiagnostic MRI due to metallic hardware such as in the spine as in Tanya's case, that's probably our most common uh indication for it. Occasionally we will do it on cancer patients when they're going uh going to undergo stereotactic radiation therapy because the radiation oncologist feel they can see the spinal cord better so they can avoid it. And then we do it on occasion for detecting spinal fluid leaks in patients with CS F hypotension. Thankfully, it's still a safe procedure even though again, it's a long standing thing that's been going on for radiology. Well, before I started, but like any procedure it can have, you know, adverse events and complications. The most common thing we see is a patient gets a headache and I tell them almost 100 percent of the time you'll get it, it'll be transient and it'll go away within minutes or hours. Most of the time CS F leak because we're putting a needle in the door. That's a possibility. Um, patient could be allergic to contrast. Thankfully, most are not, um, the, uh, potential for bleeding anytime you, you know, go through tissue, but we check their bleeding parameters. So that's usually not a problem. Infection. We do things sterilely again, not a problem. What patients don't realize is that the contrast that goes in your spinal canal also goes up around your head because all the CS F um communicates and it could be an irritant to the brain and it can cause a seizure. But I also tell them and this is how I tell them. I say it's really, really, really, really, really rare because it really is um Arno dyes. We usually don't see this anymore. That was in the old days of lipid salt Ebola or oil based contrast. And then if you can't get in down there, you have to do what's called ac 12 cervical spine puncture, which has additional risk because up there, you don't just have Cortico, you actually have the spinal cord, you also have the vertebral artery, which you could risk hitting and getting a stroke. So I thought I might have to do ac 12 puncture on her because I checked her CT scan and I saw maybe a two millimeter hole for me to get in. And I was saying, I'm hoping I could get into this limitations. Um unsuccessful access. Like I was just talking about bony overgrowth. If a patient has a complete myelographic block, meaning you can't get contrast above a certain level, you don't know what's going on above that level. And if the patient has an intrinsic cord lesion, let's say they have something not compressing the cord, but maybe a spinal cord tumor or a demyelinating lesion such as multiple sclerosis, you may not see anything or you may just see some non-specific expansion of the cord. So thankfully, luck was on our side that day and I was able to get into uh her spine in that two millimeter hole in one shot. And here's just injecting the uh contrast which appears white on the X ray. And here's the um lateral view of the myelogram and you could see there's a complete myelographic block here, contrast would not go further. We actually tilt the table so the patient's head is down, it would not go further. The other thing we noticed there was another lesion there down lower and this was an intradural extramedullary lesion, which means it arises in the dural sac itself. So I don't know if you guys can see the cursor in the audience, but uh doctor a maybe on that uh lateral view, you just want to show the there is a Hallmark good. So um let me just, but it's not, it's not so common. You can actually see a lesion on. No, I I will tell no, I will tell you the amount of times that we do milograms and find something. It's, you know, very uncommon. And that's why when he asked me, I said, do you really think she has something because this is not going to be a chip shot? And you know, I might have to go see 12 on her. So let's go to the next slide. So then we brought over for the cat scan, which is more definitive because I couldn't tell what's blocking everything. So just for orientation purposes here, first, that arrow is showing the spinal cord that gray stripe, the white is the contrast material in the cerebral spinal fluid. And then this is the mass, which is kind of hard to see because it was densely calcified. It's like the same density as the contrast. But once you kind of attune your eyes to it, you realize there's a calcified mass there. And then at this point, we knew it was a meningioma. The two most common lesions that are intradural and extra medullary are meningioma and Schwannoma or nerve sheath tumor. And here it is on the axle, the calcified mass and just below it, this is what we should see is the contrast surrounding the spinal cord there. And the other thing on this image on these images, for me, you know, it just how thick the lamina is. Um you know, because this was a very effective the actually the surgeon who did this surgery historically was an excellent scoliosis surgeon, got a very good scoliosis result. And that, that lamina is about two centimeters thick. So that was one of the big challenges in the surgery. But you know, as I look at this now today with the, with that ability to look back, right. That's really the most, the other most impressive thing to me here. Um And we'll talk about that, but just to bring it up and this is just the lower lesion because we didn't want to forget. She also had cord compression from the lower lesion, not as big, but there it is there, it widens this rle spinal fluid column. And if you look on the axial, that's the uh second meningioma compressing the spinal cord there. So with that, I felt we had a good answer called Dr Rothrock and I told him and then I turned the care over to her and I said we have an answer. So I will now turn it over to you. Thank you. Yeah, I, you know, this case I think is dramatic in a lot of different ways. Uh I'm Doctor Ro Robert Rothrock. I'm uh one of the spinal neurosurgeons, a Baptist. And um you know, there are a few challenges which I spoke about, I mean, I'll just say that this was a very dramatic circumstance because when you called me, actually, both of you called me and I was actually out of the country. And, um, but I was returning very soon and this is the sort of thing that once we know about it, you know, we don't want to dilly dally. Uh, you know, I don't know if I call it a surgical emergency, but when someone's losing function actively in their legs, they go rapidly uh from walking to not walking. The term we use is is rapidly progressive myelopathy. And that's, you know, we treat that urgently. If it's your spinal cord, you want it out. And uh I wish I could say that that was, you know, straightforward or easy. And, you know, I, I already see a question that got posted, you know, how often do you do this type of surgery? I mean, this type of surgery thankfully not that often, but intradural extramedullary tumors. We're, we're, we're treating, I'd say every at this point, every three weeks, we're doing a surgery like this. Certainly in our uh in our center, we're probably doing it more frequently. Uh but overall, these are rare tumors and, you know, just because someone has myelopathy, like Doctor Morgan was saying, you know, much more common is a metastatic tumor or disease that we're seeing this sort of presentation. So this is not a common um entity I mean, from a surgical standpoint, no question. In this case, highly symptomatic patient, rapidly progressing myelopathy. You know, I booked the surgery before I was back. And uh you know, it was the first thing I did when I got back. So, so, you know, definitely we needed to address it. I mean, there, obviously there were really three things I would say from a surgical standpoint. Uh number one was that there was pre-existing hardware and this is historical hardware. It's not something that we have removal sets for. Nor did I want to literally open the entire spine and remove all of it. I wanted to remove what I needed to, to get this out. And more importantly, looking long term to see it, you know, to remove that hardware, to remove this artifact. So we could now not have to ct myelogram heroically, every time we could trend it and look with, with MRI scans. So number one, we had to remove that hardware. Um These are not, you know, straightforward constructs that actually the historical rods usually made of a combination of, of stainless steel and other metals and these were actually about 7 to 8 millimeters thick. Um So that was one thing. Number two is in addition to that bony overgrowth that the tumor itself, especially the more cranial tumor, which was the dominant meningioma, we did remove both was highly calcified and and completely invasive of the dura. And then finally, dural reconstruction because we actually had to cut out the dura. So we have to sew in a patch. You know, the dura is the lining of the brain and spine. It it has to be repaired uh to contain the fluid into which the ct myelogram is performed through the spinal fluid. So these were all, you know, fairly major surgical challenges when we're planning a case like this. So just to give some example, you know, these are the intraoperative x-rays just where we're planning our incision. But what you can see here, thi this is a surgical instrument on top of the skin just to localize where we are. But you can see how thick and prominent uh this, these historical uh rods and side connectors and things are. So all of that has to be cut out physically uh with a car. But I mean, I use something called a carbide drill, but basically a drill that can drill out metal and what you don't want is shards of metal. So you have to contain all this. So it's, it's a pretty involved process and it adds time. So I would say just exposing and removing the hardware in this case took about 2.5 hours, which, you know, is not the standard amount of time. Usually surgical exposure even on a large case uh is, you know, half an hour to an hour. This, this was pretty involved. And then uh you know, otherwise you can see these are just some of the some of the ct miligram pictures that, that bony overgrowth I was talking about about two centimeters of bone. You have to drill through it while you're drilling that you don't really have normal cleans. So you have to protect that lining, endure it. So you have as much to close as possible. Uh I do have a few intraoperative pictures. Yeah, I'm sorry. Pardon the graphics. But uh basically this is an intraoperative microscopic image. This is you can see here these things to the side are surgical connotes these blue stripes and in the middle, there's sort of what looks like spaghetti, but this is actually shredded dura uh where the tumor had basically invaded and destroyed the the native lining. So you can see the normal dura hopefully in the audience, you're getting my cursor. But this this white out here is the normal lining of the spinal cord, the dura and, and you can see how it's sort of disrupted in the middle. And then here this is the consistency of very typical of meningioma. It's sort of like a fluffy in this case, very calcified mass. And then to the right, this is towards the patient's head where you can see normal arachnoid plane. So that's the normal lining. And then the whitish below is the native spinal cord. So basically what you're looking at is from the back of the patient. Uh just this massive tumor. And that in itself is, is usually a challenge, you know, the the tenants that we like to use, we like to try to debulk a tumor before we try to manipulate it off of the spinal cord because as you rock the spinal cord, you can damage it, you can cause spinal cord injury. Um So in this case, we wanted to debulk it, but the problem is that it was like a rock. And so, you know, I was assisted in this case, you know, joined, I should say by my chairman, Doctor mcdermott, uh by Daniel Segee, one of our expert uh neurosurgical uh uh practitioners and, and uh eventually by doctor Reer my plastic surgical partner who closes a lot of these complex cases. So it really takes a village this, I don't want anybody here to think it's just me and certainly I wouldn't have been able to do this if it weren't for the two guys on either side of me because we wouldn't have known about it. But you know, basically what we had to do in this case, we actually literally had to drill uh the tumor off of the spinal cord, which I can I think I could say is a first for me. Um although Doctor mcdermott has done it before, but then again, he's the literally the world's expert on meningioma. So he has a little bit of a cheat code there. Um But in this case, yeah, we, we had to actually drill out obviously very carefully and meticulously with, with a small bur two millimeter bur drill and, and you know, with two surgeons. So this is a very controlled thing. I mean, here it looks probably like a mess to the average viewer, but this is a very controlled microscopic operation. And, and basically in doing that, we were able to get a gross total resection. Um we were able to peel this tumor, the the secondary lesion that we saw, the lower one was not calcified. So we were able to resect it uh in much less time. But basically, you know, at the end of this, we'd basically remove the hardware and bone from about uh you know, each segments of the spine. The benefit is that because the patient was already fused, we then did not have to reinstall spinal hardware. We didn't have to add any compromised mobility. You know, we, we were creating more space for the spinal cord restoring as best possible, the native anatomy. And uh you know, that allowed us to, to get a gross total resection of both of these tumors. You can still see on the right hand panel, the metallic artifact from the lower uh uh hardware that's still there. But you know that we've resected the lesion here at the lower pole and this is obviously the upper pole. The other thing to look at here is, you know, you can see the spinal cord is diminutive, it almost looks like it's cut. And that's just because of these years and years of of being horribly compressed. This is Dr Abrams made me a prettier image here of, of the follow up post op MRI. But you can see in this right hand panel, an axial view that it's almost all CS F and you know, this diminutive spinal cord. So when you look at these images, you may think, oh my God, you know, the patient um didn't do so well. But you know, this is in a patient who's at this 0.5 months, post op is walking independently without an assistive device. So, you know, we we do see, you know that that the spinal cord can be compressed chronically and it it can recover. And in this case, you know, just we're, we're gonna talk a little bit, we're gonna see an interview with Tanya herself in a few moments here. But you know, this patient, we counseled her very cautiously because really, you know, the the truth of the matter is most patients will take time up to 18 calendar months to recover function from this sort of chronic spinal cord injury, which is what it really is. And she was able to walk, you know, within a few weeks of surgery, which was really quite amazing. Uh You know, I think that's mostly due to Tanya and her body and her determination. But one of the things that I tell patients and I'm sure you tell them the same thing, Doctor Morgan Dr Abrams, you know, is more in the radiology speed, but I'm sure you would too is that, you know, it, it takes time, it takes time and, and you can't call the game until 18 months. And, um, although we'd all like to think, you know, all these things we do in the hospital medications and things make a difference. A lot of it is just up to the, to you as an individual and um in your biology and, and, and other things, but, you know, really just an amazing um story. The other thing that, you know, really frequently asked about is spinal meningioma. Oh my God. Do I have a spinal meningioma? Yeah, very rare uh tumor entity. Uh predilection, spinal meningioma is really towards uh females greater than males about 6 to 1 in general. And um spinal meningioma tends to present in the sixth or seventh decade of life. It's usually a, um, you know, uh generally speaking, a female patient, especially if there's a calcified intra elect medullary mass. It's almost pathognomonic in that age group, especially if there's a dural tail, tail, excuse me. And, and actually the vast majority of these are, are discovered incidentally these days, I would say, and most of them were watching, you know, just because you have a tumor doesn't mean we have to remove it. That's another thing, you know, this was a very symptomatic patient who, who, you know, was being rendered paralyzed from this. But, you know, in most patients, if there's no spinal cord compression, it's called, incidentally, we'll keep an eye on it, the majority will not grow. So, so, you know, just because you have something doesn't mean you need surgery. The only other thing I want to bring up here, I think, like you said, uh Tanya is an amazing individual. When I went to see her, she was telling me about, you know, how athletic she is, she does hiking. I believe she was on a softball team. She was determined to not only walk but to run. And, uh, you know, just from the day I did the myelogram to the day, I think I saw her maybe a day or two after your surgery. It was a remarkable turnaround in such a short period of time. Like you said, we normally would expect months and she was doing things in by the hour. Yeah. No, it, it was really one of these inspiring situations and I think, you know, I think the stars aligned in this case, obviously, there was a lot of agency involved. But, uh, you know, just thinking about a dramatic story like this, you know, it could have gone a lot of different ways, it could have gone Dr Morgan, you know, maybe he was having an off day and he, you know, he didn't do it. As, although he never, he never has, you know, Doctor Abrams, what if you haven't gotten that puncture? I mean, I guess you would have done a higher puncture but, you know, there were a lot of fortuitous things that happened in this case. But, you know, as we sit here today, I, I have a young patient in the hospital, uh with a different tumor issue but has a similar story. And so, you know, of, of pretty dramatic recovery within a week after a complete, nearly complete spinal cord injury. So, you know, every day, I think we're inspired to keep doing this because it's not a one off. And uh you know, we we we were able to help these patients. Um So maybe on that note, we could uh see our interview with Tanya. I think it's really important the uh participants see the patient. I was pleased to be an assistant doctor Robert Rothrock, our spinal oncology surgeon uh during the removal of your calcified thoracic meningioma. But I was wondering if you could describe for the viewers what you experienced in terms of your sensation, leg strength and other symptoms related to this. So for about eight months before it was a gradual thing for me, it didn't happen all at once. Um It started with just some numbness and lack of sensation on my feet and it gradually went higher and higher and higher until I could no longer walk. Um I also lost, uh, b bowel control and I was incontinent and could no longer drive. I was basically not independent anymore. And which is a, which was very shocking for me because I went to many doctors and they could not explain to me what was going on. You had surgery for idiopathic spinal scoliosis. Correct. Correct. And how old were you when that surgery was done? And did you have a number of x rays after that? Do you remember I had numerous numerous x rays after that? Um I also had my cervus fused and my lumbar. So I had gotten many, many the bionic woman basically. Yeah. So one of the things we know is that low dose radiation is actually a risk factor for the development of meningioma. So we're hypothesizing in your case that the multiple diagnostic images that you have may have contributed to the origin of this thoracic um Meninga, which was right in the middle of your spinal fusion for the scoliosis. But you know, we didn't know that back in the day, we only know that now and that was required. So um that was all done correctly. It's just that there, there is a risk and even in a medical community in England, they're putting down more strict regulations about the use of diagnostic imaging because of low dose radiation exposure. I'm not gonna go into the details of the surgery. But um I remember uh you know, helping with it And the next day I asked Dr Rothrock, I said, how's your patient? And he said, well, she's actually able to lift her legs off the bed against gravity. And I said, I said, you know what, she's gonna walk in six months. But I was wrong. Why don't you tell us what happened? Post op, I was able to lift my legs the next day and I was walking in weeks in weeks. I mean, we went to, I went to through physical therapy, but they had me up and walking within a couple of weeks of my surgery, which was fantastic. It was surprising to me because I did not know what to expect and I didn't expect to be walking. You came to see me in the office about three months after and I did do a detailed exam, uh not a sensory exam because, you know, I didn't want to go through the undressing part and be that formal about it. But certainly your motor exam in your lower extremities was virtually normal. The sensory exam in your feet for a joint position, vibration sense entirely intact. And the only remnant that somebody who examines you in the future would be able to find would be hyperactive reflexes in your lower extremities. But that doesn't really cause a functional disability for it all. It doesn't bother me at all. And I only notice that when I go to the doctor and I do a physical exam so everything else, sensory wise, I am 100% again and I haven't had any problems after the surgery, everything has worked out fine. There is still some tightness in my back. Uh, I guess due to the muscle that was stitched back together or whatnot. Other than that 100% recovery, I am living my life as I used to. Yeah. You know, I, to be honest, I thought that when we had to excise the dura on the back of your spinal cord because it was intimately involved with the tumor, we had to put a patch and we were thinking well, might get a spinal fluid leak, might have hypotension and you're lucky to have nothing. Nothing. So, um you know, thank our lucky stars for that. If you can't be good, be lucky as they say, but I'm glad I was lucky. Yeah. But um no, that was uh you know, everything about it worked out better than we could have anticipated. So I'm really happy for you and I'm very thankful as well. We're going to write up your case with the purpose of reminding uh young physicians and surgeons that the physical examination is key uh a key part to the diagnosis, not just imaging and artificial intelligence algorithms because that won't do it. Um You really have to take a history and examine the patient. So if had it not been for the physical examination, I would have still been in a wheelchair. There you go. That says it all. Thank you for coming today. Thank you for having me. Well, I hope, uh hope that was insightful to see Tanya in her own words. You know, she's quite, quite remarkable and inspiring. We'll just take a few of the uh questions here. I'll just, um, restate some of them in case the audience can't see. Uh, Denise asked, uh, she's curious to know what was the cause of the patient's scoliosis. Did the patient have an MRI before her scoliosis surgery? And were there any underlying genetic association in this case, multiple men and gio you know, this patient, I think, um, as we've discussed it as a group and as you saw Doctor mcdermott discuss, you know, we can't help but to wonder if some of the uh prior surgery and, and necessary radiation exposure during childhood surgery could have been the main risk factor. But then again, actually, this patient also, we screened her her whole neural access after surgery and she does have a few incidental intracranial meningioma too. So she may have a multiple meninges syndrome genetically and, and probably should be genetically profiled for that. You know, her, her, her adolescent scoliosis was, was an a is case, I mean, it was she, she had developed that in adolescence and, and idiopathic meaning she didn't have a cause in this case, it was just developmental. Um, we had certainly, you know, it's sort of a chicken versus egg thing. I, I, I'm not aware of spinal meningioma being a cause of scoliosis. But we do see in Children with, with neurofibromatosis or multiple uh uh neural tumor syndromes, they will develop scoliosis from asymmetric post muscles, sort of interesting Trunkal muscles. So that certainly is a concern in pediatric population. I think this was more of just an adolescent scoliosis case and then this latent issue. Definitely, there's another question. Did we utilize neuromonitoring and trap? Yes, absolutely. And, and uh that's because any patient who doesn't have a complete injury, I mean, sometimes even with patients that have complete injury, I'll, I'll use monitoring because if I have an improvement at the end of the case, you know, that's a very positive prognostic sign I find practically. And so I, I almost always use neuromonitoring, meaning monitoring the electrical signals in the, in the, the extremities during these cases. Uh Doctor Morgan, we have a question for you. What rehabilitation protocols were established, post surgery and how were those tailored to address the neural recovery necessary for the patient's motor function? It's a great question. Um So one thing I I do want to emphasize is that right before she had the surgery, um she was essentially um using a wheelchair and occasionally using a, a rolling walker to ambulate and get around for mobility. Um She had near immediate improvements and pretty profound improvements in her motor strength in the, in the lower extremities right after the surgery. Um So that definitely helped with the recovery process and the, and the rehab process. Um So, some of the um rehabilitative protocols that were implemented number one gate training um to, to help her get up and moving again and retrain the lower extremities. Um One of the restrictions that we wanted to emphasize throughout the rehabilitative process is limiting forward function at the waist and at the trunk. Um And that helped um recovery and um healing at the surgical site and helped prevent that from um from um uh uh uh opening up. Um And so some of the other exercises that we incorporate into a routine were core strengthening exercises um and also strengthen the, the back extension muscles because she had a major surgery in that area and those muscles tend to get weak after a large surgery like the one that she underwent. Um But um she had almost near uh near complete recovery immediately after the surgery. So that's another point of emphasis. And it's the reason why this was a pretty remarkable case, you know, uh two questions for doctor Abrams um from the audience. So one is given the rarity of, of meningioma uh presenting without overt neurological symptoms. Would you recommend any adjustments to diagnostic protocols? You know, the implication being, would you recommend we mass scan the population for these lesions? Uh No, you know, again, you're gonna get, you're gonna find a lot of things that you're not gonna wanna treat or not really want to know about. Um, you know, general screening in the uh population when it comes to Meningioma. Thankfully, let's say sp meningioma. If the patient does have an MRI and they don't have all this metallic artifact, most likely you're going to see it because it's going to interface with the CS F column and they'll perform a nice outline of the abnormality. So they're usually not that tricky to pick up even without contrast. Once we see it, we do want to give contrast. But as far as you know, the protocols go, uh we really don't need to change much unless the patient has metal, which I think leads to the next question. The next question here is basically about metal suppression techniques, you know, for modern hardware, we definitely, you know, especially you have developed your own protocols to help us see through it. And this is not to say that every case that has metal, right? Needs ac T my. So, um why is it, do you think that you couldn't overcome those? What, what was limiting that ability to, to, you know, just to clarify to be able to limit the metallic artifact with MRI as opposed to a myelogram, right? So they're using different metal. Now, I believe you're using titanium in most of your cases, which has much less artifact than the old stainless steel that they use, which as you saw this is a tremendous amount of artifact. So very rarely would we have to do a myelogram for modern day hardware. We really see everything pretty well. And uh to the question, yes, there are metal suppression techniques which we do have and I did try it on Tanya, it got a little bit better, but it was still just different shades of black. Uh So I, I think when you have really, you know, dense hardware like this and stainless steel, sometimes even the best technology you can't do. And I think there was a question, are you better off doing it on a higher field strength magnet? And in essence, you're better off at 1.5 tesla than three tesla because you'll have more what they call susceptibility artifact at the higher magnetic field strength in general. So we try and do these on a 1.5 which we did for her. But again, to no avail. Um I think we have time for a few more. There's a surgical question. One of the meningiomas was noted on the left ventral aspect of the spinal canal. How did you achieve adequate exposure from a dorsal approach? So that, that's a great question. You know, we usually um with a wide enough laminectomy, uh sometimes we have to, you know, we have to instrument these resections to get wide enough for these exposures, but we actually usually can create a corridor that's safe as we debulk the tumor. So when, when we usually refer to a clock face. So if you imagine the image in front of you, you know, on our presentation as a clock face, um you know, if at 12 o'clock, it can be quite difficult to, to resect an intradural extra medullary tumor that has a lot of ventral compression. We need a wider exposure. Uh it caused a transversing, meaning we actually take down the rib and the pedicle. But in this case of the tumor, because it was soft, we we really were able to, to develop a plane, we can t the der we can pull it over, we can make different shapes of incisions. So in that case, we made more of ac shaped incision to land ourselves more lateral to have the view and we can rotate the patient, you know, one of the tricks we have is we physically rotate the patient who is locked in position, you know, safely, obviously, so we can get to that pole. So, so that, that actually, luckily was not a huge challenge in this case at that tumor lesion. But it's a good question. I I was certainly much more preoccupied with a dominant lesion here because it was just so calcified. But luckily it had a good plane, you know, meaning it wasn't scarred to the actual spinal cord, it actually was able to separate. And that, that was just luck of the draw for her. Um in this case, I, I think another lucky thing is and correct me if I'm wrong. Thankfully, the densely calcified one was dorsal. If that one had been the ventral one that really would have been even more difficult, I would say, definitely, we probably would have had to resect even more bone and do some of the things that I'm talking about here. Um Sacrifice the nerve root. Um You know, I, I don't think we had to sacrifice any dominant nerve roots here, you know, the thoracic nerve roots. So in either of these, so, you know, again, a lot of this is, is luck. Uh you know, and, and uh I always say to patients, you know, my business, everything is bad luck, but there's good, bad luck and bad, bad luck. And so this is like some good, bad luck. Yeah, I don't see any other questions from the audience and it's, it's been about 45 minutes. We really, really want to thank everyone for participating. Uh You know, I do think we have our contact info. If anybody would like to uh ask any further questions or for anyone our way, we're happy to see anyone that sent our way. But really, you know, I think this, this case for me, at least, I don't know how you guys feel. It really illustrates the fact that we work as a team and that uh I don't think you could do these complicated cases in a vacuum. You know, I, I don't think there's any one person uh who holds credit here and at the end of the day, you know, our reward is there's some patient out of Miami walking the streets, right? Who, who wasn't before? So thank you all for attending and thank you for your time and attention.
