To describe and analysed the functional outcome (FO) after spinal meningioma (SM) surgery.
We processed the système national des données de santé (SNDS) i.e. , the French national administrative medical database to retrieve appropriate cases. We analysed the International Classification of Diseases 10 codes to assess the FO. Logistic models were implemented to search for variables associated with a favourable FO i.e. , a patient being independent at home without disabling symptom.
A total of 2,844 patients were identified of which 79.1% were female. Median age at surgery was 66 years, interquartile range (IQR) (56–75). Ninety-five point nine percent of the SMs were removed through a posterior ± lateral approach and 0.7% need an associated stabilisation. Benign meningioma represented 92.9% and malignant 2.1%. Median follow-up was 5.5 years, IQR (2.1–8), and at data collection 9% had died. The FO was good and increased along the follow-up: 84.3% of the patients were alive and had not associated symptoms at one year, 85.9% at 2 and 86.8% at 3 years. Nonetheless, 3 years after the surgery 9.8% of the alive patients still presented at least one disabling symptom of which 2.7% motor deficit, 3.3% bladder control problem, and 2.5% gait disturbance. One point seven percent were care-provider dependent and 2.1% chair or bedfast. In the multivariable logistic regression an older age at surgery (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.29–0.47, p<0.001), a high level of comorbidities (OR, 0.71; 95% CI, 0.66–0.75, p<0.001), and an aggressive tumor (OR, 0.49; 95% CI, 0.33–0.73; p<0.001) were associated with a worse FO.
FO after meningioma surgery is favourable but, may be impaired for older patients with a high level of comorbidities and aggressive tumor.
Thought to arise from the meningothelial cells of the arachnoid, meningiomas are the most common primary intracranial extracerebral tumors accounting for 36.8%–37.6% in the Central Brain Tumor Registry of the United States [
The aim of this study was to describe the FO after SM surgery and search for associated prognostic factors: in this nationwide population-based cohort study, we retrospectively analysed cases of surgically treated SM order to assess baseline data, long-term clinical outcomes, predictors of neurological improvement and potential differences between elderly and non-elderly patients.
We performed a cross-sectional nationwide descriptive observational and analytic retrospective study using the système national des données de santé (SNDS), the national French medico-administrative database. Incidental SM never operated are not considered in this study; only surgically treated SMs were taken into account. Patients who underwent the surgical resection of a meningioma between the first of January 2008 and to the 31 December 2017 were included. Cases were selected using an algorithm combining 2 variables as described previously: the type of the surgical procedure identified by the Common Classification of Medical Acts and the primary diagnosis according to the International Classification of Diseases (ICD-10) [
We analysed the ICD-10 codes to assess the FO: 135 codes such as G82.0 flaccid paraplegia or N31.2 flaccid neuropathic bladder were classified in 7 distinct categories of symptoms or diagnostics as follows: (1) bladder disturbance, (2) care-provider dependence, (3) gait disturbance, (4) motor impairment and muscle weakness, (5) sensory alteration, (6) unspecified symptoms of spinal cord compression, (7) rehabilitation care. Unspecified symptoms of spinal cord compression include both radiological findings and unspecific or undisclosed signs. Each dates related to a specific ICD code were worked out to obtain a timeline for each patient. A total of 111,925 different observations were processed by a complex program to get a 3-dimensional-like picture of diagnostics’ evolution across the time, before, at and after the spinal meningioma surgery. A good FO was assessed by a composite variable as a patient being independent at home, excluding thus, dead patients, patients being still in rehabilitation, patients hospitalised or patients still having physiotherapy at the time considered for symptoms in relation with the SM.
For the cohort description, continuous variables are reported as medians and interquartile ranges (IQRs); categorical variables are reported as frequencies and proportions. For continuous variables, the Mann-Whitney-Wilcoxon rank-sum test was used for between-group comparisons and for categorical data, the chi-square test was applied. A univariable and stepwise multivariable logistic regression model was employed to identify predictors of a good FO defined above. Variables were included in the multivariable regression if they had a p-value<0.15 in the univariable model. In essence, there is no lost to follow-up patient in the SNDS are those who died are automatically registered as such in the database. All tests were 2-sided and statistical significance was defined with an alpha level of 0.05 (p<0.05). Analysis was performed using the SAS Enterprise Guide (ver. 7.15 HF8, SAS Institute Inc., Cary, NC, USA) and the R programming language and software environment for statistical computing and graphics (R ver. 4.1.2 [2021-11-01]) [
This study was conducted according to the ethical guidelines for epidemiological research in accordance with the ethical standards of the Helsinki Declaration (2008), to the French data protection authority (CNIL) an independent national ethical committee, authorisation number: 2008538; to the RECORD guidelines for studies conducted using routinely-collected health data and, according to the SAMPL Guidelines [
Within the SNDS, we identified 2,844 patients who had SM surgery between 2008 and 2017. 79.1% of the patients were female and the median age surgery was 66 years, IQR (56–75) (
The FO was good and increased along the follow-up: 82.5% of the patients were alive and had recovered 3 months after the surgery. Eighty-three point six percent of the patients were symptoms free and were considered as having a good FO at 6 months, 84.3% at 1 year, 85.9% at 2 years, and 86.8% at 2 years and
In univariable logistic regression, many variables were predictors of the FO (
SM are intradural extramedullary tumors originating from the meningothelial cells of the vertebral canal leptomeninges. The goal of surgery is to achieve complete tumor removal whilst avoiding additional neurological damage. SM resection is usually a relatively simple neurosurgical intervention usually performed via a hemilaminectomy approach with reported rates of complete resection usually above 90% [
Our study presents a unique modern nationwide population-based analysis of SM patients. Thanks to the SNDS, we managed to gather the largest ever published series assessing the FO after SM surgery. The strengths of the SNDS reside both in the high number of patients and in the exhaustive data available from every hospital in France, private and public. The SNDS includes many information such as demographic data, medical and surgical procedure with associated diagnoses and date of death. The database representativeness is nearly perfect, since it includes the whole country’s population of nearly 68 million of inhabitants constituting one of the largest AMDB in the world [
There are only a handful studies reporting on SM using AMDB of which all take advantage of American database such as the Surveillance, Epidemiology, and End Results (SEER) and/or the CBTRUS (Central Brain Tumor Registry of the United States) [
Compared to the preoperative assessment, our results show that SM surgery was followed by significant improvement of motor deficits, sensory deficits, gait disturbances, bladder dysfunction and pain. A severe preoperative functional status is not a limiting factor for complete recovery and favourable FO also occurs in the majority of elderly patients [
The elderly cohort also had a higher degree of preoperative neurological impairment and comorbidities compared to the non-elderly as reported previously [
This work highlights the great value of this unique database to evaluate the FO after SM surgery and its predictors. Further inclusion and prolonged follow-up are required to assess other prognostic factors such as the histopathological subtypes, best after SNDS, and the French Brain Tumour DataBase merging [
FO after meningioma surgery is favourable but, may be impaired for older patients with a high level of comorbidities and aggressive tumor.
Supplementary Tables 1 and 2 can be found via
Summary of predictors and corresponding weights for computation of the mortality-related morbidity index (MRMI) and expenditure-related morbidity index (ERMI) of each predictor in the study cohort
Summary of predictors and corresponding weights for computation of the mortality-related morbidity index (MRMI) and expenditure-related morbidity index (ERMI) of each predictor in the study cohort
The authors have nothing to disclose.
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conceptualization: CCD, JW, VJ; Data curation: CCD, JW; Formal analysis: CCD; Methodology: CCD, JW; Project administration: CCD, NP, VJ; Visualization: CCD, NP; Writing - original draft: CCD; Writing - review & editing: CCD, NP, JW, VJ.
Distribution of the patients’ symptoms with spinal meningioma at surgery (A), 3 months (B), 6 months (C), 1 year (D), 2 years (E), and 3 years (F) after the surgery for “young” patients below 70 years versus elderly above 70 years old.
Three-dimensional scatter plot of the symptoms distribution over the time after spinal meningioma surgery with the display of the associated regression plane indicating a highly significant decreased of all symptoms over the time (p<0.001).
(A) Evolution of the number of symptoms per patients over the time for the elderly and for the nonelderly patients. (B) Variation of the number of symptoms over the time, for whole enrolled patients. (C) Alluvial or Sankey diagram which represents the outcome of each symptom at 3 years.
Characteristics of the 2,844 patients for the whole cohort, for patients below 70 years, and for those above 70 years
Characteristic | Whole cohort | Nonelderly < 70 years (n = 1,699) | Elderly ≥ 70 years (n = 1,145) | p-value | |
---|---|---|---|---|---|
Sex female | 2,251 (79.1) | 1,334 (78.5) | 917 (80.1) | 0.335 | |
Symptoms at surgery | |||||
Motor impairment and muscle weakness | 1,087 (38.2) | 519 (30.5) | 568 (49.6) | < 0.001 |
|
Rehabilitation care | 1,051 (37) | 449 (26.4) | 602 (52.6) | < 0.001 |
|
Unspecified symptoms of spinal cord compression | 938 (33) | 517 (30.4) | 421 (36.8) | < 0.001 |
|
Bladder disturbance | 678 (23.8) | 301 (17.7) | 377 (32.9) | < 0.001 |
|
Gait disturbance | 636 (22.4) | 289 (17) | 347 (30.3) | < 0.001 |
|
Sensory alteration | 541 (19) | 321 (18.9) | 220 (19.2) | 0.869 | |
Care-provider dependence | 256 (9) | 77 (4.5) | 179 (15.6) | < 0.001 |
|
Symptom severity | 1 (0–3) | 1 (0–3) | 2 (0–3) | < 0.001 |
|
Previous in hospital admission | 623 (21.9) | 260 (15.3) | 363 (31.7) | < 0.001 |
|
Physiotherapy before the surgery | 1,950 (68.6) | 1,108 (65.2) | 842 (73.5) | < 0.001 |
|
Prior rehabilitation | 266 (9.4) | 81 (4.8) | 185 (16.2) | < 0.001 |
|
Need of rehabilitation 30 days prior the surgery | 316 (11.1) | 106 (6.2) | 210 (18.3) | < 0.001 |
|
Need of rehabilitation 90 days prior the surgery | 277 (9.7) | 94 (5.5) | 183 (16) | < 0.001 |
|
Surgical delay more than 30 days | 147 (5.2) | 62 (3.6) | 85 (7.4) | < 0.001 |
|
Surgical delay more than 90 days | 38 (1.3) | 22 (1.3) | 16 (1.4) | 0.947 | |
Age at surgery (yr) | 66 (56–75) | 58 (49–75) | 77 (73–75) | NA | |
Age at surgery (yr) | |||||
< 50 | NA | NA | NA | NA | |
> 50 & < 59 | 539 (19) | 539 (31.7) | NA | NA | |
> 60 & < 69 | 765 (26.9) | 705 (41.5) | NA | NA | |
≥ 70 | 1,085 (38.2) | NA | 60 (5.2) | NA | |
Neurofibromatosis (NF2) | 25 (0.9) | NA | NA | < 0.001 |
|
Mortality-related morbidity index | 1 (0–2) | 0 (0–2) | 1 (0–2) | < 0.001 |
|
Expenditure-related morbidity index | 2 (0–9) | 0 (0–9) | 5 (0–9) | < 0.001 |
|
Surgical approach or technique | |||||
Posterior approach | 2,728 (95.9) | 1,627 (95.8) | 1,101 (96.2) | 0.670 | |
Anterior approach | 116 (4.1) | 72 (4.2) | 44 (3.8) | 0.670 | |
Epidural meningioma | 198 (7) | 131 (7.7) | 67 (5.9) | 0.067 | |
Spinal fixation | 20 (0.7) | 16 (0.9) | 4 (0.3) | 0.104 | |
Tumor grading | |||||
Benign | 2,641 (92.9) | 1,561 (91.9) | 1,080 (94.3) | - | |
Atypical | 143 (5) | 98 (5.8) | 45 (3.9) | - | |
Malignant | 60 (2.1) | 40 (2.4) | 20 (1.7) | 0.044 |
|
Length of hospital stay (day) | 8 (7–13) | 8 (6–13) | 10 (8–13) | < 0.001 |
|
Transfer to rehabilitation unit after SM surgery | 706 (24.8) | 294 (17.3) | 412 (36) | < 0.001 |
|
Need of physiotherapy after the surgery | |||||
Any time | 859 (30.2) | 489 (28.8) | 370 (32.3) | 0.049 |
|
At 1 year | 631 (22.2) | 365 (21.5) | 266 (23.2) | 0.292 | |
At 2 years | 523 (18.4) | 296 (17.4) | 227 (19.8) | 0.116 | |
At 3 years | 443 (15.6) | 243 (14.3) | 200 (17.5) | 0.026 |
|
Good functional outcome | |||||
At 1 year | 2,398 (84.3) | 1,534 (90.3) | 864 (75.5) | < 0.001 |
|
At 2 years | 2,442 (85.9) | 1,559 (91.8) | 883 (77.1) | < 0.001 |
|
At 3 years | 2,468 (86.8) | 1,574 (92.6) | 894 (78.1) | < 0.001 |
|
Death | |||||
Within the postoperative month | 8 (0.3) | 2 (0.1) | 6 (0.5) | 0.0999 | |
Within the 3 postoperative months | 16 (0.6) | 6 (0.4) | 10 (0.9) | 0.118 | |
At 1 year | 37 (1.3) | 15 (0.9) | 22 (1.9) | 0.0260 |
|
At last follow-up | 257 (9) | 70 (4.1) | 187 (16.3) | < 0.001 |
|
Follow-up (yr) | 5.5 (2.1–8) | 5 (1.5–7.7) | 6.2 (3.2–8.3) | < 0.001 |
Values are presented as number (%) or median (interquartile range).
NA, not applicable; SM, spinal meningioma.
p<0.05, statistically significant difference.
Univariable logistic regression of good functional outcome after spinal meningioma surgery
Variable | At 3 months |
At 6 months |
At 1 year |
At 2 years |
At 3 years |
||||||
---|---|---|---|---|---|---|---|---|---|---|---|
OR (95 % CI) | p-value | OR (95 % CI) | p-value | OR (95 % CI) | p-value | OR (95 % CI) | p-value | OR (95 % CI) | p-value | ||
Male sex | 1.06 (0.84–1.36) | 0.623 | 1.09 (0.85–1.4) | 0.520 | 1.14 (0.89–1.48) | 0.310 | 1.01 (0.79–1.32) | 0.913 | 0.97 (0.75–1.27) | 0.827 | |
Symptoms at surgery | |||||||||||
Sensory alteration | 1.43 (1.1–1.88) | 0.009 |
1.61 (1.22–2.15) | 0.001 |
1.61 (1.22–2.17) | 0.0012 |
1.5 (1.12–2.03) | 0.008 |
1.54 (1.14–2.12) | 0.006 |
|
Motor impairment and muscle weakness | 0.55 (0.45–0.67) | < 0.001 |
0.58 (0.47–0.71) | < 0.001 |
0.58 (0.47–0.71) | < 0.001 |
0.58 (0.47–0.71) | < 0.001 |
0.56 (0.45–0.7) | < 0.001 |
|
Bladder disturbance | 0.63 (0.51–0.78) | < 0.001 |
0.68 (0.55–0.85) | < 0.001 |
0.67 (0.54–0.85) | < 0.001 |
0.66 (0.52–0.83) | < 0.001 |
0.65 (0.51–0.83) | < 0.001 |
|
Gait disturbance | 0.75 (0.6–0.94) | 0.012 |
0.8 (0.64–1.01) | 0.055 | 0.8 (0.63–1.01) | 0.059 | 0.77 (0.61–0.99) | 0.038 |
0.78 (0.61–1) | 0.048 |
|
Unspecified symptoms of spinal cord compression | 0.8 (0.66–0.98) | 0.033 |
0.86 (0.7–1.06) | 0.152 | 0.83 (0.67–1.03) | 0.081 | 0.82 (0.66–1.02) | 0.078 | 0.83 (0.66–1.04) | 0.0999 | |
Rehabilitation care | 0.51 (0.42–0.62) | < 0.001 |
0.54 (0.44–0.66) | < 0.001 |
0.57 (0.46–0.7) | < 0.001 |
0.57 (0.46–0.71) | < 0.001 |
0.57 (0.45–0.7) | < 0.001 |
|
Care-provider dependence | 0.42 (0.32–0.57) | < 0.001 |
0.46 (0.34–0.62) | < 0.001 |
0.48 (0.36–0.66) | < 0.001 |
0.46 (0.34–0.63) | < 0.001 |
0.45 (0.33–0.62) | < 0.001 |
|
No. of symptoms | 0.84 (0.79–0.88) | < 0.001 |
0.86 (0.81–0.91) | < 0.001 |
0.86 (0.82–0.92) | < 0.001 |
0.86 (0.81–0.91) | < 0.001 |
0.85 (0.8–0.91) | < 0.001 |
|
Previous in-hospital admission within 3 months | 0.47 (0.38–0.58) | < 0.001 |
0.49 (0.39–0.6) | < 0.001 |
0.46 (0.37–0.58) | < 0.001 |
0.46 (0.36–0.57) | < 0.001 |
0.85 (0.8–0.91) | < 0.001 |
|
Prior rehabilitation | 0.49 (0.37–0.66) | < 0.001 |
0.56 (0.42–0.75) | < 0.001 |
0.54 (0.4–0.73) | < 0.001 |
0.53 (0.39–0.72) | < 0.001 |
0.52 (0.38–0.72) | < 0.001 |
|
Need of rehabilitation 30 days prior the SM surgery | 0.48 (0.37–0.62) | < 0.001 |
0.52 (0.4–0.69) | < 0.001 |
0.5 (0.38–0.66) | < 0.001 |
0.48 (0.36–0.64) | < 0.001 |
0.47 (0.36–0.64) | < 0.001 |
|
Need of rehabilitation 90 days prior the SM surgery | 0.5 (0.38–0.67) | < 0.001 |
0.55 (0.41–0.74) | < 0.001 |
0.53 (0.4–0.72) | < 0.001 |
0.52 (0.38–0.7) | < 0.001 |
0.51 (0.37–0.7) | < 0.001 |
|
Surgical delay more than 30 days | 0.48 (0.33–0.69) | < 0.001 |
0.47 (0.32–0.68) | < 0.001 |
0.49 (0.34–0.73) | < 0.001 |
0.55 (0.37–0.83) | 0.003 |
0.57 (0.38–0.88) | 0.009 | |
Surgical delay more than 90 days | 0.4 (0.21–0.82) | 0.009 |
0.42 (0.21–0.86) | 0.014 |
0.45 (0.23–0.95) | 0.027 | 0.52 (0.26–1.18) | 0.094 | 0.57 (0.27–1.33) | 0.157 | |
Age at surgery | 0.96 (0.95–0.97) | < 0.001 |
0.96 (0.95–0.97) | < 0.001 |
0.96 (0.95–0.97) | < 0.001 |
0.95 (0.95–0.96) | < 0.001 |
0.95 (0.94–0.96) | < 0.001 |
|
Age at surgery (4 categories) (ref. <50 yr) (yr) | |||||||||||
> 50 & < 60 | 1 (0.66–1.53) | 0.990 | 0.96 (0.62–1.49) | 0.869 | 0.87 (0.55–1.37) | 0.558 | 0.9 (0.54–1.48) | 0.672 | 1.08 (0.64–1.81) | 0.775 | |
> 60 & < 70 | 0.71 (0.49–1.03) | 0.076 | 0.7 (0.47–1.02) | 0.069 | 0.63 (0.42–0.94) | 0.029 |
0.59 (0.37–0.91) | 0.0200 |
0.68 (0.43–1.05) | 0.088 | |
≥ 70 | 0.28 (0.19–0.38) | < 0.001 |
0.27 (0.19–0.38) | < 0.001 |
0.25 (0.17–0.35) | < 0.001 |
0.22 (0.14–0.32) | < 0.001 |
0.23 (0.15–0.34) | < 0.001 |
|
Elderly (≥ 70 yr) vs. nonelderly (< 70 yr) | 0.34 (0.28–0.42) | < 0.001 |
0.34 (0.28–0.42) | < 0.001 |
0.33 (0.27–0.41) | < 0.001 |
0.3 (0.24–0.38) | < 0.001 |
0.28 (0.22–0.36) | < 0.001 |
|
Mortality-related morbidity index | 0.67 (0.63–0.71) | < 0.001 |
0.68 (0.63–0.72) | < 0.001 |
0.67 (0.63–0.72) | < 0.001 |
0.65 (0.61–0.7) | < 0.001 |
0.65 (0.61–0.69) | < 0.001 |
|
Expenditure-related morbidity index | 0.89 (0.88–0.91) | < 0.001 |
0.9 (0.88–0.91) | < 0.001 |
0.89 (0.88–0.91) | < 0.001 |
0.89 (0.87–0.91) | < 0.001 |
0.89 (0.87–0.9) | < 0.001 |
|
Surgical technique (ref. posterior or posterior lateral approach) | |||||||||||
Anterior or anterior lateral approach | 0.77 (0.49–1.23) | 0.248 | 0.74 (0.48–1.2) | 0.203 | 0.7 (0.45–1.14) | 0.132 | 0.69 (0.44–1.14) | 0.129 | 0.64 (0.4–1.05) | 0.064 | |
Epidural meningioma | 0.83 (0.58–1.2) | 0.309 | 0.84 (0.59–1.24) | 0.365 | 0.83 (0.57–1.22) | 0.317 | 0.75 (0.52–1.11) | 0.139 | 0.74 (0.51–1.12) | 0.139 | |
Spinal fixation | 1.21 (0.4–5.19) | 0.764 | 1.11 (0.37–4.77) | 0.867 | 1.05 (0.35–4.53) | 0.933 | 0.93 (0.31–4.01) | 0.911 | 0.86 (0.29–3.71) | 0.814 | |
Tumour grading (ref. benign) | |||||||||||
Atypical | 0.61 (0.42–0.92) | 0.015 |
0.64 (0.43–0.97) | 0.029 |
0.63 (0.42–0.96) | 0.026 |
0.54 (0.36–0.84) | 0.004 |
0.6 (0.4–0.95) | 0.023 |
|
Malignant | 0.26 (0.15–0.44) | < 0.001 |
0.26 (0.15–0.44) | < 0.001 |
0.24 (0.14–0.41) | < 0.001 |
0.21 (0.13–0.36) | < 0.001 |
0.21 (0.12–0.36) | < 0.001 |
|
Length of hospital stay | 0.97 (0.96–0.98) | < 0.001 |
0.97 (0.96–0.98) | < 0.001 |
0.97 (0.96–0.98) | < 0.001 |
0.97 (0.96–0.98) | < 0.001 |
0.97 (0.96–0.98) | < 0.001 |
|
Transfer to rehabilitation after SM surgery | 0.54 (0.44–0.66) | < 0.001 |
0.56 (0.45–0.69) | < 0.001 |
0.57 (0.46–0.71) | < 0.001 |
0.6 (0.48–0.75) | < 0.001 |
0.59 (0.47–0.75) | < 0.001 |
OR, odds ratio; CI, confidence interval; SM, spinal meningioma.
p<0.05.
Multivariable logistic regression of good functional outcome after spinal meningioma surgery
Variable | At 1 year |
At 2 years |
At 3 years |
|||
---|---|---|---|---|---|---|
OR (95 % CI) | p-value | OR (95 % CI) | p-value | OR (95 % CI) | p-value | |
Elderly (≥ 70 yr) vs. nonelderly (< 70 yr) | 0.37 (0.29–0.47) | < 0.001 |
0.34 (0.26–0.43) | < 0.001 |
0.32 (0.25–0.42) | < 0.001 |
Mortality-related morbidity index | 0.71 (0.66–0.75) | < 0.001 |
0.69 (0.64–0.74) | < 0.001 |
0.68 (0.64–0.73) | < 0.001 |
Aggressive meningioma (WHO grade II & III) | 0.49 (0.33–0.73) | < 0.001 |
0.42 (0.28–0.62) | < 0.001 |
0.47 (0.31–0.71) | < 0.001 |
OR, odds ratio; CI, confidence interval; WHO, World Health Organization.
p<0.05.