A 69 year old male presented to his GP with a slowly progressive, 6 month history of left sided neck pains and occipital headaches. Examination was unremarkable and in particular, strengths and reflexes in all 4 limbs were normal.
CT scan revealed some degenerative changes low down in the cervical facet joints and a referral was made to an orthopaedic spinal specialist, and from here facet joint injections were undertaken.
When this procedure provided no relief, a greater occipital nerve injection was arranged under CT guidance and was on this procedure that the causative pathology was finally identified.
When the MRI scan was finally undertaken, a contrast enhancing, durally based, ventral and left sided tumour was identified behind C1 and C2.
Axial, Coronal and Sagittal MRI with gadolinium shoeing the tumour displacing and compressing the cervical cord.
With the benefit of hindsight, it was obviously the tumour causing the neck pain and occipital neuralgia.
The appearances were typical for a spinal menigioma and options were considered.
Analgesics alone were trialled initially, and whilst some improvements were seen with dexamethasone, lyrica and targin, the side effect profile was considerable, and the analgesia was incomplete. Consideration was given to radiation therapy up front and surgery was offered. In most clinical circumstances surgery would be considered treatment of choice for mengioma, and it was indeed the way the patient elected to go.
Informed consent was undertaken for C1 and C2 laminectomy with resection of the tumour. Spinal cord monitoring of motor and sensory potentials was undertaken to ensure real time feedback of potential spinal cord injury. The tumour was able to be resected in a 4 hour procedure, with 2 surgeons (thanks to Dr Hamish Alexander) collaborating to increase safety and avoid fatigue related mistakes. Motor and Sensory potentials were unchanged throughout the procedure and the patient woke without neurological deficit. He was able to be discharged 5 days after his procedure, once the discomfort of the neck wound settled.
The spinal cord is seen superiorly and C2 and C3 nerve rootlets are seen to cross over the top of the tumour to the edge of the dural opening.
Roughly 98% of the tumour was resected. A tiny piece of tumour was left where the C2 nerve root pierced the lateral dura. The dural attachment of the tumour ventrally was cauterised, but unable to be resected. Unfortunately, the meningioma histology was confirmed as ‘atypical’, which significantly increases the chances of tumour recurrence. For this reason, the patient has been referred on by our Neuro-Oncology Nurse Practitioner for consideration of post-operative radiation therapy.
Whilst it is acknowledged that common things occur commonly, a careful history, recognising occipital referral of pains (C2 and C3 irritation), may have prevented an unnecessary intervention into the lower cervical facets.
-By Dr Michael Bryant, Neurosurgeon and Spinal Surgeon