Cervical-Medullary Meningioma, associated with acute and persisting pain of the head and neck, is a diagnostic challenge for doctors and patients. Pain associated with the Temporomandibular joint (TMJ), ear pain, headache and other radiating pains to include radiculopathy often suggests a co-morbid condition. The key in this particular case was the progressive cascade of morbidity suffered by the patient suggesting an organic event more serious that a TM joint internal derangement, or musculoskeletal problem. A MRI scan ultimately provided diagnostic direction to reveal and confirm a cervical-medullary tumor, later confirmed by histopathology to be a meningioma.
Meningiomas were named by Harvey Cushing in 1922 and are described as common tumors that arise from the cells of the Meninges. Meningiomas are thought to originate from arachnoidal cap cells which form the outer lining of the arachnoid membrane, and from related cells such as arachnoidal fibroblasts and the meningoblast.1
Rubinstein2 includes all meningiomas under mesodermal tumors. Meningiomas constitute about 15 percent of primary brain tumors and 25 percent of spinal cord tumors. Since meningiomas are usually benign and completely resectable, the mortality numbers are much lower and account for only about 6 percent of brain tumors causing death.
This type of tumor is known as an adult tumor, with age incidence ranging be-tween 20 and 60 years of age, and peak incidence around 40 years. There is also a sex-linked factor with females having a higher incidence than males in spinal cord meningiomas.
In the spinal canal, the meningioma is a well-circumscribed oval or round lobulated tumor attached to the dura. This location often causes compression of the spinal cord with symptoms of myelopathy. Fortunately, spinal cord meningiomas are considered to be slow growing and well circumscribed.3-5
History & Review of Symptoms
A woman fifty years of age presented for evaluation of symptoms described as chronic pains of the right side of the head, neck, TMJ, ear, shoulder, arm, and fingers of the right hand. Her history revealed previous trauma to the head and neck as a result of two motor vehicular accidents (MVAs), with the latest accident occurring 2 years prior to the initial examination. After the last MVA, the patient began to complain of neck and TMJ pain, shoulder, arm, hand and finger pain, and pain radiating into the occipital and parietal regions of the head and manifested as headache and ear pain. The pain persisted as a constant stabbing pain, yet the symptoms of numbness and weakness of the right hand grip were occasional and very intermittent in nature. These very same symptoms have been noted in some patients who suffer from an injury to the temporomandibular joint. The common symptoms suggest the TMJ is the problematic source of symptoms suffered by the patient.
My initial examination—after the TMJ had been ruled out as the origin of the patient’s symptoms—suggested that a possible sprain of the cervical region had occurred. A test prescription of oral colchicine for inflammation and pain was provided and the patient initially reported pain relief with a reduction of arm and hand complaints and an overall reduction of pain of 60 percent. The patient also commented that the colchicine had helped her to sleep throughout the night for the first time in two years.
Three weeks later she was re-evaluated due to a change in her symptoms. She was dropping objects from her hand because of a progressive loss of feeling in her hand and fingers and her sleep was becoming more difficult. The pain of the head and neck had changed to one of a pounding nature. Continued use of the colchicine was problematic due to dosage-related diarrhea, and the necessary reduction from two tablets to one tablet per day was below the dosage necessary for pain and radiculopathic relief.
Re-examination revealed a positive Spurling’s test for the cervical spine. The patient was sent for an MRI scan and the scan revealed a: “expansile fusiform cervical cord lesion which appears to be intrinsic and extending from the cervical-medullary junction inferiorly to the C2-C3 interspace over an approximate 2.5 centimeter segment (see Figures 1-4). The cord is moderately expanded in this region and, on the axial views, the expansion appears to be more so on the right side. The surrounding subarachnoid space on the right side appears to be compromised” (see Figure 1).6 A referral for a neurosurgical procedure to remove the mass was made. The specimen was removed and examined microscopically and determined to be a meningioma. The patient recovered completely following surgery with no deficit and a remission of all symptoms and complaints.
Most patients with TMJ and radicular complaints are likely not suffering a spinal cord tumor, but this case serves as a reminder that a condition initially presented by a patient may be more serious than recognized, and the differential diagnosis should include the possibility of a progressive tumor. At the initial exam, the tumor was not obvious, but the rapid progression of symptoms over a 3 or 4 week period changed the initial perception of “sprain” to that of a tumor and was ultimately confirmed by imaging.