Spinal tumors

Case introduction

46 yo male not known to have any medical illness .

Presented with history of lower limp weakness and pain for
1 year , gradual and progressive in course, mainly in the
right side. With no history of incontinence
o/e :bilateral lower limp weakness . At the ankle joint the
planter flexion RT:2/5 LT:4/5 planter dorsiflexion RT:1/5
LT:3/5 decrease sensation in L4 & L5 of the Rt leg and
decreased reflexes bilaterally otherwise he is normal.

Introduction

Compression of the spinal cord

is a common neurosurgical
problem.
if the condition is
unrecognized and untreated
the eventual outcome will
inevitably be disabling
paralysis and sphincter
disturbance
Pathology
The spinal cord may be
compressed by lesions that
are:
extradural (80%)
intradural, extra medullary
(15%)
intramedullary (5%).

Introduction
The major groups of pathological causes are:
1 Tumor:
(a) metastatic (b) primary.

2 Degenerative:
(a) disc prolapse (b) osteoporosis/spondylosis.

3 Infection:
(a) vertebral body (b) disc space (c) extradural (d) intradural.

4 Hematoma:
(a) spontaneous (trauma) (b) arteriovenous malformation.

5 Developmental:
(a) syrinx (b) arteriovenous malformation (c) arachnoid cyst.

Introduction

Aspinal tumoris an abnormal mass of tissue within or

surrounding thespinal cordandspinal column

Could be benign(non-cancerous) ormalignant(cancerous).

Could be Primary tumors ORmetastaticor secondary

tumors .

the tumor can affect the:

Blood vessels, Bones of the spine, Meninges, Nerve roots, Spinal cord cells.

With time, the damage may become permanent.

Classification

These basic areas

arecervical
,thoracic,lumbarandsacrum

they also are classified by

their location in the spine
anterior(front)
andposterior(back).

Clinically, they are divided

into three major groups
according to location:
intradural-extramedullary,
intramedullary and
extradural.

Overall prevalence is estimated at one spinal tumor for every four intracranial
lesions
Lesions that compress the spinal cord
extradural (80%)
intradural, extra medullary (15%)
intramedullary (5%).

Metastatic spinal tumors are the most common type of malignant lesions of the
spine, accounting for an estimated 70 percent of all spinal tumors.

Intramedullary tumors , only 5-10% of all spinal tumors.

IntraDural:

In adults,

extra medullary tumors ,60-75% of intradural masses

with intramedullary tumors ,35-40% of intradural masses

In children,

intramedullary tumors are more common, accounting for greater than 35% of intradural
masses

Intradural tumors occur with equal frequency in both sexes, with the
exception of a higher incidence of meningiomas in women

The most frequent intradural-extramedullary tumors are nerve sheath

tumors and meningiomas with filum terminale ependymomas being a
distant third.
Most intraspinal tumors present by compression rather than invasion

Causes

The cause of most primary spinal tumors is unknown.

Some of them may be attributed to exposure to cancer-causing agents.

higher incidence of spinal tumors in particular families, so there is most

likely a genetic component

Causes

In a small number of cases, primary tumors may result from

presence of these two genetic diseases:
Neurofibromatosis 2:
In this hereditary disorder, benign tumors may develop in the
arachnoid layer of the spinal cord or in the supporting glial cells.
However, the more common tumors associated with this disorder
affect the nerves related to hearing and can inevitably lead to loss
of hearing in one or both ears.

Von Hippel-Lindau disease:

This rare, multi-system disorder is associated with benign blood
vessel tumors (hemangioblastomas) in the brain,retinaand
spinal cord, and with other types of tumors in the kidneys or
adrenal glands.

Causes

Neurofibromatosis Type 2
A patient with neurofibromatosis Type II. a, b Different intradural
extramedullary (meningiomas and neurofibromas) and intradural
intramedullary tumors (ependymoma) as well as c extraspinal tumors
are to be seen in the whole spine.

Symptoms
Pain
a common early feature of cord compression and often precedes the onset
of any neurological disturbance
due to involvement of local, pain sensitive structures
girdle pain or radicular pain: is due to involvement of the nerve root at the level of the compression.
severe, sharp, shooting pain

Central pain
due to spinal cord compression itself
diffuse dull ache, often with a burning quality, and is frequently described with
difficulty.

Lhermittes sign : electric shock or tingling radiating down through the body to the extremities of
the limbs cuased by Flexion or extension of the neck .
associated with cervical cord involvement, either by a compressive lesion or due
to an inflammatory process.

Gets worse over time

Is usually severe and not relieved by pain medication
In any area -- middle or low back are most common
Is worse when lying down, with strain, cough or sneeze
May extend to the hip, leg, or feet (or arms), or all
extremities OR May stay in the spine

Neurological deficit
The neurological features of spinal
cord compression consist of:
progressive weakness
sensory disturbance
sphincter disturbance.

 Motor impairment
depend on the position of the cord compression
The compression of the corticospinal pathways will result
in an upper motor neuron weakness
an initial pyramidal pattern

 the pattern of weakness may also be influenced

by the position of the compressing lesion.
lateral compression ,weakness, predominantly on the
side of the compressing lesion.
cervical region ,lower motor neuron weakness of the
involved nerve roots in the upper limb
below T1 in the thoracic area will cause no clinically
demonstrable nerve root weakness.
conus medullaris ,mixture of lower motor neuron
features and upper motor neuron signs in the lower
limbs.
Cauda equina ,lower motor neuron pattern of
weakness.

Sensory disturbance
A sensory level is the hallmark of spinal cord compression.
band of minor hyperesthesia at the level of the compression.

Specific patterns of sensory loss will occur depending on the tracts

within the cord that are initially involved.
A laterally placed mass will initially cause a Brown-Squard
syndrome.
There will be contralateral impairment of pain and temperature
sensation, with ipsilateral pyramidal weakness and impairment
of joint position sense, vibration and fine touch.

 Analgesia affecting primarily the saddle area (buttocks

and upper posterior thigh) occurs particularly in cauda
equina or conus medullaris lesions.

Compression Syndromes
Root
severe, sharp, shooting pain with
weakness or numbness in distribution of
root (radicular)

Bone
continuous dull pain and tenderness
may not be relieved by rest

 Anterior
bilateral weakness, dissociated sensory
loss (loss of pain and temperature,
retained position sense, pressure,
vibration)

Posterior
rare, produces paresthesias, impaired
posterior column function

 Lateral
aka Brown Sequard
contralateral loss of
pain and temperature
1-2 segments below
injury
ipsilateral loss of
posterior column
function and
weakness
best prognosis of any
spinal cord syndrome

 Central
weakness of UE
> LE
cape-like
sensory deficit

Sphincter involvement
compression of conus medullaris or cauda equina
The first symptom is difficulty in initiating micturition
and this is followed by urinary retention, which is often
relatively painless.
Constipation and fecal incontinence will subsequently
occur.
The clinical signs include an enlarged, palpable bladder,
diminished perianal sensation and decreased anal tone.

Intradural-extramedullary
tumors

develop in
1. the spinal cord'sarachnoid membrane(meningiomas)
2. in the nerve roots that extend out from the spinal cord
( schwannomasandneurofibromas)
3. or at the spinal cord base (filum terminale
ependymomas).

Nerve Sheath Tumors

(Schwannoma & neurofibroma)

most common of the intrathecal tumors

may occur at any position
up to 30% of spinal neoplasms
typically arise from the posterior sensory nerve root near its
entrance into the neural foramen
extends through the intervertebral foramen to form a
dumb-bell tumor
Present:
1. slowly growing tumor causing cord compression
2. Pain in a radicular distribution
3. some degree of a Brown- Squard syndrome due to
the lateral position of the tumor.

Schwannoma
&neurofibroma

Although both tumors are thought to be of Schwann cell origin, their significant histologic,
epidemiologic, and biologic differences warrant discussing them separately

schwannoma

80% of nerve sheath tumor

M=F
Solitary tumor
Occur equally through the spinal cord
Associated with neurofibromatosis 2
(NF2) and schwannomatosis
well-demarcated masses associated
with a nerve root, intensely enhance,
can include cystic areas
30% of schwannomas grow through
the neural foramen, giving the classic
dumbbell
At surgery, schwannomas are smooth,
well-demarcated tumors that are
discretely attached to an intact nerve
root and can usually be separated
from the root without nerve injury. The
goal of surgery should be complete
tumor removal

neurofibroma

15%
more than half of them are associated with
neurofibromatosis 1 (NF1)
typically, but not exclusively, arise from the
sensory root
solid, not cystic. Yet they, too, can extend
through the Dural root sleeve as a
dumbbell tumor
characteristically arise from central nerve
root fibers
total surgical removal of tumor, often
necessitating the sacrifice of the nerve
root.

Schwannoma & neurofibroma

Radiology : X-ray shows
1. evidence of bone
erosion
2. enlargement of the
intervertebral foramen
is typical (Fig. 15.6).
3. an increase in the
interpedicular
distance.
CT and myelogram will
show spinal tumor with
compression
MRI with contrast is the
standard for diagnosis now.
.
.
.
.
.

isointense on T1W images

hyperintense on T2W images;
almost 100% CE positive;
foraminal widening;
Calcification rare

Nerve Sheath Tumors

Treatment:
surgical excision of the tumor.
Access to the tumor is obtained by a laminectomy.
If there is a large extraspinal extension it may be
necessary to obtain additional exposure through the
neck, chest or abdomen.

Spinal meningioma

M<F
occur particularly in 50-70s
75% of intraspinal meningiomas arise in the thoracic spine
and are typically dorsolateral to the cord
cervical tumors (20%) do occur and are frequently located
in the upper cervical region and ventral to the cord

Spinal meningioma

grow extremely slowly ,

usually a long history of ill-defined back pain, often
nocturnal, and a very slowly progressive paralysis prior to
diagnosis.
typically benign, encapsulated, slow-growing masses,
growth patterns are seen including en plaque, atypical, and
invasive malignant meningiomas
derive their blood supply from a broad Dural base that is
often visible as a Dural tail on MRI

Spinal meningioma
Radiology
Plain X-rays may show
1.
2.

erosion of the pedicles due to longstanding intradural compression.

Hyperostosis, which is frequently
present in cranial meningiomas,
does not occur in spinal
meningiomas.

MRI
. isointense with cord on both T1W images
and T2W images;
. moderate CE with or without association of
Dural tail;
. no bone destruction;
. calcification occasional.

preoperative CT scans are helpful to

determine the presence and extent
of tumor calcification, which can
significantly affect surgical strategy.

Spinal meningioma

Treatment
The treatment of spinal meningioma is resection of the
tumor and the involved Dura.

Intramedullary:

These tumors grow inside the spinal cord or individual

nerves, most frequently occurring in the cervical (neck)
region

They typically derive fromglialorependymal cellsthat are

found throughout the interstitium of the cord.

Astrocytomasand ependymomas are the two most

common types

Ependymomas

15% to 30% of intradural spinal lesions

the most common type of intramedullary spinal cord
tumors
Occur anywhere but the majority in filum terminal
middle age years
NF2 patients harbor intramedullary ependymomas,
typically solitary tumors that arise from ependymal lining of
the central canal
50% of cases have an associated syrinx.

Ependymomas

Radiology
On MRI,

isointense with cord on T1W images

hyperintense on T2W images;
CE strong somewhat inhomogeneous due to
cyst formation or hemorrhage;
foci of points or trails of signal void due to
strong vascularization;
vertebral body scalloping in conus tumors.

Classic radiographic features of

spinal cord ependymomas
include
1. distinct tumorspinal cord
border,
2. an associated syrinx, cysts
within or adjacent to the
mass,
3. and hemosiderin deposits or
caps near the poles of the
tumor on T1 and T2

Ependymomas
Treatment
total surgical resection.
In contrast to intracranial
ependymomas, intramedullary spinal
cord ependymomas have a good
prognosis

Astrocytoma

are the second most common intramedullary spinal cord

tumor in adults, representing 6% to 8% of intradural tumors
In children, they are the most common histologic type of
intramedullary tumors, accounting for 60% to 90% of these
lesions
The average symptom duration before presentation is
between 12 and 29 months
infiltrative tumors that are located dorsal or lateral to the
central canal.

Astrocytoma

Radiology
MRI

iso- to hypointense on T1W

images
hyperintense onT2W images with
no sharp delineation;
almost 100% CE positive but
rather spotty;
cyst formation common.

A case of cervical
astrocytoma with cyst
formation at the caudal
tumor
pole and within the
tumor.

Astrocytoma

Fortunately, intramedullary astrocytomas in adults are

largely low grade (Kernohan grade I and II) with
approximately 25% considered high grade (Kernohan grade
III and IV).
In children, where pilocytic astrocytomas predominate,
high-grade lesions are even less common, occurring at a
rate of 10% to 15%.

Extradural:

typically attributed to metastatic cancer or schwannomas

derived from the cells covering the nerve roots.
malignant tumors , the most common cause of spinal cord
compression results from.
The most common tumors are:
carcinoma of the lung
carcinoma of the breast
carcinoma of the prostate
carcinoma of the kidney
lymphoma
myeloma.

Extradural:

may occur at any site and are often multiple.

The compression is due to the tumor itself or to vertebral
collapse, or a combination of these.
Urgent investigation and treatment is essential if
permanent severe disability is to be avoided.
Surgical treatment for malignant spinal cord compression
utilizes either:
decompressive laminectomy (posterior approach)
or
vertebrectomy and fusion (anterior approach).

Imaging Studies
X-ray
Plain films are still routinely obtained but have a limited
diagnostic value.
Abnormal findings of intradural tumors can be:
bony destruction in metastasis or anaplastic tumors
widening of the spinal canal represented by widening of the
intrapedicular distance
thinning of the pedicle
scalloping of the posterior vertebral surface (in cases with slowgrowing tumors)
widening of the intervertebral foramen (especially in patients with
neuromas)
disappearance of the normal spinal curvature
progressive scoliosis
tumor calcification

 Myelography
Myelography has been superseded by MRI for the
diagnostic work-up of intradural spinal tumors.

CT and Myelo-CT
For whom MRI cannot be performed because of
contraindications
bony deformation such as destruction, scalloping, widening
of the spinal canal and/or the intervertebral foramen
calcification
contrast enhancement
spinal cord compression
expanding medullary mass

MRI

MRI is the diagnostic imaging procedure of choice.

T1W- and T2W-weighted(=W) images as well as gadoliniumenhanced T1W images should be systematically obtained.
The entire spinal cord must be studied
At least two different imaging planes must be used in order
to locate the tumor properly

Nerve sheath tumors

isointense on T1W images

hyperintense on T2W images;
almost 100% CE positive;
foraminal widening;
Calcification rare

Meningiomas

isointense with cord on both T1W images and

T2W images;
moderate CE with or without association of
Dural tail;
no bone destruction;
calcification occasional.

Ependymomas

isointense with cord on T1W images

hyperintenseon T2W images;
CE strong somewhat inhomogeneous due to
cyst formation or hemorrhage;
foci of points or trails of signal void due to
strong vascularization;
vertebral body scalloping in conus tumors.

Astrocytoma

iso- to hypointense on T1W images

hyperintense onT2W images with no sharp
delineation;
almost 100% CE positive but rather spotty;
cyst formation common.

 Angiography
Spinal angiography has a place in the
definitive diagnosis of
hemangioblastoma
(showing dense vascular stain and
prominent draining veins) and vascular
malformations

Treatment
Non-surgical Treatment
Recent developments in chemotherapy
and radiotherapy have made it possible
to apply these modalities, especially the
former for intramedullary gliomas of
children

 Surgical Treatment
The goal of surgery for any benign intradural
neoplasms is gross total resection
The goal for a malignant glioma is debulking with
preservation of the function.

Recent technological developments

such as MRI, ultrasonography, the Cavitron
Ultrasound Aspirator (CUSA), and microsurgical
technique with intraoperative neurophysiological
monitoring have brought about a remarkable
improvement in surgical results.

Perioperative administration of steroids is now a routine

procedure.
Administration of a high doses of Solumedrol
(methylprednisolone 30 mg/kg, followed by 5.4 mg/kg/h for
23 h) instead of dexamethasone especially for
intramedullary tumors is preferred to prevent spinal shock
due to surgical manipulation by some authors.
tumors associated with hemorrhage-hematoma the optimal
timing of surgery might be the subacute stage

The sitting position ,above the level of T5,

the prone position ,above the level of T5.
The target level should be marked under the fluoroscope
prior to surgery.

Extension of laminectomies should be one more lamina

above and below tumor extension
Intraoperative neurophysiological monitoring with
somatosensory evoked potentials (SSEPs) is recommended.

Knowledge of standard peri- and intraoperative management such

as:
edema prevention
respiratory management in cervical tumors
critical interpretation of neurophysiological monitoring
Possible surgical complications (amongst other complications)
include:
bladder and bowel dysfunction
bleeding or hematoma
CSF leak
Infection
chronic pain
neurological deterioration
sexual dysfunction
spinal instability
ventilator dependence

postoperative neurological morbidity in the surgery of

extramedullary tumors is usually less than 15%.
Surgical results are usually curative in nerve sheath
tumors, while a total recurrence rate of meningiomas is 7
15%.
The neurological deterioration in filum terminale
ependymomas is more frequent, also the recurrence rate.
Postoperative radiotherapy and chemotherapy are often
applied in such situations.

Recovery

The typical hospital stay after surgery to remove a spinal

tumor is about 5-10 days, depending on the patient's case.
A period of post-surgery physical rehabilitation is required .
The total recovery time after surgery may be as short as
three months or as long as one year, depending on the
complexity of the surgery and the patient's overall health.

 The patient was admitted electively for surgical intervention for

excision of intradural extramedullary spinal tumor at the level of
T12-L1.
The patient went for surgery on 02 September 2012 in which
T12-L1 laminectomy was performed followed by excision of the
spinal tumor.
The patient postoperatively was followed in the ICU for 1 day and
he was tolerating the surgery well with no postoperative
complication.
2nd day postoperatively, the patient was transferred to the ward
and started on physiotherapy and showed an improvement in the
power bilaterally in the lower limb in which the ankle dorsiflexion
and plantar extension bilaterally in the lower limb was improving
in the right side, it was about 4/5 and in the left side; it was about
3/5.

Thank you