Download - Spine and Spinal cord Tumors 1. Spine tumors Benign, primary malignant, and metstatic tumors 2
Spine and Spinal Spine and Spinal cord Tumorscord Tumors
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Spine tumorsSpine tumors
Benign , primary malignant , and metstatic tumors
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Sign and symptoms:Cord compression and n. deficitMechanical instabilityStructural change like scoliosis Pain ( persistent , at rest and at night)Local pain or mechanical painLocal tenderness and muscle spasmRadicular symptoms due to neural
foramen involvement
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15% of primary CNS tumors are intraspinal
Most primary CNS spinal tumors are benign
Most present by compression rather than invasion
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Primary Skeletal Neoplasms
Cell of origin
Osseous
Cartilagenous
Fibrous
Benign MalignantNeoplasms Neoplasms
Osteoid osteoma OsteosareomaOsteoblastoma ( and variants
Osteochondroma EnchondromaChondroblastomaChondromyxoid- fibroma
ChondrosarcomaPrimary, secondary
FibromaFibrosarcomaMalignant fibrousHistiocytoma
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MarrowMarrow
OtherOther
Ewing’s sarcomaEwing’s sarcomaMultiple myelomaMultiple myelomaLymphomaLymphomaMetastasisMetastasis
Giant cell tumorGiant cell tumorHemangiomaHemangiomaRelated lesionsRelated lesionsEosinophilic-GranulomaEosinophilic-GranulomaAneurysmal-Bone cystAneurysmal-Bone cyst
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OOsteoid osteomassteoid osteomas
first discovered by Jaffe in 1935 .first discovered by Jaffe in 1935 .
May be seen in the spine.May be seen in the spine.
OOsteoid osteomas involve males more steoid osteomas involve males more commonly than females. commonly than females.
men to women is 2:1men to women is 2:1
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Osteoid osteomas are seen
predominantly in childen or
young adults from 10 to 25
years of age .
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Osteoid Osteomas
• Have a strong predilection for the posterior elements of the vertebra (lamina, pedicle, most
frequent sites).• Neural arch is affected in about
75%, articular facets in about 18%, vertebral bodies in only 7%.
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Osteoid Osteomas Osteoid Osteomas
Are slightly more common in
the lumbar area, followed by
the cervical, thoracic, sacral regions.
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Osteoid OsteomasOsteoid Osteomas
All patients will present with
back pain & usually is the
primary complaint and is not
relieved by rest or heat .
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PPain ain is worse at night and withis worse at night and with
recumbency and is frequentlyrecumbency and is frequently
relieved by aspirin or other relieved by aspirin or other
nonsteroidal drugs.nonsteroidal drugs.
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More commonly the patients will
present with scoliosis, osteoid
osteoma is the most frequent cause
of painful scoliosis in adolescents .
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Osteoid osteoma is often diagnosed
late with the delay reported being
between 18 & 27 months.
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Early in its courses,
plain X-Ray films are
negative
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Any back pain of greater than
6 weeks, duration in children
and young adults should be
studied by a technetium bone scan.
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The bone scan will show increased
radionuclide uptake at the site of
the lesion .
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Radiologically , the lesion is
characterized by a radiolucent
area with a central nidus and
surrounding sclerosis (a lesion
about 1.5 cm diameter ).
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Treatement is surgery when lesions
involved the posterior elements, they
can usually be completely remove
through a posterior approach.
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If the lesion has beenIf the lesion has been
completely removed ,completely removed ,
recurrence is unlikely.recurrence is unlikely.
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Osteiod osteomas constitute about
2.6% of all excised primary tumors
of bone and about 12.1% of all
benign tumors .
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Location
Between 7% and 18% of all osteoid
osteomas are located in the spine.
Lumbar 40% , thoracic 30%, and cervical 30%.
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Osteeoblastoma
Osteoblastoma : is a rare benign
neoplasm of bone that accounts for
3% of all benign bone tumors.
Pathogenesis of tumor is unknown.
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The major clinical symptom
of osteoblastoma is dull aching,
localized pain over the involved bone.
osteoblastoma
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Pain is insidious in onset
and may have a duration of
months to years before diagnosis.
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As opposed to osteoid osteoma, pain of an osteoblastomais less severe, not nocturnal, and not relieved by salicylates
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Osteoblastoma located in the lumbar spine may be associated with pain radiation into the legs.
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Pain may be aggravated by activity, was the presenting symptom in 81% and radicular pain was in 29% of patients with spinal involvement.
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Osteoblastoma appear during
the second or third decade of life
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Osteoblastoma has a predilection
for the spine, approximately 40% are
located in the axial skeleton.
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Male to female
ratio is 2.5 to 10
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In the past osteoblastoma
has been referred to as an
osteogenic fibroma, giant
osteoid osteoma,
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Physical examination may
demonstrate local tenderness
on palpation with mild swelling
over the spine .
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A positive straight leg raising
test is present in bout 25% of
patients .
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Osteoblastoma associated with
spinal cord compression with result
in abnormalities on sensory and
motor examination of the lower extremities.
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Radiographics evaluation
of osteoblastoma are variable
and nonspecific.
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In the spine lesions are most
commonly located in the posterior
elements of the vertebrae (pedicles,
lamina, transverse, & spinous processes).
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Osteoblastoma is locted in the sacrum
or lumbar spine in 40% of the lesions,
in the cervical spine in 36%, and in the
thoracic spine in 24%
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In x-ray osteobastoma is expansile,
with well-circumscribed margins and
homogeneous ossification.
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CT. may provide better localization
of the tumor particularly when
when the lesion is obscured on
plain roentgenograms.
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MRI. is better than CT. in
demonstrating the extension
of the bone sclerosis.
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Osteochondroma Osteochondroma
Is a common benign tumor
of bone that occurs in single
or multiple location in the skeleton .
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Osteochondromas representOsteochondromas represent
up to 36% of all benign bone up to 36% of all benign bone
tumorstumors
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Approximately 60 % of patients
develop the lesion between the
second and third decade of life
( in multiple lesions before 20 years )
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Pathogenesis of osteochondroma
is postulated to be related to an
abnormality of cartilage growth .
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1% to 2% of osteochondromas
are located in the spine
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50% in the Lumbosacral30% in the thoracic20% in the cervical
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Osteochondroma is frequently
asymptomatic and is discovered
only as a painless prominence
of bone.
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If pain is present, it is mild,
deep , pain may increase
with activity.
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Osteochondromas attached
to the spinal column have
been associated with kyphosis
and spondylolisthesis
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Osteochondroma may even
grow large enough to
cause nerve or spinal
compression .
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InIn the spine osteochondromas the spine osteochondromas
usually occur in the posteriorusually occur in the posterior
elements especially the spinouselements especially the spinous
process .process .
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Radionuclide bone scan
shows increased uptake
at the site of the tumor .
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Treatment: Osteochondroma requires no therapy when they are asymptomatic
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Removal is indicated if the tumor
is causing persistent pain or disability
or increase in size, or X-Ray features
suggestive of malignancy .
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Osteochondroma may
occasionally change
into malignant chondrosarcoma
( about 10% in patients
with multiple lesion ).
Aneurysmal bone cystUnknown origin1.4-2.3% primary bone neoplasms12% in spinePresent with LBPMost in children and infrequent after 30 y32% associate with other lesion60% in post elements of spineGrowth pattern : enlarg and bone destruction and n.
defecitTreatment : endovascular embolization and surgical
curettage
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Spinal Cord Spinal Cord TumorsTumors
In AdultsIn Adults
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The Spinal CordThe Spinal Cord
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Anatomy of the Spinal CordAnatomy of the Spinal Cord61Figure 13.30a
Anatomy of the Spinal CordAnatomy of the Spinal Cord
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15% of CNS neoplasm arise from cellular
constituent of the: spinal cord Filum terminal Nerve Roots meninges
Metastatic involvement: rare
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Spinal cord tumors in Adults
S.C.T are categorized according to their relationship to the spinal cord.
1-Intramedullary (I.M) tumors arise within the substance of the spinal cord (S.C)
2-Extramedullary (E.M.) tumor are extrinsic to the spinal cord.
3-I.M & E.M. S.C.T: Small number Communication through a nerve root entry zone. Conus medularis-filum terminale transition zone. Some I.D. tumors extend through the nerve root to
extradural compartment.
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Spinal cord tumors in Adults
SPINAL CORD TUMORS IN ADULTS
Exteramedullary (2/3 of cases) Nerve sheath tumor (40%) Menengioma (40%) Filum terminal ependymoma (15%) Miscellaneous * (rare) (5%)
Intramedullary (1/3 of cases) Ependymoma (45%) Astrocytoma † (40%) Hemangioblastoma (5%) Miscellansous † (10%)
*Includes paraganglioma, drop metatasis, and ganglioma.† includes oligodendroglioma, ganglioma, neurocytoma, and
subependymoma.†includes metatitic tumor. Inclusion tumor (e.g., lipoma), inflammatory
pathology (e.g., abscess, tuberculuma, sarcoid), and vascullar pathology (e.g., cavernous malformation, aneurysm).
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Extramedullary (2/3 of cases) Nerve sheath tumor (40%) Meningioma (40%) Filum terminale ependymoma (15%) Miscellaneous (Rare) (5%)
Metastases Inclusion tumors Cysts Para gangliomas Melanocytic neoplasm
E.M. tumor are almost benign and resectable.
Intramedullary tumors (1/3 of case) (more than 80%) are primary glial tumors) most of these are histologically benign.
Ependymomas 45% Astrocytomas 40%
◦ Oligodendroglioma, ◦ Ganglioglioma ◦ Neurocutoma ◦ Subependymoma
hemangio blastoma 5% Miscellaneous 10%
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Spinal cord tumors in Adults
nerve sheath tumors 40% of E.M.S.C.T
Schwannomas From schwann cell
neurofibromas Schwann cell, perineural cells & fibroblasts.
Neurofibromas and schwannomas have different demographical, histological and biological characterstics.
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Neurofibromas◦Histological appearance
Abundance of fibrous tissues obvious nerve fibers within the tumor
stroma Fusiform (plexiform) enlargement of
the involved nerve.
multiple neurofibromas establish the diagnosis of Neurofibromatousis
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Schwannomas gross appearance◦Smooth globoid mass◦Do not enlarge nerve ◦balanced eccentrically◦distinct attachment
◦Histological appearance Elongated bipolar cells Fusiform darkly staining nuclei Arranged in compact interlacing palisade formation
(antoni-A) Antoni – B- (less common)
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Nerve sheath tumors 25% of I.D. S.C.T. in adults.
Most are solitary schwannoma Peak incidence; 4th – 6th decade of age Men = women Majority arise from dorsal nerve root Ventral root tumors are more common in
Neurofibromas. 10% of nerve sheath tumors are epidural or
paraspinal. 1% of nerve sheath tumors are intramedullary Retrograde or Antegrade extension of
schwannoma is possible 2.5% of I.D. spinal nerve sheath tumors are
malignant ½ in neurofibromatosis Malignant nerve sheath tumors rarely survives 1
year.
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Nerve Sheath TumorsNerve Sheath Tumors
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MeningiomasMeningiomasMeningiomas= nerve sheath tumors= 40% of
E.M.S.C.TArise from: (mesodermal origin) Arachnoid cap cells embedded in the dura near the root sleeve Pia Dural fibroblastPeak incidence= 60-80 year, 75 -80% occur in
women 80% are thoracicUpper cervical and foramen magnum are other
common sites ventral position Ventrolateral position
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MeningiomasMeningiomas
90% intradural10% intra-extradural & entirely
extradural gross characteristic smooth fibrous Histological characteristic : Broad dura attachment Bony involvement does not occurred
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MeningiomasMeningiomas
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40% of spinal canal ependymomas arise within filum terminale
Proximal portion of filum = most common site.Astrocytoma, oligodendroglioma and para ganglioma may also originate in the filum terminal
3th – 5th decade= most common Men= women Myxopapillary= most common Almost all are biologically benign
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FILUM TERMINAL EPENDYMOMA
Variable clinical presentation Features slow growing intra spinal mass Venrtra location in upper cervical & foramen magnum
Suboccipital pain Distal arm weak ness & atrophy Clumsiness of intrinsic hand muscle ↑I.C.P. & hydrocephallus
Differnet cord syndromes (Broun Sequard, hemicord) Long tract sings Bowel and bladder dysfunctional Back pain, radicullar pain Worsening pain on recumbency
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CLINICAL FEATURES
Miscellaneous pathologyMiscellaneous pathology(Rare)(Rare)
Neoplastic Inclusion cyst
◦Dermoids ◦Epidermoids◦Lipomas◦Teratomas◦Neurentric cyst◦Paraganglioma ◦ Inclusion tumors
Non-neoplasticArachnoid cyst Intraspinal
aneurysmSarcoidosisTuberculomaSubdural empyema
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Miscellaneous pathologyMiscellaneous pathology(Rare)(Rare)
NeoplasticCavernous mass effectHemangioblastomaGangloneuromaSpinal carcinomatosis (rarely presents as mass
lesion)
Drap metastasis (from intracranial mass lesion)
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Miscellaneous pathologyMiscellaneous pathology(Rare)(Rare)
Treatment◦Excision of mass◦Release of tetherd cord ◦Excision of sinus tract◦Total extirpation in some cases is not possible
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Iclusion cyst
Miscellaneous pathologyMiscellaneous pathology(Rare)(Rare)
Rare tumor of neural crest origion ◦ Arise from filum terminale or cauda equina
◦ Benign non- functioning tumor ◦ Histologically resembles extra adrenal paraganglioma (carotid
body- glomus jugulare)◦ Well circumscribed vascular tumor◦ Non- secretory granules on electronic microscopy ◦ Complete removal is possible is most cases
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Paraganglioma
NeoplasticNeoplastic
Spinal carcinomatous meningitis ◦(frequently complicates systemic cancers)
Malignant intracranial tumors ◦ (that appose the subarachnoid space or ventricles are the most
likely intracranial tumors to demonstrate CSF drop MX. In to spinal SAS)
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Miscellaneous pathology(Rare)
Intramedullary and / or extramedullary mass
◦ Arachnoid cyst (well know example/ most common in thoracic region)
◦ Intraspinal aneurysm (extremely rare, associated with AVM or coarctation of aorta)
Dx: MRI, Selective spinal angiography ◦ HIVD: trasgressed HIVD to intradural space ◦ Inflamatory pathologies (tuberculoma, sarcoidosis, subdural
empyema)
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Miscellaneous pathology(Rare)
NON Neoplastic
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TREATMENT
NERVE SHEATH TUMORS NERVE SHEATH TUMORS TREATMENT (1)TREATMENT (1)
1) Gross total excision:◦Surgical excision in
benign N.ST. ◦Recurrence is rare, if
gross total removal has been achieved
◦Small I.D. NST◦Most dumbbell tumor
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NERVE SHEATH TYMORS TREATMENT (2)
2) Gross subtotal excision :• NST embeded in the S.C. or on epipial tissues.
• Some cervical NST
• Thoracic & cervical paraspinal extension (dumbbell tumors)
• Anteriorly located N.S.T.
TECNIQUES: • 1) standard laminectomy with or without facetectomy. dentate
ligament section followed by contra lateral facet fusion and lateral mass plating
• 2) lateral extracavitary approach for concomitant complex exposure of intraspinal and paraspinal compartments.
• 3) anterior & posterior dumbbell sacral tumors.
complete surgical removal= treatment of choice
Favorable features in compare to intracranial meningiomas
Less difficult ventral exposure requirementAbsence of bony involvement Lack of venous sinus or major blood vessel
involvement 10-15% recurrence rate of intraspinal
meningiomas at 10 years after total or near total removal.
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(Meningiomas)Treatment 1
technique: 1. standard posterior laminectomy2. Unilateral laminectomy and facetectomy3. Costotransversectomy for ventral thoracic
tumors4lateral extra cavitary for ventral thoracic
tumor5. extreme lateral approach (Sen & Sekhar
method) for significant tumor components above foramen magnum.
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MeningiomasTreatment 2
6. Always the reflected arachnoid layer over the central tumor surface should be approached.
7. large tumors are debulked and then removed, dural attachement is excised or extensively coagulated.
8. devide archnoid adhesions to prevent A. Tetherig B. delayed syrinx formation C. arachnoiditis D. hydrocephalus
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MeningiomasTreatment 3
Rarery spinal meningiomas may extend through a dural nerve root sleeve & present as dumbbell tumor
Management federal base ◦ Excision and patch graft ◦ Extensive in situ
coagulation
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MeningiomasTreatment 4
Size and relation ship of tumor to the surrounding roots and cauda equina determine the role of surgery.
Gross total en bloc resection should be attempted when ever possible.◦For small and moderate size tumor ◦Well sircumescribed.◦Inter and decompression may increase the risk
of dissemination .◦Recurrence after en bloc resection are rate.
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Filum Terminale Treatment
Larg filum terminal ependymomas can present significant problems for surgical resection.
High risk of seminarian through CSF ( have been present for many years)
Entire neuro axis should be evaluated.These tumor may reach enormous size.May insinuate among the roots and within
the archnoid sheaths of the caud equina (un encapsulated and pliable neoplasm).
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Filum ependymomas treatment)
SurginalTechnique
piecemeal & subtotal removal Diminish the tumor build 20% recurrence rate anon if a near total piecemeal removal
has been acheaved.Radiotherapy delay in situration in which surgery canbe contem
plate For early tumor recurrence in biologically
aggressive tumors.Posoperatively: for significant tumor buden or
disseminationAfter repeated surger for tumor recurrence.
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Filum ependymomas treatment)
Neoplastic Neoplastic primary glial tumors
80% Astrocytomas Ependymomas Gangliogliomas Oligodendrogllioms Subependymomas Hemangioblastoma(3-
6%) Metastatic
involvement (<5%) (lung & breast = most
common)
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Intramedullary Tumors
Inclusion tumors
Cycts
Metastasis
Nerve sheath tumors
Neurocytomas
melanocytoms
Inflammatory condition Bacterial abscess Tuberculoma Sarcoidosis
Acute or sub acute clinical course
Is characteristic and evidence of systemic involvement further suggests the diagnosis
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Non-Neoplastic
Intramedullary Tumors
DDX◦Inflammatory or demyelinating conditions
of the cord ◦Multiple sclerosis ◦Viral or parainfections myelitis◦Para neoplastic involvement
Many of these conditions are grouped as transverse myelitis
Acute or subacute course (few hours to few days)
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Non-Neoplastic
Intramedullary Tumors
Intramedullary Tumors Intramedullary Tumors MRI of an acute M.S.
Plaque◦ Focal homogeneous
contrast enhancement that may be comfined today white matter.
◦ Little or no cord enlargement
MRI of viral or parainfectious myelitis ◦ Patchy contrast
enhancement over several cord segments
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3% of CNS astrocytomas arise within spinal cord.
Most prevalent in the first 3 decades of life.Most common pediatric “I.M” S.C.T.90% of I.M .S.C.T in patient younger than l0
years of age.60% of IM SCT are in adolescence.60% in cervical and cervicothoracic spinal
cord segments.Less common in: thorasic,, lumbosacral
cord & conus medularis.
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astrocytoma (occurrence)
Intramedullary Tumors
S.C. Astrocytomas represents a heterogeneous group with respect to
◦Histology.◦Gross characteristics◦Biology◦Natural history
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astrocytomas(occurrence)
Intramedullary Tumors
Includes◦ Low grade fibrillary astrocytomas.◦ pilocytic astrocytomas◦ Malignant astrocytomas◦ Gangliogliomas◦ Oligodendrogliomas
90% of pediatric astrocytic tumors are benign Most are grade I or II fibrillary astrocutomas up to 1/3 are juvenile epilocytic
astrocytomas or gangliogliomas)◦ 10% of pediatric gliomas are malignant
astrocytomas or glioblastomas
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astrocytomas(occurrence)
Intramedullary Tumors
Fibrillary astrocytomas prevails in adult.
Juvenile pilocytic astrocytomas prevail in adulthood.
25% of adult astrocytomas are malignant.
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astrocytomas(occurs)
Intramedullary Tumors
Most common I.M.T in adults.Middle adult year (most frequent)Men and women are equally affected.Variety of histological subtypes.
◦ Cellular ependymoma (most common)◦ Epithelial ◦ Tanycytic (fibrillary)◦ Sub ependymomas◦ myxopapillary ◦ mixed
almost All are histologically benign Unencapsulated and well circumscribed
glial derived tumor. 101
Intramedullary Tumors Eependymomas (occurrence)
3-8% of I.M. S.C.T15-25% occur in association with von hippel-
lindau Syndrome.Rare in childhood.Benign tumor of vascular origin.Sharply circumscribed not encapsulated.All have a pial attachmentsMost are dorsally or dorsolaterally located.
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Hemangioblastomas(occurrence)
Intramedullary Tumors
Dysembryogenic lesions Lipomas= most common=
1% of intra medullary S.C.T Inclusion tumors= rare Cysts= rare
◦ These are not true neoplasm◦ Arise from inclusion of
mesenchymal tissue◦ Produce symptom in early
and middle adult age.◦ They are juxtamedullary
(subpial)
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miscellaneous pathology(occurrence)
Intramedullary Tumors
metastases 2% of S.C.T ◦ (small size of S.C., remote
vascular accessibility to hematogenous tumor emboli)
◦ Lung, breast, most common
◦ Melanocytoma, fibrosarcoma, myxoma
Vascular malformation (cavernous)
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miscellaneous pathology(occurrence)
Intramedullary Tumors
Variable Early symptoms are non- specificSymptom duration before diagnosis:
◦ 2-3 years=◦ Weeks-month= for malignant or metastatic neoplasms◦ Shorter course= intratumoral hemorrhage (associated
with ependymomas)
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Clinical features
Intramedullary Tumors
Symptome ◦Pain= most common◦Sensory complaints= 1/3 of patients ◦Motor complaints= 1/3 of patients ◦Dysesthesia◦Paradysesthesia◦Numbness ◦Back & leg pain
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Clinical featurs
Intramedullary Tumors
Signs◦Different weaknesses◦Centeral cord syndrome ◦Spasticity and sensory disturbances◦urogenital dysfunction◦Anorectal dysfunction
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Clinical featurs
Intramedullary Tumors
plain x Ray: obsolete C.T Scan Myelography MRI: modality of choice for
diagnosis and pre operative evaluation ◦ Most I.M. S.C.T are isointense or
slightly hypointense on T1-weighted images.
◦ Often there is only ill-defined Spinal cord enlargment on T1 weighted images.
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Radiology & imaging
Intramedullary Tumors
T2- weighted images are more sensitive (because most tumors are hypintense to the spinal cord on T2)
Contrasted T2 studies are more specific
Almost all I.M. SCT uptake contrast◦ Uniform contrast enhancement
(ependymomas)◦ Polar cysts◦ Heterogeneous enhancements◦ Variable appearance
(astrocytoma) histological diagnosis is not
possible on the basis Neuroimaging.
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Radiology imaging
Intramedullary Tumors
Treatment priority should be long- term tumor control with preservation of neurosurgical
function.
Surgery most effective treatment Radical Gross total removal objectively documented on
posoperative MRI prolongs event- free survival in some patients, but in others it has no effect
for most I.M. S.C.T
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Treatment
Intramedullary Tumors
Gross total removal ◦For benign & demarcated tumors
(Hemangioblastomas, most Edendymos some well circumscribed Astrocytomas & Gangliogliomas)
◦For intra medullary metastasis
Surgical histology verinfication Subtotal removal: judicious subtotal internal
decompression (lipoma, inclusion tumors)Radiation Chemotherapy
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Treatment
Intramedullary Tumors
Radiation therapy (R.T)◦ Benign tumor
Uncertain role Indolent natural history of most benign I.M S.C.T is
misinterpreted as benefit of radiation therapy. Never theless R.T. may provide some tumor control in
some patients with low-grade ependymomas or astrocytomas. This response is neither uniform nor predictable R.T is given for benign but infiltrative S.C.T.
Not recommended affer substantial removal of reasonably well circumscribed tumor.
R.T is recommended for recurrence of tumor. R.T is recommended for malignant I.M astrocytomas.
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Treatment
Intramedullary Tumors
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