spine and spinal cord tumors 1. spine tumors benign, primary malignant, and metstatic tumors 2

Spine and Spinal Spine and Spinal cord Tumorscord Tumors

1

Spine tumorsSpine tumors

Benign , primary malignant , and metstatic tumors

2

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

3

15% of primary CNS tumors are intraspinal

Most primary CNS spinal tumors are benign

Most present by compression rather than invasion

4

5

Primary Skeletal Neoplasms

Cell of origin

Osseous

Cartilagenous

Fibrous

Benign MalignantNeoplasms Neoplasms

Osteoid osteoma OsteosareomaOsteoblastoma ( and variants

Osteochondroma EnchondromaChondroblastomaChondromyxoid- fibroma

ChondrosarcomaPrimary, secondary

FibromaFibrosarcomaMalignant fibrousHistiocytoma

6

MarrowMarrow

OtherOther

Ewing’s sarcomaEwing’s sarcomaMultiple myelomaMultiple myelomaLymphomaLymphomaMetastasisMetastasis

Giant cell tumorGiant cell tumorHemangiomaHemangiomaRelated lesionsRelated lesionsEosinophilic-GranulomaEosinophilic-GranulomaAneurysmal-Bone cystAneurysmal-Bone cyst

7

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

8

Osteoid osteomas are seen

predominantly in childen or

young adults from 10 to 25

years of age .

9

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%.

10

Osteoid Osteomas Osteoid Osteomas

Are slightly more common in

the lumbar area, followed by

the cervical, thoracic, sacral regions.

11

Osteoid OsteomasOsteoid Osteomas

All patients will present with

back pain & usually is the

primary complaint and is not

relieved by rest or heat .

12

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.

13

More commonly the patients will

present with scoliosis, osteoid

osteoma is the most frequent cause

of painful scoliosis in adolescents .

14

Osteoid osteoma is often diagnosed

late with the delay reported being

between 18 & 27 months.

15

Early in its courses,

plain X-Ray films are

negative

16

Any back pain of greater than

6 weeks, duration in children

and young adults should be

studied by a technetium bone scan.

17

The bone scan will show increased

radionuclide uptake at the site of

the lesion .

18

Radiologically , the lesion is

characterized by a radiolucent

area with a central nidus and

surrounding sclerosis (a lesion

about 1.5 cm diameter ).

19

Treatement is surgery when lesions

involved the posterior elements, they

can usually be completely remove

through a posterior approach.

20

If the lesion has beenIf the lesion has been

completely removed ,completely removed ,

recurrence is unlikely.recurrence is unlikely.

21

Osteiod osteomas constitute about

2.6% of all excised primary tumors

of bone and about 12.1% of all

benign tumors .

22

Location

Between 7% and 18% of all osteoid

osteomas are located in the spine.

Lumbar 40% , thoracic 30%, and cervical 30%.

23

Osteeoblastoma

Osteoblastoma : is a rare benign

neoplasm of bone that accounts for

3% of all benign bone tumors.

Pathogenesis of tumor is unknown.

24

The major clinical symptom

of osteoblastoma is dull aching,

localized pain over the involved bone.

osteoblastoma

25

Pain is insidious in onset

and may have a duration of

months to years before diagnosis.

26

As opposed to osteoid osteoma, pain of an osteoblastomais less severe, not nocturnal, and not relieved by salicylates

27

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.

29

Osteoblastoma appear during

the second or third decade of life

30

Osteoblastoma has a predilection

for the spine, approximately 40% are

located in the axial skeleton.

31

Male to female

ratio is 2.5 to 10

32

In the past osteoblastoma

has been referred to as an

osteogenic fibroma, giant

osteoid osteoma,

33

Physical examination may

demonstrate local tenderness

on palpation with mild swelling

over the spine .

34

A positive straight leg raising

test is present in bout 25% of

patients .

35

Osteoblastoma associated with

spinal cord compression with result

in abnormalities on sensory and

motor examination of the lower extremities.

36

Radiographics evaluation

of osteoblastoma are variable

and nonspecific.

37

In the spine lesions are most

commonly located in the posterior

elements of the vertebrae (pedicles,

lamina, transverse, & spinous processes).

38

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%

39

In x-ray osteobastoma is expansile,

with well-circumscribed margins and

homogeneous ossification.

40

CT. may provide better localization

of the tumor particularly when

when the lesion is obscured on

plain roentgenograms.

41

MRI. is better than CT. in

demonstrating the extension

of the bone sclerosis.

42

Osteochondroma Osteochondroma

Is a common benign tumor

of bone that occurs in single

or multiple location in the skeleton .

43

Osteochondromas representOsteochondromas represent

up to 36% of all benign bone up to 36% of all benign bone

tumorstumors

44

Approximately 60 % of patients

develop the lesion between the

second and third decade of life

( in multiple lesions before 20 years )

45

Pathogenesis of osteochondroma

is postulated to be related to an

abnormality of cartilage growth .

46

1% to 2% of osteochondromas

are located in the spine

47

50% in the Lumbosacral30% in the thoracic20% in the cervical

48

Osteochondroma is frequently

asymptomatic and is discovered

only as a painless prominence

of bone.

49

If pain is present, it is mild,

deep , pain may increase

with activity.

50

Osteochondromas attached

to the spinal column have

been associated with kyphosis

and spondylolisthesis

51

Osteochondroma may even

grow large enough to

cause nerve or spinal

compression .

52

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 .

53

Radionuclide bone scan

shows increased uptake

at the site of the tumor .

54

Treatment: Osteochondroma requires no therapy when they are asymptomatic

55

Removal is indicated if the tumor

is causing persistent pain or disability

or increase in size, or X-Ray features

suggestive of malignancy .

56

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

57

Spinal Cord Spinal Cord TumorsTumors

In AdultsIn Adults

59

The Spinal CordThe Spinal Cord

60Figure 13.29a

Anatomy of the Spinal CordAnatomy of the Spinal Cord61Figure 13.30a

Anatomy of the Spinal CordAnatomy of the Spinal Cord

62Figure 13.30b

15% of CNS neoplasm arise from cellular

constituent of the: spinal cord Filum terminal Nerve Roots meninges

Metastatic involvement: rare

63

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

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).

65

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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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.

67

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

68

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)

69

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.

70

Nerve Sheath TumorsNerve Sheath Tumors

71

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

72

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

75

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

76

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

77


NeoplasticCavernous mass effectHemangioblastomaGangloneuromaSpinal carcinomatosis (rarely presents as mass

lesion)

Drap metastasis (from intracranial mass lesion)

78


Treatment◦Excision of mass◦Release of tetherd cord ◦Excision of sinus tract◦Total extirpation in some cases is not possible

79

Iclusion cyst


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

80

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)

81

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)

82

Miscellaneous pathology(Rare)

NON Neoplastic

83

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

84

85

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.

86

(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.

87

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

88


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

89


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.

90

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).

91

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.

92

Filum ependymomas treatment)

Neoplastic Neoplastic primary glial tumors

80% Astrocytomas Ependymomas Gangliogliomas Oligodendrogllioms Subependymomas Hemangioblastoma(3-

6%) Metastatic

involvement (<5%) (lung & breast = most

common)

93

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

94

Non-Neoplastic


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)

95

Non-Neoplastic


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

96

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.

97

astrocytoma (occurrence)


S.C. Astrocytomas represents a heterogeneous group with respect to

◦Histology.◦Gross characteristics◦Biology◦Natural history

98

astrocytomas(occurrence)


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

99

astrocytomas(occurrence)


Fibrillary astrocytomas prevails in adult.

Juvenile pilocytic astrocytomas prevail in adulthood.

25% of adult astrocytomas are malignant.

100

astrocytomas(occurs)


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.

102

Hemangioblastomas(occurrence)


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)

103

miscellaneous pathology(occurrence)


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)

104

miscellaneous pathology(occurrence)


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)

105

Clinical features


Symptome ◦Pain= most common◦Sensory complaints= 1/3 of patients ◦Motor complaints= 1/3 of patients ◦Dysesthesia◦Paradysesthesia◦Numbness ◦Back & leg pain

106

Clinical featurs


Signs◦Different weaknesses◦Centeral cord syndrome ◦Spasticity and sensory disturbances◦urogenital dysfunction◦Anorectal dysfunction

107

Clinical featurs


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.

108

Radiology & imaging


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.

109

Radiology imaging


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

110

Treatment


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

111

Treatment


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.

112

Treatment


spine and spinal cord tumors 1. spine tumors benign, primary malignant, and metstatic tumors 2

Documents

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osteoid osteomas

benign tumors

primary cns tumors

spine tumors benign

o steoid osteomas

osteiod osteomas

excised primary tumors