SPINAL CORD TUMORS Dr.Ghavam Tavallaee Neurosurgeon

EPIDEMIOLOGY 4% to 10% of all primary CNS tumors 0.5 to 1.4 per 100,000 Three groups Extradural (most common) Intradural extramedullary Intramedullary

CLINICAL MANIFESTATIONS Tumors tend to be indolent Most common symptoms Pain Weakness sensory disturbances gait change bowel and bladder dysfunction sexual dysfunction

Pain Midline or axial spinal pain Paraspinal pain and tenderness Radicular pain

Weakness 1- may be secondary to direct involvement of the anterior horn cells or descending motor tracts 2- compression or infiltration of the ventral roots 3- external compression of the corticospinal tracts (UMN)

well-recognized syndromes conus medullaris syndrome early bowel, bladder, and sexual dysfunction upper and lower motor neuron weakness cauda equina syndrome urinary retention,saddle anesthesia, lower motor neuron weakness, and reflex loss

Brown-Séquard syndrome ipsilateral weakness contralateral pain and loss of proprioception, vibration sensa-tion, and temperature sensation

Differential diagnosis

DIAGNOSTIC TESTS Plain Radiographs has not been routinely used abnormalities in the bony structures widening erosion scalloping of the posterior vertebral bodies flattening of pedicles scoliosis

Computed Tomography and Computed Tomographic Myelography Used in patients who cannot tolerate or who have a contraindication to MRI study of choice for visualization of osseous structures

Magnetic Resonance Imaging plays a central role in the imaging of spinal cord tumors superior anatomical localization of soft tissue masses

MRI Astrocytomas focal enlargements of the spinal cord typically hypointense or isointense on T1-weighted images hyperintense on T2-weighted images

Ependymomas enhanced more intensely than are astrocytomas more likely to have heterogeneous signals more central on axial cuts greater predilection for the lower spinal cord

Hemangioblastomas isointense on T1 hyperintense on T2 uniformly enhanced with gadolinium

Intramedullary metastases hyperintensity on T2-weighted images homogenous enhancement after gadolinium additional leptomeningeal deposits are often seen

Nerve sheath tumors isointense signal on T1 markedly strong signal on T2 (target appearance) enhancement is variable multiple tumors are more likely to represent neurofibromas than schwannomas

Spinal meningiomas isointense or hypointense appearance on T1 slightly hyperintense appearance on T2 intensely and homogeneously enhanced after contrast areas of calcification are dark

Epidural metastatic lesions isointense on T1 hyperintense on T2 enhanced after contrast the entire spine must be imaged

MANAGEMENT Surgery Radiation Chemotherapy

Surgery indicated for all symptomatic lesions objectives of surgery range from gross total resection to limited biopsy for pathological diagnosis must take into account spinal stability hardware may be necessary

Most tumors are resected with a dorsal approach, laminectomy, and durotomy. Intramedullary lesions a midline myelotomy is required for exposure intraoperative ultrasonography may be used except pia-based hemangioblastomas Intraoperative motor and somatosensory evoked potentials are routinely employed

The extent of resection is guided by lesion anatomy surgical experience results of intraoperative monitoring Preliminary histological diagnosis obtained from frozen sections

Radiation Initial treatment of choice for extradural spinal cord compression (metastatic disease) 3000 cGy (30 Gy) administered over 2 weeks Surgery was confined to patients presenting with extradural cord compression without a histological diagnosis radioresistant tumors compression of the spinal cord by bone recurrent cord compression after radiation therapy.

The efficacy of radiation for primary spinal cord tumors are controversy No role for radiation in patients with completely resected low-grade gliomas Image-guided frameless stereotactic radiosurgery

Postoperative radiation therapy 4000 to 5400 cGy Dosages higher than 5500 cGy increased risk of radiation-induced myelopathy Rarely employed for Hemangioblastomas nerve sheath tumors spinal meningiomas except in the case of malignant peripheral nerve sheath tumor or malignant meningioma

Chemotherapy limited role in the treatment of primary spinal cord tumors, except in children have a role in the treatment of epidural cord compression from chemosensitive tumors such as lymphoma and myeloma

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