Spinal Tumors: approach and management

The spinal cord consists of
Central canal surrounded by an H-shaped gray matter region containing neurons
Outer myelinated nerve tracts, termed white matter, surround the central gray matter
Central canal is lined with ependymal cells
Astrocytes support gray matter neurons and white matter axons

1. Spinal Tumors: approach and management Dr Amit Agrawal , MCh

2. The spinal cord consists of Central canal surrounded by an H-shaped gray matter region containing neurons Outer myelinated nerve tracts, termed white matter, surround the central gray matter Central canal is lined with ependymal cells Astrocytes support gray matter neurons and white matter axons Spinal cord

3. The great vessels contribute arterial supply via segmental arteries Which branch into medullary and radicular arteries Radicular artery provides extramedullary blood supply to the nerve root and dura The medullary artery bifurcates into anterior and posterior divisions to form the spinal arteries One anterior and two posterior spinal arteries Arterial

4. The venous plexus of the spinal column, termed the Batson plexus Do not contain valves that prevent retrograde flow This valveless system may permit retrograde venous Venous

5. 15% of primary CNS tumors Incidence

6. Extradural-55% Intradural extramedullary-40% Intradural intramedullary-5% Types of spinal tumors

7. Unknown Genetic predisposition - Astrocytomas and ependymomas are more common in patients with neurofibromatosis type 2 Spinal hemangioblastomas occur in 30% of patients with von Hippel-Lindau syndrome Etiology

8. Extradural Metastatic Lymphoma Lung Breast Prostate Primary spinal tumors (Rare) Chordoma Neurofibromas Osteoid osteoma Osteoblastoma Aneurysmal bone cyst Vertebral haemangioma Primary intradural but may be extradural Meningiomas Neurofibromas Chloroma Angiolipoma

9. Meningiomas Neurofibromas Lipomas metastases Intradural extramedullary

10. Astrocytoma Ependymoma Others Glioblastoma Dermoid Epidermoid Teratoma Lipoma Haemangioblastoma Intramedullary

11. Pain Motor disturbances Sensory disturbances Sphincter disturbances Others Scoliosis Torticolis Deformity SAH Presentation

12. Motor weakness (late finding) Sensory Decreased touch, pain, and/or temperature sensation Hyperesthesias Decreased proprioception Abnormal sensation below the level of lesion Abnormal sensation only at level of lesion (suspended level) Physical examination

13. Hyperreflexia Hoffman sign for cervical lesions Clonus Extensor plantar response (Basins sign) Spasticity Increased tone Muscle atrophy (late finding) Physical examination

14. Complete trasection Central cord syndrome Anterior cord syndrome Brown-Sequard syndrome Posterior cord syndrome Cauda equina/conus medullaris syndromes Spinal cord syndromes

15. Complete trasection

16. Central cord syndrome

17. Anterior cord syndrome

18. Brown-Sequard syndrome

19. Posterior cord syndrome

20. Difficult on clinical grounds Investigations Diagnosis

21. Plain radiographs Lumbar puncture Myelography CT scan MRI Spinal angiography Investigations

22. Complete blood cell count Prothrombin time/activated partial thromboplastin time Lab studies

23. Abnormalities identified in 20% of patients Scalloping of the vertebral bodies on lateral radiographs Widening of interpedicular distance on anteroposterior radiographs Scoliosis in children resulting from neuromuscular impairment Plain radiograph

24. Nonspecific spinal canal and spinal cord widening Multisegmental involvement Block of contrast dye Conus region lesions, possible meniscus around the tumor Myelogram

25. Nonspecific spinal canal and spinal cord widening Scalloping of vertebral bodies Possible intraparenchymal syringomyelia CT scan

26. Enlargement of the spinal cord Syringomyelia or cystic cavity associated within the lesion MRI of spine with and without gadolinium

27. T1-weighted images - Isointense signal with spinal cord T2-weighted images - Hyperintense signal Strong homogeneous enhancement with contrast Ependymoma

28. T1-weighted images - Isointense or hypointense signal with spinal cord T2-weighted images - Hyperintense signal Cyst formation Heterogeneous enhancement with contrast Astrocytoma

29. T1-weighted images - Isointense signal to spinal cord T2-weighted images - Hyperintense signal Cystic with tumor nodule (50-70%) Enhances strongly with contrast Extramedullary extension in 15% Hemangioblastoma

30. This may be beneficial only if a hemangioblastoma is suggested as a differential diagnosis Hemangioblastoma arteriogram findings include a vascular blush with a prominent draining vein. Spinal arteriogram

31. Findings may assist in diagnosing abnormal bladder function Baseline urodynamics

32. Is not indicated unless the patient is being evaluated for drop metastasis or leptomeningeal spread of intracranial disease (as in cranial ependymomas) Neurological deterioration can be precipitated after lumbar puncture if a complete myelographic block is present from changes in the compliance of the lesion and position of the neoplasm Lumbar puncture

33. Tumor-specific characteristics

34. Mean age at presentation of 43 years Slight female predominance Pain localized to the spine (65%) Pain worse at night or upon awakening Dysesthesias Long history of symptoms Myxopapillary variant (mean age of presentation of 21 y; slight male predominance) Ependymomas

35. Equal male and female prevalence Pain localized to spine Pain worse at night or upon awakening Paresthesias Astrocytomas

36. Onset of symptoms by the fourth decade of life, 80% symptomatic by age 40 years Familial disorder (ie, von Hippel-Lindau syndrome) present in a third of patients Decreased posterior column sensation Back pain localized over lesion Hemangioblastomas

37. Medical Surgical Management

38. Limited benefit High-dose intravenous corticosteroids (Prolonged use of steroids can be associated with gastric ulceration, hyperglycemia, and immunosuppression with cushingoid features) Medical therapy

39. Chemotherapeutic regimens have had limited success in the treatment of spinal cord neoplasms This may be partly due to the inability of the chemotactic agents to cross the blood-brain barrier. Chemotherapy

40. Symptomatic control Recurrence and malignant tumor transformation Spinal cord radiation toxicity and/or necrosis Radiosurgery

41. Under general anesthesia Prone position Radiographic confirmation of the appropriate spinal level Laminectomy Intraoperative microscope Benign neoplasms is gross total resection Surgical resection

42. Closely monitored in an ICU Analgesics for pain (IM/IV) Monitoring for neurologic deterioration Rehabilitation Postoperative care

43. Complications Bladder and bowel dysfunction Bleeding or haematoma Cerebrospinal fluid leak Chronic pain Injury to central nervous system tissue Meningitis Paralysis Sensory loss Sexual dysfunction Skin infection or cellulitis Spine instability Ventilator dependence Wound dehiscence

44. Overall prognosis depends on the neoplasm's histopathology 5-year survival rate for patients with benign spinal cord neoplasms is greater than 90% The goal of surgery is to prevent further neurologic dysfunction and to cure the neoplastic condition with complete resection. Outcome and Prognosis

45. Thank You