intramedullary spinal cord tumors k. liaropoulos, p. spyropoulou, n. papadakis 3rd neurosurgery...
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INTRAMEDULLARY SPINAL CORD TUMORS
K. Liaropoulos, P. Spyropoulou, N. Papadakis3rd Neurosurgery clinic, Athens Euroclinic
EPIDEMIOLOGY
2-4% of tumors in the CNS inadults and children
Exception: the first year of life(Around 12%)
ORIGIN
Most tumors are of glial origin
Ependymoma (52%)Ependymoma (52%)Astrocytoma (46%)Astrocytoma (46%)
LOCALIZATION IN THE SPINAL CORD
cervicobulbar 11% cervical 24% cervicothoracic 25% thoracic 22% thoracolumbar 13% total 5%
SYMPTOMS
a) Pain (back or radicular)b) Paresthesiac) Scoliosis (in children)
CLINICAL PROFILE
TorticollisMotor deficitSphincter disorders
Neurological examination
HypoaesthesiaMotor deficitPyramidal syndrome
HISTOLOGICAL EXAMINATION
A) EPENDYMOMAAccording to the World Health Organization (WHO)
• of 2nd grade (90%)of 2nd grade (90%)
• rarely of 3rd graderarely of 3rd grade
B) ASTROCYTOMA
•most of 2nd grade most of 2nd grade • rarely of 3rd graderarely of 3rd grade
• glioblastomas very rareglioblastomas very rare
NEURORADIOLOGY
A) Radiography• Very limited contributionVery limited contribution
B) Myelography• Indirect diagnosis due to swelling ofIndirect diagnosis due to swelling of
the spinal cord• Does not indicate the characteristics of theDoes not indicate the characteristics of the
lesion• Invasive examinationInvasive examination
C) Computed tomography• Limited contributionLimited contribution
The MRI plays a dominant role in imaging
Advantages of MRI
In most cases it contributes to:
A) LocalizationB) SizeC) Solid - cystic componentsD) Composition some times(Lipoma, cavernous hemangioma)
MRI of grade II ependymoma
MRI of grade II conus astrocytoma
MRI in multiple sclerosis
MRI of grade II ependymoma
MRI of metastases
MRI of melanoma
MRI in lipoma
ATTENTION!
MRI can not distinguish between astrocytoma and
ependymoma with any degree of accuracy.
TREATMENT
The main treatment issurgery
SURGICAL TECHNIQUE
•Position: prone
• laminectomy / laminotomy
•Exposure of dura mater
•Exposure of arachnoid mater(With microscissors)
•Overview of the spinal cord(swelling - change in the color)
•Localization of posterior medianfissure (sometimes difficult)
•Overview of the spinal cord(swelling - change in the color)
•Localization of posterior medianfissure (sometimes difficult)
•Exposure of spinal cord•Biopsy•Ultrasound-guided resection•Detailed haemostasis•Suture
Surgical resection of grade II ependymoma
COMPLICATIONS
A) Sensory:Change little after the thirdmonth
B) Motor:Typically improve by1 ½ years
IMPORTANT
In the best case scenariothe long-term neurological condition will be
the same as the condition that first drove the patient to the doctor
RADIOTHERAPY
• We mention it last in order toemphasize that we do not believe there is any reason for this method,unless for treatment of malignanttumors, especially in children.•Even in these casesits value and safety have yetto be proved.
SUMMARY AND CONCLUSIONS
There is no pathognomonic profileof intramedullary tumors.However, pain in the back orneck or radicular pain or diffusedysesthesia, are always the firstsigns of an intramedullary tumor
The MRI is the preferredscreening test and shouldinclude full sections and the injection of contrast medium.Only the following cases presenta characteristic picture:Hemangioblastoma, dermoidcysts, epidermoid cysts andlipomas
2/3 of intramedullary tumorsare of glial origin. Sometimes thehistological verification isdifficult and requires additionalstaining and immunohistochemical
techniques
The operation of intramedullarytumors is guided by the anatomyand relies on the accessthrough the posterior median fissure.The main risk is lesion(Temporary or permanent) of the
posteriorcolumn in 70% of cases
The resection of intramedullarytumors is currently performed with
CUSA.Laser is not indicated becauseit blackens the surgical field and characteristics of the intramedullary tumor are lost
The main goal of the surgeryof intramedullary tumors is totalresection. This is possible only whenthere is a separating regionbetween the intramedullary tumor and the
spinal cord.In absence thereof, total resection is impossible andsuch attempt is dangerous and unnecessary.
If the tumor is astrocytoma,the prognosis is not necessarilyhopeless.Approximately 50% are totallyresectable
When the MRI indicatesthe presence of an intramedullary
tumor, surgeryis necessary since evencompletely benign tumors havebeen resected in patients wherethe MRI is referred to as invasive type of diagnostics
Radiotherapy is contraindicatedin dealing withintramedullary tumors
The low mortality,morbidity and recurrence ofintramedullary tumors constitutesurgery the onlyeffective treatment forintramedullary tumors.