KHALED M F SAOUD

PROFESSOR OF NEUROSURGERY, AIN SHAMS UNIVERSITY

Spinal Tumors

Collaboration

Diagnosis and Management

Epidemiology 15% of primary CNS tumors are intraspinal

Intracranial: intraspinal ratio of astrocytoma is 10 :1, and for ependymomas 3-20 :1.

Most of primary CNS Spinal tumors are benign!!.

Anatomical Classification of Spinal Cord Tumors

Extradural : Benign and malignant verteberal tumors, tumors near the spinal cord.

Intradural tumors◦ Extramedullary: nerve sheath and menengial ◦ Intramedullary: glial and other

Intra-dural Lesions

Meningioma

Slow growing benign masses

~15% of all meningiomas are spinal

5:1 female to male ratio

Typically intradural extramedullary but can be extadural

Most commonly thoracic in location, Cervical second most common

Schwannomas

Neurofibromas and Neurofibromatosis

Commonly seen in NF-1

Occur more frequently in the cervical spine in NF-1

May be intradural, extradural or dumbell

Often multiple

Sometimes plexiform

Benign

Fusiform expansion of the nerve (Schwann, perineural and neural cells)

Difficult to get complete resection because of the extra-foramenal extension and risk of functional loss

Ependymomas Seen in adults, 15 to 40

Male = Female

Presenting signs depend on location

Longer duration, more severe symptoms = less favorable functional outcome with surgery

Arise from ependymal lining of the central canal & from filum terminale

Sometimes associated with a syrinx

Filum origin usually myxopapillary type

Very rarely malignant

Total resection is possible in the majority of tumors

The goal of surgery is complete resection with good functional outcome

Functional improvement common after resection

Progression free survival similar for total resection vs partial resection + RT

Conus and filum terminale

Astrocytoma Occur at any age, average age of dx is 35 to 40

Accompanying syrinx in 40%

Occurs equally throughout cord

Presenting sign depend upon location

Most are grade I or II

Complete surgical resection is impossible

RT recommended after dx

Outcomes similar for biopsy + RT and resection + RT

Low grade recurrent tumor can be treated with reresection

Spinal radiosurgery?

Hemangioblastoma Highly vascular tumors comprising 2% of spinal cord tumors

¼ associated with von Hippel-Lindau, ¾ sporadic

10 times less common than intracranial

Male predominance

Presents mid life

Spinal Angiography?

Cavernous AngiomaOften dorsally located and comes to surfaceHemosiderin stained

Resection with second hemorrhage or progressive deficit

Thin walled abnormal vascular channels

Spinal radiosurgery??

LipomaTypically associated with spinal dysrahpism

Presents like any space occupying lesion with progressive myelopathy

Onset of symptoms often associated with weight gain

Treatment is surgical with debulking of the tumor and duraplasty

Must take care not to injure normal spinal cord.

Spinal metastasis Theatrically can happen anywhere in the spine, ED,ID EM

Treatment depends on the symptoms.

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Primary Skeletal Neoplasms

Cell of origin

Osseous

Cartilagenous

Fibrous

Benign MalignantNeoplasms Neoplasms

Osteoid osteoma OsteosarcomaOsteoblastoma ( and variants

Osteochondroma EnchondromaChondroblastomaChondromyxoid- fibroma

ChondrosarcomaPrimary, secondary

FibromaFibrosarcomaMalignant fibrousHistiocytoma

Vertebral hemangioma Most common benign spinal neoplasm.

More in the thoracic and lumber spine.

Mostly asymptomatic.

May present with pain or rarely neurological deficit.

Vertebral hemangiomas

Spinal radiosurgery Why?

• Indications Post resection local irradiation• Post resection local irradiation

• Disease progression despite previous surgery and/or irradiation

• Patients with severe medical comorbidities that preclude surgery

• Inoperable lesions

Components• Immobilization device

• Radiation unit

• Beam shaping unit

• Respiratory tracking unit

Respiratory tracking

Cyber Knife (Frameless SRS):

Real-time X-ray imaging to establish the position of the lesion during treatmentThe patient wears a vest that contains LED external Fiducials.

Objectives of spinal RS in spinal mets:

1) Pain relief (up to 90%)

2) Control of progression (80-90%) –lung and breast best prognosis

Combined kyphoplasty and spinal radiosurgery for spinal mets COMPRESSION

FRACTURES

Spinal arteriovenous malformations

Indications• Comorbidities• Residual/recurrent tumors

Teamwork Clinical Oncology Professor Dr Khaled Abdelkarim

Professor Dr Mohamed Sabry AlKady

Professor Dr Mohamed Yassin Mostafa

Neurology Professor Dr Ahmed AbdelMenem Gaber