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Spinal Tumor ManagementRully Hanafi Dahlan. Farid Yudoyono. Sevline Estethia Ompusunggu

SPINE RESEARCH LABORATORY TM.  SPINE CARE TM

Division of Neurospine, Peripheral Nerve and Pain

Department of Neurosurgery.  Hasan Sadikin Hospital. School of Medicine

Padjadjaran University . Bandung City

I N D O N E S I A

SPINE CASES IN OUR DEPARTMENT2009‐2014

419 PATIENTS SURGERY

139 PATIENTS NON SURGERY

108 PATIENTS TUMOR

99 PATIENTS TRAUMA

35 PATIENTS CONGENITAL

46 PATIENTS INFECTION

19 PATIENTSVASCULAR

112 PATIENTS DEGENERATIF

INTRODUCTION• 15 % of Primary CNS Tumors

• Most primary are benign, most present by compression rather than invasion

• Broadly organized into 3 Categories depending on the spine compartment invaded by the tumor

• MRI is the best modalityExtradural

IntraduralExtramedullary

Intramedullary

Anatomy

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Extradural Tumor

• 55 % of Spinal tumors

• Hematogenous spread or direct extension 

• Metastatic  Tumor : most common  breast, lung, prostate, lymphoma

• Primary spinal tumor : very rare  Chordomas, Osteoid osteoma, osteoblastoma, Aneurysmal Bone Cyst (ABC)

Metastatic Spinal Tumors

• Bad prognosis

• Spread through blood, CSF, or direct extension

• The most common  breast, lung, prostate, lymphoma

• Osteolytic or Osteoblastic

• Presentation• Pain  the most common first presenting symptom

• Neurological dysfunction

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Metastatic Spinal Tumors on Imaging

• MRI multifocal lytic lesions characterized by low signal on T1‐and high signal on T2

Intradural Extramedullary Tumor• 40 % of Spinal tumors• Arise from perineural coverings of nerve roots or from the meningens

• Peaks: fourth – sixth decade• Majority benign  neurologic dysfunction• Meningioma, Schwanomma, Neurofibroma, Lipoma

• Intramedullary extension  Lipoma

Spinal Meningioma• 90 % extradural, 5 % intradural, 5 % both intra‐extra dural

• Peak age : 4th ‐8th decades• Female : male = 4 : 1

• Location : 82% thoracic, 15% cervical, 2% lumbar

• 68% lateral of spinal cord, 18% posterior, 15% anterior• Clinical symptoms :

• Local or clinical pain• Motor deficits• Sensory symptomps

• Recurrence rate 7%

Spinal Meningioma on Imaging

• Isointense to cord T1&T2

• Bright homogenous enhancement

• “dural tail”

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Spinal Schwanomma• 30 % of all spinal tumors

• Slow growing benign tumors

• Most arise from dorsal root (75%)

• Most are intradural, but 8‐32% may be extradural

• Early symptoms are often radicular

• May be associated with neurofibromatosis type 2 (NF2)

• “dumbbell tumors”

Spinal Schwanomma on imaging

•MRI  Isointense or Hypointensecompared to the spinal cord on T1 and hyperintense on T2

•CT  bone erosion

INTRAMEDULLARY TUMOR 5 % of Spinal tumors

3 main groups :

tumor of glial origin (astrocytoma, ependymoma)

tumor of non-glial origin (hemangioblastoma, cavernoma)

other mass lesion

Dissociation of sensibility

The two most common : Astrocytoma & Ependymoma

SPINAL ASTROCYTOMA 6-8% of spinal tumors

Peak 3rd -5th decade

Male : Female = 1.5 : 1

Low grade : High grade = 3 : 1

Most common at Thoracic, then cervical

Intratumoral cyst formation & associated syrinx are common

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SPINAL ASTROCYTOMA ON IMAGING MRI Iso to hypointense on T1 & hyperintense

on T2, essentially all enhance

Enlargement of the cord at tumor location

Tumor, syrinx and cysts can be delineated

SPINAL EPENDYMOMA 15% of all spinal cord tumors

Arise from ependymal cells lining the central canal

Peak 3rd – 6th decade

The most common glioma of lower cord, conus & filum.

More common in adults

Symmetric cord expansion

Associated cysts are common

SPINAL EPENDYMOMA ON IMAGING MRI shows a widened cord

or filum terminale mass.

Isointense compare to cord on T1 and hyperintense on T2

Nearly all strongly enhance

Goal of Surgical Treatment• Pain Relief• Mechanical stabilization

• Preserving neurologic function

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Surgical Technique

• Tumor Excision

• Decompression

• Stabilization

CASE 1• ♂/51 yo

• Weakness both lower extremities

• D/ : SOL Extradural at level VL2‐VL4 due to Metastasis

INTRAOPERATIVE FINDINGS• ♂/51 yo

• D/ : SOL Extradural at level VL2‐VL4 due to Metastasis

CASE 2• ♀/45 yo• Numbness of all extremities• D/ SOL intradural ekstramedullar level C4‐C6 due to Schwanomma

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INTRAOPERATIVE FINDINGS• ♀/45 yo

• D/ SOL intradural ekstramedullar level C4‐C6 due to Schwanomma

CASE 3• ♂/53 yo• Weakness both lower extremities• D/ SOL intradural extramedullary at level Vertebra Thoracal 3 due to Spinal meningioma

INTRAOPERATIVE FINDINGS• ♂/53 yo

• D/ SOL intradural extramedullary at level Vertebra Thoracal 3 due to Spinal meningioma

• T/ Laminectomy Tumor Removal (Posterior Approach)

CASE 4• ♀/36 yo• Weakness all extremities• D/ SOL intramedullary at spinal cord level vertebra C2‐C7 due to Astrocytoma

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INTRAOPERATIVE FINDINGS• ♀/36 yo• D/ SOL intramedullary at spinal cord level vertebra C2‐C7 due to Astrocytoma

CASE 5• ♀/18 yo• Weakness all extremities• D/ SOL Intramedullary at cervicomedullary to conus medullaris (holocord) due to ependymoma

INTRAOPERATIVE FINDINGS• ♀/18 yo

• D/ SOL Intramedullary at cervicomedullary to conus medullaris (holocord) due to ependymoma

• D/ Foramen magnum decompression + laminoplasty tumor removal

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CASE 6• ♂/50 yo• Weakness both lower extremities• D/ SOL Intradural Extramedullary di level Vertebra Thoracal 8‐11 due to Spinal Lipoma

INTRAOPERATIVE FINDINGS• ♂/50 yo

• D/ SOL Intradural Extramedullary di level Vertebra Thoracal 8‐11 due to Spinal Lipoma

CASE 7 : 44 YO . Quadriparesis

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CASE 8 : 14 yo. Pain. Vegerative disturbance. Quadriplegic

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CASE 9 :  45, yo Male . Quadriplegic

PA RESULTS : Schwannoma Antoni A

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Case 10 :  Female, 24 yo, G3P2A0 gravida 27 mgg + SOL Extradura e.c Langerhans cell hystiocitosis P

PA : Serpentine‐like meningioma

Case 11 :47 yo female with quadriparesis

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CASE 12 : Male, 55 YO, Quadriparesis

CAUDAL

ROSTRAL

LATERALMEDIAL

*  N XII

PLATYSMA

CRICOID *ARTERI FASIALIS  *

GLANDULA SUBMANDIBULARIS

ESOFAGUS *

* M.LONGUS COLLIM.LONGUS COLLI *C3

*TUMOR

MANAGEMENT• Surgery to establish definitive diagnosis, decompress the neuralelements, maintain the stability, cure the patient.

• Radiotherapy the dose that the spinal cord can tolerate vs local tumorcontrol.

• Chemotherapy has not been found to be beneficial in majority ofspinal tumors.

• Long term clinical and radiological follow up to evaluate the recurrencyrisk.

Benzel. Spine Surgery – Techniques, Complication Avoidanceand Management. 3rd edition. Elsevier, 2012.Mc Lain. Cancer in the Spine – Comprehensive Care. HumanaPress, 2006.

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