spinal tumors (8).pptx

7/23/2019 Spinal tumors (8).pptx

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Spinal tumors


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Case introduction

46 yo male not known to have any medical illness .Presented with history of lower limp weakness and pain for1 year , gradual and progressive in course, mainly in theright side. With no history of incontinence

o/e !ilateral lower limp weakness . "t the ankle #oint theplanter $e%ion &'(/) *'4/) planter dorsi$e%ion &'1/)*'+/) decrease sensation in *4 *) of the &t leg anddecreased re$e%es !ilaterally otherwise he is normal.


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-ntroduction

Compression of the spinal cordis a common neurosurgicalpro!lem.

if the condition isunrecognied and untreated

the eventual outcome willinevita!ly !e disa!lingparalysis and sphincterdistur!ance

Pathology

'he spinal cord may !ecompressed !y lesions thatare

e%tradural 023

intradural, e%tra medullary1)23

intramedullary )23.


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-ntroduction

'he ma#or groups of pathological causes are 1 'umor

a3 metastatic !3 primary.

( egenerative

a3 disc prolapse !3 osteoporosis/spondylosis. + -nfection

a3 verte!ral !ody !3 disc space c3 e%tradural d3 intradural.

4 5ematoma a3 spontaneous trauma3 !3 arteriovenous malformation.

) evelopmental a3 syrin% !3 arteriovenous malformation c3 arachnoid cyst.


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-ntroduction

" spinal tumoris an a!normal mass of tissue within orsurrounding the spinal cord and spinal column

Could !e benignnon7cancerous3 or malignantcancerous3.

Could !e Primary tumors 8& metastatic or secondarytumors.

the tumor can afectthe 9lood vessels, 9ones of the spine, :eninges, ;erve roots,


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Classi=cation

'hese basic areasare cervical,thoracic, lum!ar and sacrum

they also are classi=ed !y

their location in the spine> anteriorfront3and posterior !ack3.

Clinically, they are divided

into three ma#or groupsaccording to locationintradural7e%tramedullary,intramedullary ande%tradural.


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8verall prevalence is estimated at one spinal tumor or every our intracraniallesions

Lesions that compress the spinal cord

e%tradural 023

intradural, e%tra medullary 1)23

intramedullary )23.

Metastatic spinal tumors are the most common type of malignant lesions of thespine, accounting for an estimated ? percent of all spinal tumors.

Intramedullary tumors , only )712 of all spinal tumors.


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IntraDural: In adults

e%tra medullary tumors ,67?)2 of intradural masses

with intramedullary tumors ,+)742 of intradural masses

In children intramedullary tumors are more common, accounting for greater than +)2 of intradural

masses

-ntradural tumors occur with e@ual fre@uency in !oth se%es, with thee%ception of a higher incidence of meningiomas in women

'he most fre@uent intradural!e"tramedullary tumors are nerve sheath

tumors and meningiomas with =lum terminale ependymomas !eing adistant third.

:ost intraspinal tumors present !y compression rather than invasion


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Causes

'he cause of most primary spinal tumors is un#no$n%


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Causes

-n a small num!er of cases, primary tumors may result frompresence of these two genetic diseases

&euro'bromatosis (: -n this hereditary disorder, !enign tumors may develop in the

arachnoid layer of the spinal cord or in the supporting glial cells.

5owever, the more common tumors associated with this disorderaAect the nerves related to hearing and can inevita!ly lead to lossof hearing in one or !oth ears.

)on *ippel!Lindau disease: 'his rare, multi7system disorder is associated with !enign !lood

vessel tumors hemangioblastomas3 in the !rain, retina and

spinal cord, and with other types of tumors in the kidneys oradrenal glands.


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Causes

&euro'bromatosis +ype (" patient with neuro=!romatosis 'ype --. a, b iAerent intradurale%tramedullary meningiomas and neuro=!romas3 and intraduralintramedullary tumors ependymoma3 as well as c e%traspinal tumorsare to !e seen in the whole spine.


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Symptoms

Pain a common early feature of cord compression and often precedes the onset

of any neurological distur!ance

due to involvement of local, pain sensitive structures

girdle pain or radicular pain7 is due to involvement of the nerve root at the level of the compression%

severe, sharp, shooting pain

Central pain due to spinal cord compression itself

diAuse dull ache, often with a B!urning @uality, and is fre@uently descri!ed with

diDculty. Lhermitte,s sign :!

electric shock or tingling radiating down through the !ody to the e%tremities ofthe lim!s cuased !y Ele%ion or e%tension of the neck .

associated with cervical cord involvement, either !y a compressive lesion or dueto an in$ammatory process.


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Fets worse over time

-s usually severe and not relieved !y pain medication

-n any area 77 middle or low !ack are most common

-s worse when lying down, with strain, cough or sneee

:ay e%tend to the hip, leg, or feet or arms3, or alle%tremities 8& :ay stay in the spine


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&eurological de'cit

'he neurological features of spinalcord compression consist of progressive weakness

sensory distur!ance

sphincter distur!ance.


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Motor impairment depend on the position of the cord compression

'he compression of the corticospinal pathways will resultin an upper motor neuron weakness

an initial Bpyramidal pattern


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the pattern of weakness may also !e in$uenced!y the position of the compressing lesion. lateral compression ,weakness, predominantly on the

side of the compressing lesion.

cervical region ,lower motor neuron weakness of theinvolved nerve roots in the upper lim!

!elow '1 in the thoracic area will cause no clinicallydemonstra!le nerve root weakness.

conus medullaris ,mi%ture of lower motor neuron

features and upper motor neuron signs in the lowerlim!s.

Cauda e@uina ,lower motor neuron pattern ofweakness.


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"nalgesia aAecting primarily the saddle area !uttocksand upper posterior thigh3 occurs particularly in caudae@uina or conus medullaris lesions.


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Compression


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"nterior !ilateral weakness, dissociated sensory

loss loss of pain and temperature,

retained position sense, pressure,vi!ration3

Posterior

rare, produces paresthesias, impairedposterior column function


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*ateral aka 9rown


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Central weakness of HI

J *I

Kcape7likeLsensory de=cit


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Sphincter involvement

compression of conus medullaris or cauda e@uina

'he =rst symptom is diDculty in initiating micturitionand this is followed !y urinary retention, which is often

relatively painless. Constipation and fecal incontinence will su!se@uently

occur.

'he clinical signs include an enlarged, palpa!le !ladder,diminished perianal sensation and decreased anal tone.


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Intradural!e"tramedullarytumors

develop in

1. the spinal cordMs arachnoid mem!ranemeningiomas3

(. in the nerve roots that e%tend out from the spinal cord schwannomas and neuro=!romas3

+. or at the spinal cord !ase =lum terminaleependymomas3.


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&erve Sheath +umors-Sch$annoma . neuro'broma/

most common of the intrathecal tumors

may occur at any position

up to +2 of spinal neoplasms

typically arise from the posterior sensory nerve root near its

entrance into the neural foramen e%tends through the interverte!ral foramen to form a

Bdum!7!ell tumor

Present

1. slowly growing tumor causing cord compression

(. Pain in a radicular distri!ution+. some degree of a 9rown7


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Sch$annoma.neuro'broma "lthough !oth tumors are thought to !e of


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Sch$annoma . neuro'broma

&adiology 7

7ray shows

1. evidence of !oneerosion

(. enlargement of theinterverte!ral foramenis typical Eig. 1).63.

+. an increase in theinterpediculardistance.

C' and myelogram willshow spinal tumor withcompression

:&- with contrast is thestandard for diagnosis now.. isointense on '1W images

. hyperintense on '(W imagesQ

. almost 12 CI positiveQ

. foraminal wideningQ

. Calci=cation rare


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&erve Sheath +umors

'reatment

surgical e%cision of the tumor.

"ccess to the tumor is o!tained !y a laminectomy.

-f there is a large e%traspinal e%tension it may !e

necessary to o!tain additional e%posure through theneck, chest or a!domen.


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-ntramedullary

'hese tumors grow inside the spinal cord or individualnerves, most fre@uently occurring in the cervical neck3region

'hey typically derive from glial or ependymal cells that arefound throughout the interstitium of the cord.

"strocytomas and ependymomas are the two mostcommon types


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Ipendymomas

1)2 to +2 of intradural spinal lesions

the most common type of intramedullary spinal cordtumors

8ccur anywhere !ut the ma#ority in =lum terminal

middle age years ;E( patients har!or intramedullary ependymomas,

typically solitary tumors that arise from ependymal lining ofthe central canal

)2 of cases have an associated syrin%.


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Ipendymomas

&adiology

8n :&-, isointense $ith cord on +01 images

hyperintense on +(1 images2

C3 strong some$hat inhomogeneous due tocyst ormation or hemorrhage2

oci o points or trails o signal void due tostrong vasculari4ation2

vertebral body scalloping in conus tumors%

Classic radiographic features ofspinal cord ependymomasinclude

1. distinct tumorSspinal cord!order,

(. an associated syrin%, cystswithin or ad#acent to themass,

+. and hemosiderin deposits orKcapsL near the poles of thetumor on '1 and '(


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Ipendymomas

'reatment total surgical resection.

-n contrast to intracranial

ependymomas, intramedullary spinalcord ependymomas have a goodprognosis


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"strocytoma

are the second most common intramedullary spinal cordtumor in adults, representing 62 to 02 of intradural tumors

In children they are the most common histologic type ofintramedullary tumors, accounting for 62 to T2 of theselesions

'he average symptom duration !efore presentation is!etween 0( and (5 months

in'ltrative tumors that are located dorsal or lateral to thecentral canal.


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"strocytoma

&adiology

:&- iso7 to hypointense on '1W

images

hyperintense on'(W images withno sharp delineationQ

almost 12 CI positive !utrather spottyQ

cyst formation common.

" case of cervicalastrocytoma with cystformation at the caudal

tumor pole and within the

tumor.


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"strocytoma

Eortunately, intramedullary astrocytomas in adults arelargely low grade Uernohan grade - and --3 withappro%imately ()2 considered high grade Uernohan grade--- and -V3.

-n children, where pilocytic astrocytomas predominate,high7grade lesions are even less common, occurring at arate of 12 to 1)2.


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I%tradural:

typically attri!uted to metastatic cancer or schwannomasderived from the cells covering the nerve roots.

malignant tumors , the most common cause of spinal cordcompression results from.

'he most common tumors are

carcinoma of the lung

carcinoma of the !reast

carcinoma of the prostate

carcinoma of the kidney

lymphoma myeloma.


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I%tradural:

may occur at any site and are often multiple.

'he compression is due to the tumor itself or to verte!ralcollapse, or a com!ination of these.

Hrgent investigation and treatment is essential ifpermanent severe disa!ility is to !e avoided.


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-maging


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Myelography :yelography has !een superseded !y :&- for the

diagnostic work7up of intradural spinal tumors.

C+ and Myelo!C+

Eor whom :&- cannot !e performed !ecause ofcontraindications

!ony deformation such as destruction, scalloping, wideningof the spinal canal and/or the interverte!ral foramen

calci=cation

contrast enhancement spinal cord compression

e%panding medullary mass


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:&-

:&- is the diagnostic imaging procedure of choice.

'1W7 and '(W7weightedNW3 images as well as gadolinium7enhanced '1W images should !e systematically o!tained.

'he entire spinal cord must !e studied

"t least two diAerent imaging planes must !e used in orderto locate the tumor properly


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&erve sheath tumors isointense on '1W images hyperintense on '(W imagesQ almost 12 CI positiveQ foraminal wideningQ Calci=cation rare

Meningiomas isointense with cord on !oth '1W images and

'(W imagesQ moderate CI with or without association of

ural tailQ no !one destructionQ calci=cation occasional.

3pendymomas isointense with cord on '1W images hyperintenseon '(W imagesQ CI strong somewhat inhomogeneous due to

cyst formation or hemorrhageQ foci of points or trails of signal void due to

strong vasculariationQ verte!ral !ody scalloping in conus tumors.


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7strocytoma iso7 to hypointense on '1W images hyperintense on'(W images with no sharp

delineationQ almost 12 CI positive !ut rather spottyQ cyst formation common.


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7ngiography


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'reatment

&on!surgical +reatment &ecent developments in chemotherapy

and radiotherapy have made it possi!le

to apply these modalities, especially theformer for intramedullary gliomas ofchildren


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Surgical +reatment'he goal of surgery for any !enign intradural

neoplasms is gross total resection

'he goal for a malignant glioma is de!ulking with

preservation of the function.

&ecent technological developments such as :&-, ultrasonography, the Cavitron

8ltrasound 7spirator CH


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Perioperative administration of steroids is now a routineprocedure.

"dministration of a high doses of


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+hesitting position ,a!ove the level of '),

the prone position a!ove the level of ').

'he target level should be mar#ed under the $uoroscopeprior to surgery.


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I%tension of laminectomies should !e one more laminaa!ove and !elow tumor e%tension

Intraoperative neurophysiological monitoring withsomatosensory evoked potentials


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Unowledge of standard peri7 and intraoperative management suchas

edema prevention

respiratory management in cervical tumors

critical interpretation of neurophysiological monitoring

Possible surgical complications amongst other complications3include

!ladder and !owel dysfunction

!leeding or hematoma

C


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postoperative neurological morbidity in the surgery ofe%tramedullary tumors is usually less than 1)2.


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&ecovery

'he typical hospital stay after surgery to remove a spinaltumor is a!out )71 days, depending on the patientMs case.

" period of post7surgery physical reha!ilitation is re@uired .

'he total recovery time after surgery may !e as short asthree months or as long as one year, depending on thecomple%ity of the surgery and the patientMs overall health.


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'he patient was admitted electively for surgical intervention fore%cision of intradural e%tramedullary spinal tumor at the level of'1(7*1.

'he patient went for surgery on (


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+han# you

spinal tumors (8).pptx

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