Primary Spinal Tumors (Soft tissue tumors) H. Louis Harkey Department of Neurosurgery University of Mississippi Jackson, MS

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

Meningioma Slow growing benign masses producing indolent symptoms ~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

Meningioma Clinical presentation is indistinguishable from any other slow growing intraspinal mass Deficits are often dramatically reversible Treatment is resection by safest route Total resection including dural attachment and/or cauterization of the adjacent dura = 1% recurrence rate Subtotal resection has much higher risk of recurrence

Schwannoma Account for ~25% of intradural & ~50% of intradural, extramedullary tumors 70% intradural, 15% dumbbell, 5% extradural cases/100,000 per year Typically present in 4 th and 5 th decade No male-female predilection Present with radicular pain, weakness in lumbar tumors, long tract motor signs & urinary retention in cervical & thoracic

Schwannoma Benign tumors Arise from Schwann cells of the sensory rootlets Tumor only contains Schwann cells and causes symptoms by compressing neural elements Can be removed via hemilaminectomy in most cases Total resection is curative Residual tumor should be followed long term Long tract signs typically improve after resection Fewer Antoni B cells

Neurofibroma & 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

Neurofibroma 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

Ganglioneuroma Pathology –Ganglioneuroma (extradural, dumbbell) –Gangliocytoma –Ganglioglioma (intradural- intramedullary) Most are benign though Gangliogliomas may become malignant More often seen in patients < 30 Male:female 3:2

Ganglioglioma 10% of gangliogliomas are spinal, rest cranial Most are paraspinal, may extend into canal Arise from sympathetic NS Rarely intramedullary IM tumors do not have a plane T 2Contrast

Ependymoma 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

Ependymoma Arise from ependymal lining of the central canal, 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 Perivascular pseudorosettes

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

Astrocytoma 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

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

Hemangioblastoma Usually dorsal Treatment is surgical resection Sometimes multiple Take feeding artery before draining vein Grade I neoplasm Differential renal cell CA (common in VHL)

Cavernous Angioma Vascular malformation M = F, Female more likely to hemorrhage More likely to present in 3 rd & 4 th decade

Cavernous Angioma Often dorsally located and comes to surface Hemosiderin stained Resection with second hemorrhage or progressive deficit Thin walled abnormal vascular channels

Lipoma Typically associated with spinal dysrahpism Presents like any space occupying lesion with progressive myelopathy Onset of symptoms often associated with weight gain

Lipoma Treatment is surgical with debulking of the tumor and duraplasty Must take care not to injure normal spinal cord.