Khaled M F SAOUD Professor of neurosurgery, Ain shams university Spinal Tumors Khaled M F SAOUD Professor of neurosurgery, Ain shams university

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

Lipoma Typically 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.

Primary Skeletal Neoplasms Cell of origin Osseous Cartilagenous Fibrous Benign Malignant Neoplasms Neoplasms Osteoid osteoma Osteosarcoma Osteoblastoma ( and variants Osteochondroma Enchondroma Chondroblastoma Chondromyxoid- fibroma Chondrosarcoma Primary, secondary Fibrosarcoma Malignant fibrous Histiocytoma Fibroma

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 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 treatment The patient wears a vest that contains LED external Fiducials.

Objectives of spinal RS in spinal mets: Pain relief (up to 90%) 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 Neurology Professor Dr Khaled Abdelkarim Professor Dr Mohamed Sabry AlKady Professor Dr Mohamed Yassin Mostafa Neurology Professor Dr Ahmed AbdelMenem Gaber