1. Spine and Spinal cord Tumors

2. Spine tumors
Benign , primary malignant , and metstatic tumors

3. Sign and symptoms: Cord compression and n. deficit
Mechanical instability
Structural change like scoliosis
Pain ( persistent , at rest and at night)
Local pain or mechanical pain
Local tenderness and muscle spasm
Radicular symptoms due to neural foramen involvement

4. 15% of primary CNS tumors are intraspinal
Most primary CNS spinal tumors are benign
Most present by compression rather than invasion

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

6. Marrow Other Ewing’s sarcoma Multiple myeloma Lymphoma Metastasis
Giant cell tumor
Hemangioma
Related lesions
Eosinophilic-Granuloma
Aneurysmal-Bone cyst

7. Osteoid osteomas first discovered by Jaffe in 1935 .
May be seen in the spine.
Osteoid osteomas involve males more commonly than females.
men to women is 2:1

8. Osteoid osteomas are seen
predominantly in childen or
young adults from 10 to 25
years of age .

9. Osteoid Osteomas Have a strong predilection for the posterior
elements of the vertebra (lamina, pedicle, most
frequent sites).
Neural arch is affected in about
75%, articular facets in about 18%,
vertebral bodies in only 7%.

10. Osteoid Osteomas Are slightly more common in
the lumbar area, followed by
the cervical, thoracic, sacral regions.

11. Osteoid Osteomas All patients will present with
back pain & usually is the
primary complaint and is not
relieved by rest or heat .

12. Pain is worse at night and with
recumbency and is frequently
relieved by aspirin or other
nonsteroidal drugs.

13. More commonly the patients will
present with scoliosis, osteoid
osteoma is the most frequent cause
of painful scoliosis in adolescents .

14. Osteoid osteoma is often diagnosed
late with the delay reported being
between 18 & 27 months.

15. Early in its courses,
plain X-Ray films are
negative

16. Any back pain of greater than
6 weeks, duration in children
and young adults should be
studied by a technetium bone scan.

17. The bone scan will show increased
radionuclide uptake at the site of
the lesion .

18. Radiologically , the lesion is
characterized by a radiolucent
area with a central nidus and
surrounding sclerosis (a lesion
about 1.5 cm diameter ).

19. Treatement is surgery when lesions
involved the posterior elements, they
can usually be completely remove
through a posterior approach.

20. If the lesion has been
completely removed ,
recurrence is unlikely.

21. Osteiod osteomas constitute about
2.6% of all excised primary tumors
of bone and about 12.1% of all
benign tumors .

22. Between 7% and 18% of all osteoid
Location
Between 7% and 18% of all osteoid
osteomas are located in the spine.
Lumbar 40% , thoracic 30%, and cervical 30%.

23. Osteeoblastoma Osteoblastoma : is a rare benign
neoplasm of bone that accounts for
3% of all benign bone tumors.
Pathogenesis of tumor is unknown.

24. osteoblastoma
The major clinical symptom
of osteoblastoma is dull aching,
localized pain over the involved bone.

25. Pain is insidious in onset
and may have a duration of
months to years before diagnosis.

26. As opposed to osteoid osteoma, pain of
an osteoblastomais less severe, not nocturnal,
and not relieved by salicylates

27. Osteoblastoma located in the lumbar spine may be associated with pain radiation into the legs.

28. Pain may be aggravated by activity,
was the presenting symptom in 81% and radicular pain was in 29% of patients with spinal involvement.

29. Osteoblastoma appear during
the second or third decade of life

30. Osteoblastoma has a predilection
for the spine, approximately 40% are
located in the axial skeleton.

31. Male to female
ratio is 2.5 to 10

32. In the past osteoblastoma
has been referred to as an
osteogenic fibroma, giant
osteoid osteoma,

33. Physical examination may
demonstrate local tenderness
on palpation with mild swelling
over the spine .

34. A positive straight leg raising
test is present in bout 25% of
patients .

35. Osteoblastoma associated with
spinal cord compression with result
in abnormalities on sensory and
motor examination of the lower extremities.

36. Radiographics evaluation
of osteoblastoma are variable
and nonspecific.

37. In the spine lesions are most
commonly located in the posterior
elements of the vertebrae (pedicles,
lamina, transverse, & spinous processes).

38. Osteoblastoma is locted in the sacrum
or lumbar spine in 40% of the lesions,
in the cervical spine in 36%, and in the
thoracic spine in 24%

39. In x-ray osteobastoma is expansile,
with well-circumscribed margins and
homogeneous ossification.

40. CT. may provide better localization
of the tumor particularly when
when the lesion is obscured on
plain roentgenograms.

41. demonstrating the extension
MRI. is better than CT. in
demonstrating the extension
of the bone sclerosis.

42. Osteochondroma Is a common benign tumor of bone that occurs in single
or multiple location in the skeleton .

43. Osteochondromas represent
up to 36% of all benign bone
tumors

44. Approximately 60 % of patients
develop the lesion between the
second and third decade of life
( in multiple lesions before 20 years )

45. is postulated to be related to an abnormality of cartilage growth .
Pathogenesis of osteochondroma
is postulated to be related to an
abnormality of cartilage growth .

46. 1% to 2% of osteochondromas are located in the spine

47. 50% in the Lumbosacral
30% in the thoracic
20% in the cervical

48. Osteochondroma is frequently
asymptomatic and is discovered
only as a painless prominence
of bone.

49. If pain is present, it is mild,
deep , pain may increase
with activity.

50. Osteochondromas attached
to the spinal column have
been associated with kyphosis
and spondylolisthesis

51. Osteochondroma may even
grow large enough to
cause nerve or spinal
compression .

52. In the spine osteochondromas
usually occur in the posterior
elements especially the spinous
process .

53. Radionuclide bone scan
shows increased uptake
at the site of the tumor .

54. Treatment: Osteochondroma requires no therapy when they are
asymptomatic

55. Removal is indicated if the tumor
is causing persistent pain or disability
or increase in size, or X-Ray features
suggestive of malignancy .

56. Osteochondroma may
occasionally change
into malignant chondrosarcoma
( about 10% in patients
with multiple lesion ).

57. Aneurysmal bone cyst Unknown origin 1.4-2.3% primary bone neoplasms
12% in spine
Present with LBP
Most in children and infrequent after 30 y
32% associate with other lesion
60% in post elements of spine
Growth pattern : enlarg and bone destruction and n. defecit
Treatment : endovascular embolization and surgical curettage

59. Spinal Cord Tumors In Adults

60. The Spinal Cord
Figure 13.29a

61. Anatomy of the Spinal Cord
Figure 13.30a

62. Anatomy of the Spinal Cord
Figure 13.30b

63. Spinal cord tumors in Adults
15% of CNS neoplasm
arise from cellular constituent of the:
spinal cord
Filum terminal
Nerve Roots
meninges
Metastatic involvement: rare

64. Spinal cord tumors in Adults
S.C.T are categorized according to their relationship to the spinal cord.
1-Intramedullary (I.M) tumors arise within the substance of the spinal cord (S.C)
2-Extramedullary (E.M.) tumor are extrinsic to the spinal cord.
3-I.M & E.M. S.C.T:
Small number
Communication through a nerve root entry zone.
Conus medularis-filum terminale transition zone.
Some I.D. tumors extend through the nerve root to extradural compartment.

65. SPINAL CORD TUMORS IN ADULTS
Exteramedullary (2/3 of cases)
Nerve sheath tumor (40%)
Menengioma (40%)
Filum terminal ependymoma (15%)
Miscellaneous * (rare) (5%)
Intramedullary (1/3 of cases)
Ependymoma (45%)
Astrocytoma † (40%)
Hemangioblastoma (5%)
Miscellansous † (10%)
*Includes paraganglioma, drop metatasis, and ganglioma.
† includes oligodendroglioma, ganglioma, neurocytoma, and subependymoma.
†includes metatitic tumor. Inclusion tumor (e.g., lipoma), inflammatory pathology (e.g., abscess, tuberculuma, sarcoid), and vascullar pathology (e.g., cavernous malformation, aneurysm).

66. Spinal cord tumors in Adults
Extramedullary (2/3 of cases)
Nerve sheath tumor (40%)
Meningioma (40%)
Filum terminale ependymoma (15%)
Miscellaneous (Rare) (5%)
Metastases
Inclusion tumors
Cysts
Para gangliomas
Melanocytic neoplasm
E.M. tumor are almost benign and resectable.
Intramedullary tumors (1/3 of case) (more than 80%) are primary glial tumors) most of these are histologically benign.
Ependymomas %
Astrocytomas 40%
Oligodendroglioma,
Ganglioglioma
Neurocutoma
Subependymoma
hemangio blastoma %
Miscellaneous 10%

67. nerve sheath tumors 40% of E.M.S.C.T
Schwannomas
From schwann cell
neurofibromas
Schwann cell, perineural cells & fibroblasts.
Neurofibromas and schwannomas have different demographical, histological and biological characterstics.

68. Neurofibromas Histological appearance
Abundance of fibrous tissues
obvious nerve fibers within the tumor stroma
Fusiform (plexiform) enlargement of the involved nerve.
multiple neurofibromas establish the diagnosis of Neurofibromatousis

69. Schwannomas gross appearance
Smooth globoid mass
Do not enlarge nerve
balanced eccentrically
distinct attachment
Histological appearance
Elongated bipolar cells
Fusiform darkly staining nuclei
Arranged in compact interlacing palisade formation (antoni-A)
Antoni – B- (less common)

70. Nerve sheath tumors 25% of I.D. S.C.T. in adults.
Most are solitary schwannoma
Peak incidence; 4th – 6th decade of age
Men = women
Majority arise from dorsal nerve root
Ventral root tumors are more common in Neurofibromas.
10% of nerve sheath tumors are epidural or paraspinal.
1% of nerve sheath tumors are intramedullary
Retrograde or Antegrade extension of schwannoma is possible
2.5% of I.D. spinal nerve sheath tumors are malignant ½ in neurofibromatosis
Malignant nerve sheath tumors rarely survives 1 year.

71. Nerve Sheath Tumors

72. Meningiomas Meningiomas= nerve sheath tumors= 40% of E.M.S.C.T
Arise from: (mesodermal origin)
Arachnoid cap cells
embedded in the dura near the root sleeve
Pia
Dural fibroblast
Peak incidence= year, % occur in women 80% are thoracic
Upper cervical and foramen magnum are other common sites ventral position
Ventrolateral position

73. Meningiomas 90% intradural 10% intra-extradural & entirely extradural
gross characteristic smooth fibrous
Histological characteristic :
Broad dura attachment
Bony involvement does not occurred

74. Meningiomas

75. FILUM TERMINAL EPENDYMOMA
40% of spinal canal ependymomas arise within filum terminale
Proximal portion of filum = most common site.
Astrocytoma, oligodendroglioma and para ganglioma may also originate in the filum terminal
3th – 5th decade= most common
Men= women
Myxopapillary= most common
Almost all are biologically benign

76. CLINICAL FEATURES Variable clinical presentation
Features slow growing intra spinal mass
Venrtra location in upper cervical & foramen magnum
Suboccipital pain
Distal arm weak ness & atrophy
Clumsiness of intrinsic hand muscle
↑I.C.P. & hydrocephallus
Differnet cord syndromes (Broun Sequard, hemicord)
Long tract sings
Bowel and bladder dysfunctional
Back pain, radicullar pain
Worsening pain on recumbency

77. Miscellaneous pathology (Rare)
Neoplastic
Inclusion cyst
Dermoids
Epidermoids
Lipomas
Teratomas
Neurentric cyst
Paraganglioma
Inclusion tumors
Non-neoplastic
Arachnoid cyst
Intraspinal aneurysm
Sarcoidosis
Tuberculoma
Subdural empyema

78. Miscellaneous pathology (Rare)
Neoplastic
Cavernous mass effect
Hemangioblastoma
Gangloneuroma
Spinal carcinomatosis (rarely presents as mass lesion)
Drap metastasis (from intracranial mass lesion)

79. Miscellaneous pathology (Rare)
Iclusion cyst
Treatment
Excision of mass
Release of tetherd cord
Excision of sinus tract
Total extirpation in some cases is not possible

80. Miscellaneous pathology (Rare)
Paraganglioma
Rare tumor of neural crest origion
Arise from filum terminale or cauda equina
Benign non- functioning tumor
Histologically resembles extra adrenal paraganglioma (carotid body- glomus jugulare)
Well circumscribed vascular tumor
Non- secretory granules on electronic microscopy
Complete removal is possible is most cases

81. Miscellaneous pathology (Rare)
Neoplastic
Spinal carcinomatous meningitis
(frequently complicates systemic cancers)
Malignant intracranial tumors
(that appose the subarachnoid space or ventricles are the most likely intracranial tumors to demonstrate CSF drop MX. In to spinal SAS)

82. Miscellaneous pathology (Rare)
NON Neoplastic
Intramedullary and / or extramedullary mass
Arachnoid cyst (well know example/ most common in thoracic region)
Intraspinal aneurysm (extremely rare, associated with AVM or coarctation of aorta)
Dx: MRI, Selective spinal angiography
HIVD: trasgressed HIVD to intradural space
Inflamatory pathologies (tuberculoma, sarcoidosis, subdural empyema)

83. TREATMENT

84. NERVE SHEATH TUMORS TREATMENT (1)
1) Gross total excision:
Surgical excision in benign N.ST.
Recurrence is rare, if gross total removal has been achieved
Small I.D. NST
Most dumbbell tumor

85. NERVE SHEATH TYMORS TREATMENT (2)
2) Gross subtotal excision :
NST embeded in the S.C. or on epipial tissues.
Some cervical NST
Thoracic & cervical paraspinal extension (dumbbell tumors)
Anteriorly located N.S.T.
TECNIQUES:
1) standard laminectomy with or without facetectomy. dentate ligament section followed by contra lateral facet fusion and lateral mass plating
2) lateral extracavitary approach for concomitant complex exposure of intraspinal and paraspinal compartments.
3) anterior & posterior dumbbell sacral tumors.

86. (Meningiomas) Treatment 1
complete surgical removal= treatment of choice
Favorable features in compare to intracranial meningiomas
Less difficult ventral exposure requirement
Absence of bony involvement
Lack of venous sinus or major blood vessel involvement
10-15% recurrence rate of intraspinal meningiomas at 10 years after total or near total removal.

87. Meningiomas Treatment 2
technique:
1. standard posterior laminectomy
2. Unilateral laminectomy and facetectomy
3. Costotransversectomy for ventral thoracic tumors
4lateral extra cavitary for ventral thoracic tumor
5. extreme lateral approach (Sen & Sekhar method) for significant tumor components above foramen magnum.

88. Meningiomas Treatment 3
6. Always the reflected arachnoid layer over the central tumor surface should be approached.
7. large tumors are debulked and then removed, dural attachement is excised or extensively coagulated.
8. devide archnoid adhesions to prevent
A. Tetherig
B. delayed syrinx formation
C. arachnoiditis
D. hydrocephalus

89. Meningiomas Treatment 4
Rarery spinal meningiomas may extend through a dural nerve root sleeve & present as dumbbell tumor
Management federal base
Excision and patch graft
Extensive in situ coagulation

90. Filum Terminale Treatment
Size and relation ship of tumor to the surrounding roots and cauda equina determine the role of surgery.
Gross total en bloc resection should be attempted when ever possible.
For small and moderate size tumor
Well sircumescribed.
Inter and decompression may increase the risk of dissemination .
Recurrence after en bloc resection are rate.

91. Filum ependymomas treatment)
Larg filum terminal ependymomas can present significant problems for surgical resection.
High risk of seminarian through CSF ( have been present for many years)
Entire neuro axis should be evaluated.
These tumor may reach enormous size.
May insinuate among the roots and within the archnoid sheaths of the caud equina (un encapsulated and pliable neoplasm).

92. Filum ependymomas treatment)
SurginalTechnique
piecemeal & subtotal removal
Diminish the tumor build
20% recurrence rate anon if a near total piecemeal removal has been acheaved.
Radiotherapy
delay in situration in which surgery canbe contem plate
For early tumor recurrence in biologically aggressive tumors.
Posoperatively: for significant tumor buden or dissemination
After repeated surger for tumor recurrence.

93. Intramedullary Tumors
Neoplastic
primary glial tumors 80%
Astrocytomas
Ependymomas
Gangliogliomas
Oligodendrogllioms
Subependymomas
Hemangioblastoma(3- 6%)
Metastatic involvement (<5%)
(lung & breast = most common)
Inclusion tumors
Cycts
Metastasis
Nerve sheath tumors
Neurocytomas
melanocytoms

94. Intramedullary Tumors
Non-Neoplastic
Inflammatory condition
Bacterial abscess
Tuberculoma
Sarcoidosis
Acute or sub acute clinical course
Is characteristic and evidence of systemic involvement further suggests the diagnosis

95. Intramedullary Tumors
Non-Neoplastic
DDX
Inflammatory or demyelinating conditions of the cord
Multiple sclerosis
Viral or parainfections myelitis
Para neoplastic involvement
Many of these conditions are grouped as transverse myelitis
Acute or subacute course (few hours to few days)

96. Intramedullary Tumors
MRI of an acute M.S. Plaque
Focal homogeneous contrast enhancement that may be comfined today white matter.
Little or no cord enlargement
MRI of viral or parainfectious myelitis
Patchy contrast enhancement over several cord segments

97. Intramedullary Tumors
astrocytoma (occurrence)
3% of CNS astrocytomas arise within spinal cord.
Most prevalent in the first 3 decades of life.
Most common pediatric “I.M” S.C.T.
90% of I.M .S.C.T in patient younger than l0 years of age.
60% of IM SCT are in adolescence.
60% in cervical and cervicothoracic spinal cord segments.
Less common in: thorasic,, lumbosacral cord & conus medularis.

98. Intramedullary Tumors
astrocytomas (occurrence)
S.C. Astrocytomas represents a heterogeneous group with respect to
Histology.
Gross characteristics
Biology
Natural history

99. Intramedullary Tumors
astrocytomas (occurrence)
Includes
Low grade fibrillary astrocytomas.
pilocytic astrocytomas
Malignant astrocytomas
Gangliogliomas
Oligodendrogliomas
90% of pediatric astrocytic tumors are benign
Most are grade I or II fibrillary
astrocutomas up to 1/3 are juvenile epilocytic astrocytomas or gangliogliomas)
10% of pediatric gliomas are malignant astrocytomas or glioblastomas

100. Intramedullary Tumors
astrocytomas (occurs)
Fibrillary astrocytomas prevails in adult.
Juvenile pilocytic astrocytomas prevail in adulthood.
25% of adult astrocytomas are malignant.

101. Intramedullary Tumors
Eependymomas (occurrence)
Most common I.M.T in adults.
Middle adult year (most frequent)
Men and women are equally affected.
Variety of histological subtypes.
Cellular ependymoma (most common)
Epithelial
Tanycytic (fibrillary)
Sub ependymomas
myxopapillary
mixed
almost
All are histologically benign
Unencapsulated and well circumscribed glial derived tumor.

102. Intramedullary Tumors
Hemangioblastomas (occurrence)
3-8% of I.M. S.C.T
15-25% occur in association with von hippel- lindau Syndrome.
Rare in childhood.
Benign tumor of vascular origin.
Sharply circumscribed not encapsulated.
All have a pial attachments
Most are dorsally or dorsolaterally located.

103. Intramedullary Tumors
miscellaneous pathology (occurrence)
Dysembryogenic lesions
Lipomas= most common= 1% of intra medullary S.C.T
Inclusion tumors= rare
Cysts= rare
These are not true neoplasm
Arise from inclusion of mesenchymal tissue
Produce symptom in early and middle adult age.
They are juxtamedullary (subpial)

104. Intramedullary Tumors
miscellaneous pathology (occurrence)
metastases 2% of S.C.T
(small size of S.C., remote vascular accessibility to hematogenous tumor emboli)
Lung, breast, most common
Melanocytoma, fibrosarcoma, myxoma
Vascular malformation (cavernous)

105. Intramedullary Tumors
Clinical features
Variable
Early symptoms are non- specific
Symptom duration before diagnosis:
2-3 years=
Weeks-month= for malignant or metastatic neoplasms
Shorter course= intratumoral hemorrhage (associated with ependymomas)

106. Intramedullary Tumors
Clinical featurs
Symptome
Pain= most common
Sensory complaints= 1/3 of patients
Motor complaints= 1/3 of patients
Dysesthesia
Paradysesthesia
Numbness
Back & leg pain

107. Intramedullary Tumors
Clinical featurs
Signs
Different weaknesses
Centeral cord syndrome
Spasticity and sensory disturbances
urogenital dysfunction
Anorectal dysfunction

108. Intramedullary Tumors
Radiology & imaging
plain x Ray: obsolete
C.T Scan
Myelography
MRI: modality of choice for diagnosis and pre operative evaluation
Most I.M. S.C.T are isointense or slightly hypointense on T1- weighted images.
Often there is only ill-defined Spinal cord enlargment on T1 weighted images.

109. Intramedullary Tumors
Radiology imaging
T2- weighted images are more sensitive (because most tumors are hypintense to the spinal cord on T2)
Contrasted T2 studies are more specific
Almost all I.M. SCT uptake contrast
Uniform contrast enhancement (ependymomas)
Polar cysts
Heterogeneous enhancements
Variable appearance (astrocytoma)
histological diagnosis is not possible on the basis Neuroimaging.

110. Intramedullary Tumors
Treatment
Treatment priority should be long- term tumor control with preservation of neurosurgical function.
Surgery most effective treatment Radical
Gross total removal objectively documented on posoperative MRI prolongs event- free survival in some patients, but in others it has no effect for most I.M. S.C.T

111. Intramedullary Tumors
Treatment
Gross total removal
For benign & demarcated tumors (Hemangioblastomas, most Edendymos some well circumscribed Astrocytomas & Gangliogliomas)
For intra medullary metastasis
Surgical histology verinfication
Subtotal removal: judicious subtotal internal decompression (lipoma, inclusion tumors)
Radiation
Chemotherapy

112. Intramedullary Tumors
Treatment
Radiation therapy (R.T)
Benign tumor
Uncertain role
Indolent natural history of most benign I.M S.C.T is misinterpreted as benefit of radiation therapy.
Never theless R.T. may provide some tumor control in some patients with low-grade ependymomas or astrocytomas. This response is neither uniform nor predictable R.T is given for benign but infiltrative S.C.T.
Not recommended affer substantial removal of reasonably well circumscribed tumor.
R.T is recommended for recurrence of tumor.
R.T is recommended for malignant I.M astrocytomas.