1. INTRAMEDULLARY SPINAL CORD TUMORS K. Liaropoulos, P. Spyropoulou, N. Papadakis 3rd Neurosurgery clinic, Athens Euroclinic

2. EPIDEMIOLOGY 2-4% of tumors in the CNS in adults and children   Exception: the first year of life (Around 12%)

3. ORIGIN Most tumors are of glial origin  Ependymoma (52%)  Astrocytoma (46%)

4. LOCALIZATION IN THE SPINAL CORD cervicobulbar 11% cervical 24% cervicothoracic 25% thoracic 22% thoracolumbar 13% total 5%

5. SYMPTOMS a) Pain (back or radicular) b) Paresthesia c) Scoliosis (in children)

6. CLINICAL PROFILE   Torticollis   Motor deficit   Sphincter disorders

7. Neurological examination   Hypoaesthesia   Motor deficit   Pyramidal syndrome

8. HISTOLOGICAL EXAMINATION A) EPENDYMOMA According to the World Health Organization (WHO) of 2nd grade (90%) of 2nd grade (90%) rarely of 3rd grade rarely of 3rd grade B) ASTROCYTOMA most of 2nd grade most of 2nd grade rarely of 3rd grade rarely of 3rd grade glioblastomas very rare glioblastomas very rare

9. NEURORADIOLOGY A) Radiography Very limited contribution Very limited contribution B) Myelography Indirect diagnosis due to swelling of Indirect diagnosis due to swelling of the spinal cord Does not indicate the characteristics of the Does not indicate the characteristics of the lesion Invasive examination Invasive examination C) Computed tomography Limited contribution Limited contribution

10. The MRI plays a dominant role in imaging

11. Advantages of MRI In most cases it contributes to: A) Localization B) Size C) Solid - cystic components D) Composition some times (Lipoma, cavernous hemangioma)

12. MRI of grade II ependymoma

13. MRI of grade II conus astrocytoma

14. MRI in multiple sclerosis

15. MRI of grade II ependymoma

16. MRI of metastases

17. MRI of melanoma

18. MRI in lipoma

19. ATTENTION! MRI can not distinguish between astrocytoma and ependymoma with any degree of accuracy.

20. TREATMENT   The main treatment is surgery

21. SURGICAL TECHNIQUE Position: prone laminectomy / laminotomy Exposure of dura mater Exposure of arachnoid mater (With microscissors)

22. Overview of the spinal cord (swelling - change in the color) Localization of posterior median fissure (sometimes difficult)

23. Overview of the spinal cord (swelling - change in the color) Localization of posterior median fissure (sometimes difficult)

24. Exposure of spinal cord Biopsy Ultrasound-guided resection Detailed haemostasis Suture

25. Surgical resection of grade II ependymoma

26. COMPLICATIONS A) Sensory: Change little after the third month B) Motor: Typically improve by 1 ½ years

27. IMPORTANT In the best case scenario the long-term neurological condition will be the same as the condition that first drove the patient to the doctor

28. RADIOTHERAPY We mention it last in order to emphasize that we do not believe there is any reason for this method, unless for treatment of malignant tumors, especially in children. Even in these cases its value and safety have yet to be proved.

29. SUMMARY AND CONCLUSIONS   There is no pathognomonic profile of intramedullary tumors. However, pain in the back or neck or radicular pain or diffuse dysesthesia, are always the first signs of an intramedullary tumor

30.   The MRI is the preferred screening test and should include full sections and the injection of contrast medium. Only the following cases present a characteristic picture: Hemangioblastoma, dermoid cysts, epidermoid cysts and lipomas

31.   2/3 of intramedullary tumors are of glial origin. Sometimes the histological verification is difficult and requires additional staining and immunohistochemical techniques

32.   The operation of intramedullary tumors is guided by the anatomy and relies on the access through the posterior median fissure. The main risk is lesion (Temporary or permanent) of the posterior column in 70% of cases

33.   The resection of intramedullary tumors is currently performed with CUSA. Laser is not indicated because it blackens the surgical field and characteristics of the intramedullary tumor are lost

34.   The main goal of the surgery of intramedullary tumors is total resection. This is possible only when there is a separating region between the intramedullary tumor and the spinal cord. In absence thereof, total resection is impossible and such attempt is dangerous and unnecessary.

35.   If the tumor is astrocytoma, the prognosis is not necessarily hopeless. Approximately 50% are totally resectable

36.   When the MRI indicates the presence of an intramedullary tumor, surgery is necessary since even completely benign tumors have been resected in patients where the MRI is referred to as invasive type of diagnostics

37.   Radiotherapy is contraindicated in dealing with intramedullary tumors

38.   The low mortality, morbidity and recurrence of intramedullary tumors constitute surgery the only effective treatment for intramedullary tumors.