Spine and Spinal cord Tumors 1 Spine tumors Benign primary malignant and metstatic tumors 2 Sign by umsymums33

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									Spine and Spinal
  cord Tumors




                   1
Spine tumors

 Benign , primary malignant , and metstatic tumors




                                                     2
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



                                                3
 15% of primary CNS tumors are
  intraspinal
 Most primary CNS spinal tumors are
  benign
 Most present by compression rather than
  invasion




                                            4
          Primary Skeletal Neoplasms

Cell of origin   Benign            Malignant
                 Neoplasms         Neoplasms


Osseous          Osteoid osteoma   Osteosareoma
                 Osteoblastoma      ( and variants

                 Osteochondroma
Cartilagenous    Enchondroma       Chondrosarcoma
                 Chondroblastoma   Primary, secondary
                 Chondromyxoid-
                   fibroma


Fibrous                            Fibrosarcoma
                 Fibroma           Malignant fibrous
                                   Histiocytoma         5
Marrow    Ewing’s sarcoma
          Multiple myeloma
          Lymphoma
          Metastasis



         Giant cell tumor
Other    Hemangioma
         Related lesions
         Eosinophilic-Granuloma
         Aneurysmal-Bone cyst


                                  6
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


                                       7
Osteoid osteomas are seen
 predominantly in childen or

 young adults from 10 to 25

 years of age .


                               8
     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%.

                                                   9
    Osteoid Osteomas


Are slightly more common in

the lumbar area, followed by

the cervical, thoracic, sacral regions.


                                          10
Osteoid Osteomas
All patients will present with

back pain & usually is the

primary complaint and is not

relieved by rest or heat .

                                 11
Pain is worse at night and with

recumbency and is frequently

relieved by aspirin or other

nonsteroidal drugs.

                                  12
More commonly the patients will
present with scoliosis, osteoid

osteoma is the most frequent cause

of painful scoliosis in adolescents .


                                        13
Osteoid osteoma is often diagnosed
late with the delay reported being

between 18 & 27 months.



                                     14
Early in its courses,

plain X-Ray films are

       negative


                        15
Any back pain of greater than

6 weeks, duration in children

and young adults should be

studied by a technetium bone scan.


                                     16
The bone scan will show increased
radionuclide uptake at the site of

the lesion .



                                     17
Radiologically , the lesion is
characterized by a radiolucent

area with a central nidus and

surrounding sclerosis (a lesion

about 1.5 cm diameter ).


                                  18
Treatement is surgery when lesions
involved the posterior elements, they

can usually be completely remove

through a posterior approach.


                                        19
If the lesion has been

completely removed ,

recurrence is unlikely.


                          20
Osteiod osteomas constitute about

2.6% of all excised primary tumors

of bone and about 12.1% of all

benign tumors .


                                     21
Location

Between 7% and 18% of all osteoid
osteomas are located in the spine.

Lumbar 40% , thoracic 30%, and cervical
30%.

                                          22
  Osteeoblastoma
Osteoblastoma : is a rare benign
neoplasm of bone that accounts for

3% of all benign bone tumors.

Pathogenesis of tumor is unknown.
                                     23
    osteoblastoma

The major clinical symptom

of osteoblastoma is dull aching,

localized pain over the involved bone.


                                     24
Pain is insidious in onset

and may have a duration of

months to years before diagnosis.


                                    25
As opposed to osteoid
osteoma, pain of
an osteoblastomais less
severe, not nocturnal,
and not relieved by salicylates


                                  26
Osteoblastoma located
in the lumbar spine
may be associated
with pain radiation into
the legs.

                           27
Pain may be aggravated by activity,
was the presenting symptom in
81% and radicular pain was in 29%
of patients with spinal involvement.




                                       28
Osteoblastoma appear during

the second or third decade of life




                                     29
Osteoblastoma has a predilection

for the spine, approximately 40% are

located in the axial skeleton.


                                       30
Male to female

ratio is 2.5 to 10


                     31
In the past osteoblastoma

has been referred to as an

osteogenic fibroma, giant

osteoid osteoma,

                             32
Physical examination may

demonstrate local tenderness

on palpation with mild swelling

over the spine .


                                  33
A positive straight leg raising

test is present in bout 25% of

patients .


                                  34
Osteoblastoma associated with
spinal cord compression with result

in abnormalities on sensory and

motor examination of the lower extremities.



                                              35
Radiographics evaluation

of osteoblastoma are variable

and nonspecific.


                                36
In the spine lesions are most

commonly located in the posterior

elements of the vertebrae (pedicles,

lamina, transverse, & spinous processes).


                                            37
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%


                                           38
In x-ray osteobastoma is expansile,
with well-circumscribed margins and

homogeneous ossification.



                                      39
CT. may provide better localization

of the tumor particularly when

when the lesion is obscured on

plain roentgenograms.


                                      40
  MRI. is better than CT. in

demonstrating the extension

   of the bone sclerosis.


                               41
Osteochondroma
Is a common benign tumor

of bone that occurs in single

or multiple location in the skeleton .



                                         42
Osteochondromas represent

up to 36% of all benign bone

tumors



                               43
Approximately 60 % of patients

develop the lesion between the

second and third decade of life

( in multiple lesions before 20 years )


                                          44
Pathogenesis of osteochondroma

is postulated to be related to an

abnormality of cartilage growth .



                                    45
1% to 2% of osteochondromas

   are located in the spine




                              46
50% in the Lumbosacral
30% in the thoracic
20% in the cervical




                         47
Osteochondroma is frequently

asymptomatic and is discovered

only as a painless prominence

of bone.

                                 48
If pain is present, it is mild,

deep , pain may increase

with activity.

                                  49
Osteochondromas attached

to the spinal column have

been associated with kyphosis

and spondylolisthesis

                                50
Osteochondroma may even

grow large enough to

cause nerve or spinal

compression .


                          51
In the spine osteochondromas

usually occur in the posterior

elements especially the spinous

process .


                                  52
Radionuclide bone scan

shows increased uptake

at the site of the tumor .



                             53
Treatment:
Osteochondroma requires no
therapy when they are
asymptomatic




                             54
Removal is indicated if the tumor

is causing persistent pain or disability

or increase in size, or X-Ray features

suggestive of malignancy .



                                           55
Osteochondroma may

occasionally change

into malignant chondrosarcoma

( about 10% in patients

with multiple lesion ).

                                56
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
                                                 57
58
Spinal Cord
  Tumors
 In Adults

              59
The Spinal Cord




                             60
                  Figure 13.29a
Anatomy of the Spinal Cord
                                        61
                             Figure 13.30a
Anatomy of the Spinal Cord




                                   62
                        Figure 13.30b
           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


                                          63
          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.


                                                            64
        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).
                                                                               65
                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                                      45%
   Astrocytomas                               40%
    ◦   Oligodendroglioma,
    ◦   Ganglioglioma
    ◦   Neurocutoma
    ◦   Subependymoma
   hemangio blastoma                        5%
   Miscellaneous                            10%

                                                                            66
   nerve sheath tumors40% 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.

                                                         67
   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




                                                68
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)




                                                            69
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.

                                                        70
Nerve Sheath Tumors




                      71
      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= 60-80 year, 75 -80% occur in
  women 80% are thoracic
 Upper cervical and foramen magnum are other
  common sites ventral position
 Ventrolateral position

                                                  72
    Meningiomas
 90% intradural
 10% intra-extradural & entirely
  extradural
 gross characteristic smooth fibrous
 Histological characteristic :
     Broad dura attachment
     Bony involvement does not occurred

                                      73
Meningiomas




              74
    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




                                                        75
     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


                                                          76
       Miscellaneous pathology
                         (Rare)
  Neoplastic                     Non-neoplastic
 Inclusion cyst                Arachnoid cyst
  ◦   Dermoids                  Intraspinal
  ◦   Epidermoids
                                 aneurysm
  ◦   Lipomas
                                Sarcoidosis
  ◦   Teratomas
  ◦   Neurentric cyst           Tuberculoma
  ◦   Paraganglioma             Subdural empyema
  ◦   Inclusion tumors



                                                    77
Miscellaneous pathology
                   (Rare)
Neoplastic
 Cavernous mass effect
 Hemangioblastoma
 Gangloneuroma
 Spinal carcinomatosis (rarely presents as mass
    lesion)

   Drap metastasis     (from intracranial mass lesion)




                                                          78
             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




                                                          79
            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




                                                                      80
           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)


                                                                   81
           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)




                                                                    82
TREATMENT




            83
      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


                               84
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.


                                                                  85
                (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.


                                                    86
         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.


                                                 87
              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




                                                 88
               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




                                      89
           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.


                                                      90
         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).


                                                91
           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.
                                                         92
          Intramedullary Tumors
               Neoplastic
 primary glial tumors        Inclusion tumors
  80%
     Astrocytomas            Cycts
     Ependymomas             Metastasis
     Gangliogliomas
     Oligodendrogllioms      Nerve sheath tumors
     Subependymomas
     Hemangioblastoma(3-
                              Neurocytomas
      6%)                     melanocytoms
     Metastatic
      involvement (<5%)
     (lung & breast = most
      common)

                                                 93
      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



                                    94
        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)


                                                               95
       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

                                 96
      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.
                                             97
       Intramedullary Tumors
    astrocytomas
    (occurrence)

   S.C. Astrocytomas represents a
    heterogeneous group with respect
    to
        ◦   Histology.
        ◦   Gross characteristics
        ◦   Biology
        ◦   Natural history




                                       98
                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
                                                           99
      Intramedullary Tumors
              astrocytomas
             (occurs)

   Fibrillary astrocytomas prevails in
    adult.
   Juvenile pilocytic astrocytomas
    prevail in adulthood.
   25% of adult astrocytomas are
    malignant.



                                          100
              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.
                                              101
             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.

                                                   102
           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)

                                         103
           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)

                                        104
             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)




                                                            105
              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



                                              106
          Intramedullary Tumors
                 Clinical featurs

   Signs
    ◦   Different weaknesses
    ◦   Centeral cord syndrome
    ◦   Spasticity and sensory disturbances
    ◦   urogenital dysfunction
    ◦   Anorectal dysfunction



                                              107
                 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.




                                           108
              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.


                                           109
           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


                                                    110
            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
                                                     111
              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.
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