Spine and Spinal cord Tumors

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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

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Primary Skeletal Neoplasms Cell of
origin Osseous Cartilagenous Fibrous
Benign
Malignant Neoplasms
Neoplasms
Osteoid osteoma Osteosareoma Osteoblast
oma ( and variants
Osteochondroma Enchondroma Chondroblastoma Chondr
omyxoid- fibroma
Chondrosarcoma Primary, secondary
Fibrosarcoma Malignant fibrous Histiocytoma
Fibroma
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Marrow Other
Ewings sarcoma Multiple myeloma Lymphoma Metasta
sis
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 21

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

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Osteoid Osteomas
Are slightly more common in the lumbar area,
followed by the cervical, thoracic, sacral
regions.
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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
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.
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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
MRI. is better than CT. in demonstrating the
extension of the bone sclerosis.
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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
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 .
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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 .
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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 .
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Osteochondroma may occasionally change into
malignant chondrosarcoma ( about 10 in
patients with multiple lesion ).
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• 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

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Spinal Cord TumorsIn Adults
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The Spinal Cord
Figure 13.29a
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Anatomy of the Spinal Cord
Figure 13.30a
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Anatomy of the Spinal Cord
Figure 13.30b
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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

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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.

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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

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• 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.

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• 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

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• 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)

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• 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.

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Nerve Sheath Tumors
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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

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Meningiomas

• 90 intradural
• 10 intra-extradural entirely extradural
• gross characteristic smooth fibrous
• Histological characteristic
• Broad dura attachment
• Bony involvement does not occurred

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Meningiomas
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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

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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

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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

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Miscellaneous pathology(Rare)

• Neoplastic
• Cavernous mass effect
• Hemangioblastoma
• Gangloneuroma
• Spinal carcinomatosis (rarely presents as mass
  lesion)
• Drap metastasis (from intracranial mass lesion)

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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

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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

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Neoplastic
Miscellaneous pathology(Rare)

• 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)

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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)

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TREATMENT
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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

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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.

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(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.

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MeningiomasTreatment 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.

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MeningiomasTreatment 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

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MeningiomasTreatment 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

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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.

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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).

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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.

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Neoplastic
Intramedullary Tumors

• primary glial tumors 80
• Astrocytomas
• Ependymomas
• Gangliogliomas
• Oligodendrogllioms
• Subependymomas
• Hemangioblastoma(3-6)
• Metastatic involvement (lt5)
• (lung breast most common)

• Inclusion tumors
• Cycts
• Metastasis
• Nerve sheath tumors
• Neurocytomas
• melanocytoms

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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

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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)

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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

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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.

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Intramedullary Tumors
astrocytomas(occurrence)

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

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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

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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)

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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)

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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)

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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

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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

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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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