Treated conditions

Spinal Tumors

Extradural tumors or tumors of the spine

Metastasis

75% of all patients with malignant tumors are affected by vertebral metastases. The most commonly reported neoplasms that cause vertebral metastases are: lung, breast, prostate, kidney, thyroid, and colon. The vertebral body is usually the starting point for metastasis growth. 95% of all spinal metastases are extradural.

Distribution

Lumbar: 22%

Thoracic: 70%

Cervical: 8%

The average age is 56 years.

Osteogenic tumors

• Benign: osteoma, osteoid osteoma, osteoblastoma, giant cell tumors
• Malignant: osteosarcoma, Ewing’s sarcoma, myeloma

Cartilage tumors

• Benign: chondroma, osteochondroma, chondroblastoma
• Malignant: condrosarcoma

Vascular Tumors

• Benign: hemangioma, lymphangioma, angioreticuloma
• Malignant: Angiosarcoma, Hemangiopericytoma

Connective Tissue Tumors

• Benign: fibroma, lipoma
• Malignant: fibrosarcoma, liposarcoma

Intradural Extramedullary Tumors  

• Benign: meningiomas, neuromas, dermoids, epidermoids, lipomas
• Malignant: metastases

These tumors are “attached” to the nerve roots (neuromas) or to the dura mater (meningioma). The most common kind is the neuroma or schwannoma (30%). Meningiomas are the second most common (25%) tumor. Other tumors are more rare. About 40% of all neuromas and 80% of all meningiomas affect the thoracic segment. Neuromas affect any age group without gender prevalence, and they are seldom malignant. Meningiomas are more frequent in women (3:1 over males) between fifty and seventy years of age.

Intradural Intramedullary Tumors

• Benign: ependymomas, juvenile astrocytomas, angioreticulomas, dermoids, epidermoids, cholesteatoma, lipomas
• Malignant: anaplastic astrocytomas, glioblastomas, metastases

They are very rare and are prevalent in adults. The most common are ependymomas (45%) and astrocytomas (35%). Ependymomas affect slightly more males than females between 30-60 years of age and they are mainly found at a cervical level.

Astrocytomas are predominant in children and young adults, where they are located on a cervical and cervical-thoracic level. They are mostly benign.

Hemangioblastoma and lipoma represent respectively 2-3% of intramedullary neoplasms. Cavernous angiomas, dermoid and epidermal tumors, teratomas, metastases, are much more rare.

Symptoms

Pain

Pain is the main symptom of spinal neoplasms.

It is a vertebral pain or rachiodynia: it is a dull, deep pain with antalgic contracture of the para-vertebral muscles. It may be associated with nerve root pain (corresponding to the affected sensory nerve) more common in intradural extramedullary tumors.

Motor Disorders

The patient will feel a sense of heaviness or weakness in one or more limbs.

Motor disorders may be due to damage to the structures that control the motor function. There may be damage to:

• motor nerve roots (flaccid paralysis)
• anterior horn cells of the spinal cord (flaccid paralysis)
• cortical-spinal tracts (spastic paralysis)

The propagation of motors deficiencies is characteristic and indicative of the type of spinal tumor. In fact, in the cross-pyramidal section, the nerves that control the lower limbs are placed laterally, while the more internal fibers innervate the upper limbs. This means that intramedullary tumors will provoke a descending motor deficiency (initial impairment of central fibers and then of the lateral ones), while extramedullary tumors will have an ascending symptomatology.

The speed with which symptoms occur varies according to the type of tumor. Obviously, they will arise faster in the case of malignant neoplasms and intramedullary tumors (which grow in a very narrow space, and therefore quickly communicate their presence and every variation in size).

Sensory Disorders

Characteristics are paresthesia, which provokes a tingling “pins and needles” effect, numbness, or a hot / cold feeling.

Also in this case, as for the motor disorders, these sensations will have an ascending progression in extramedullary tumors and descending in the case of intramedullary neoplasms.

The hypo-anesthesia (patients report a sense of dead skin, a sensation of losing part or all of a limb) may have different distributions. Also in this case, it presents an ascending distribution in extramedullary tumors and descending with intramedullary tumors.

Sexual and Sphincter dysfunctions

They occur at a later age, and they are a characteristic of conus medullaris tumors (the terminal part of the spinal cord between the (XI) thoracic vertebra and the (I) lumbar).

Diagnosis

Once there is a suspicion of the pathology, based on the clinical examination, you proceed with the instrumental examinations.

The neoplasms have a characteristic radiological appearance (RX, CT, spine MRI) that helps to determine their nature.

Although it is very useful, radiology does not allow for a certain diagnosis. The diagnosis can be confirmed only with histological tests. It is therefore necessary to perform a biopsy of the lesion or a histological test of the tissues removed during surgery.

Treatment

For the metastases, the approach must consider the general conditions of the patient, the primitive lesion that has metastasized, as well as the patient’s life expectancy. The treatment is therefore multidisciplinary and uses different methods: surgery, chemotherapy and radiotherapy.

Surgery is indicated in the case of:

• Radiotherapy failure
• Unknown diagnosis
• Unstable pathological fractures
• Progressive neurological impairment on the motor and / or sensory side
• Single location
• Severe root irritation symptoms

The criteria for choosing the type of surgery, whether decompression or stabilization, are:

• Tumor location
• Tumor extension
• Bone integrity
• Patient’s degree of debilitation (at least 6 months of life expectancy)

The types of surgical approaches are:

• Posterior decompression for:
• a) extradural metastases mainly distributed at the level of the posterior arch
• b) intradural metastases, for better transdural removal
• Anterior decompression and stabilization are used when a corpectomy is necessary, even at multi-levels, for a stabilization that guarantees a valid support to neoplasm-free segments.

Intradural tumor therapy is surgical and it consists in removing the lesion, with the goal of entirely removing it.

Specifically, intradural extramedullary tumors, mostly neuromas and meningiomas, are always removable, because they are small, they do not involve cellular infiltration and because they often present a cleavage plane. The prognosis is good with the possibility of experiencing complete and definitive functional recovery.

Intramedullary non-infiltrating tumors (ependymomas, hemangioblastomas, juvenile astrocytomas) can be completely removed and a complete cure is possible.

Infiltrating intramedullary tumors (astrocytomas, glioblastomas, lipomas) cannot be totally removed. In these cases, a small residue is usually left in contact with the healthy structures, with a consequent recurrence after some time.

Spinal cord and nerve structure relations should be carefully evaluated and the parameters of medullary function (potential evoked) should be monitored. For neuromas, although they originate within the vertebral canal, the extension towards the contiguous structures outside the spine must be considered. This may happen in delicate areas, such as the neck or mediastinum structures.