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Case introduction
Introduction
Introduction
The major groups of pathological causes are:
1 Tumor:
(a) metastatic (b) primary.
2 Degenerative:
(a) disc prolapse (b) osteoporosis/spondylosis.
3 Infection:
(a) vertebral body (b) disc space (c) extradural (d) intradural.
4 Hematoma:
(a) spontaneous (trauma) (b) arteriovenous malformation.
5 Developmental:
(a) syrinx (b) arteriovenous malformation (c) arachnoid cyst.
Introduction
Blood vessels, Bones of the spine, Meninges, Nerve roots, Spinal cord cells.
Classification
Overall prevalence is estimated at one spinal tumor for every four intracranial
lesions
Lesions that compress the spinal cord
extradural (80%)
intradural, extra medullary (15%)
intramedullary (5%).
Metastatic spinal tumors are the most common type of malignant lesions of the
spine, accounting for an estimated 70 percent of all spinal tumors.
IntraDural:
In adults,
In children,
intramedullary tumors are more common, accounting for greater than 35% of intradural
masses
Intradural tumors occur with equal frequency in both sexes, with the
exception of a higher incidence of meningiomas in women
Causes
Causes
Causes
Neurofibromatosis Type 2
A patient with neurofibromatosis Type II. a, b Different intradural
extramedullary (meningiomas and neurofibromas) and intradural
intramedullary tumors (ependymoma) as well as c extraspinal tumors
are to be seen in the whole spine.
Symptoms
Pain
a common early feature of cord compression and often precedes the onset
of any neurological disturbance
due to involvement of local, pain sensitive structures
girdle pain or radicular pain: is due to involvement of the nerve root at the level of the compression.
severe, sharp, shooting pain
Central pain
due to spinal cord compression itself
diffuse dull ache, often with a burning quality, and is frequently described with
difficulty.
Lhermittes sign : electric shock or tingling radiating down through the body to the extremities of
the limbs cuased by Flexion or extension of the neck .
associated with cervical cord involvement, either by a compressive lesion or due
to an inflammatory process.
Neurological deficit
The neurological features of spinal
cord compression consist of:
progressive weakness
sensory disturbance
sphincter disturbance.
Motor impairment
depend on the position of the cord compression
The compression of the corticospinal pathways will result
in an upper motor neuron weakness
an initial pyramidal pattern
Sensory disturbance
A sensory level is the hallmark of spinal cord compression.
band of minor hyperesthesia at the level of the compression.
Compression Syndromes
Root
severe, sharp, shooting pain with
weakness or numbness in distribution of
root (radicular)
Bone
continuous dull pain and tenderness
may not be relieved by rest
Anterior
bilateral weakness, dissociated sensory
loss (loss of pain and temperature,
retained position sense, pressure,
vibration)
Posterior
rare, produces paresthesias, impaired
posterior column function
Lateral
aka Brown Sequard
contralateral loss of
pain and temperature
1-2 segments below
injury
ipsilateral loss of
posterior column
function and
weakness
best prognosis of any
spinal cord syndrome
Central
weakness of UE
> LE
cape-like
sensory deficit
Sphincter involvement
compression of conus medullaris or cauda equina
The first symptom is difficulty in initiating micturition
and this is followed by urinary retention, which is often
relatively painless.
Constipation and fecal incontinence will subsequently
occur.
The clinical signs include an enlarged, palpable bladder,
diminished perianal sensation and decreased anal tone.
Intradural-extramedullary
tumors
develop in
1. the spinal cord'sarachnoid membrane(meningiomas)
2. in the nerve roots that extend out from the spinal cord
( schwannomasandneurofibromas)
3. or at the spinal cord base (filum terminale
ependymomas).
Schwannoma
&neurofibroma
Although both tumors are thought to be of Schwann cell origin, their significant histologic,
epidemiologic, and biologic differences warrant discussing them separately
schwannoma
neurofibroma
15%
more than half of them are associated with
neurofibromatosis 1 (NF1)
typically, but not exclusively, arise from the
sensory root
solid, not cystic. Yet they, too, can extend
through the Dural root sleeve as a
dumbbell tumor
characteristically arise from central nerve
root fibers
total surgical removal of tumor, often
necessitating the sacrifice of the nerve
root.
Treatment:
surgical excision of the tumor.
Access to the tumor is obtained by a laminectomy.
If there is a large extraspinal extension it may be
necessary to obtain additional exposure through the
neck, chest or abdomen.
Spinal meningioma
M<F
occur particularly in 50-70s
75% of intraspinal meningiomas arise in the thoracic spine
and are typically dorsolateral to the cord
cervical tumors (20%) do occur and are frequently located
in the upper cervical region and ventral to the cord
Spinal meningioma
Spinal meningioma
Radiology
Plain X-rays may show
1.
2.
MRI
. isointense with cord on both T1W images
and T2W images;
. moderate CE with or without association of
Dural tail;
. no bone destruction;
. calcification occasional.
Spinal meningioma
Treatment
The treatment of spinal meningioma is resection of the
tumor and the involved Dura.
Intramedullary:
Ependymomas
Ependymomas
Radiology
On MRI,
Ependymomas
Treatment
total surgical resection.
In contrast to intracranial
ependymomas, intramedullary spinal
cord ependymomas have a good
prognosis
Astrocytoma
Astrocytoma
Radiology
MRI
A case of cervical
astrocytoma with cyst
formation at the caudal
tumor
pole and within the
tumor.
Astrocytoma
Extradural:
Extradural:
Imaging Studies
X-ray
Plain films are still routinely obtained but have a limited
diagnostic value.
Abnormal findings of intradural tumors can be:
bony destruction in metastasis or anaplastic tumors
widening of the spinal canal represented by widening of the
intrapedicular distance
thinning of the pedicle
scalloping of the posterior vertebral surface (in cases with slowgrowing tumors)
widening of the intervertebral foramen (especially in patients with
neuromas)
disappearance of the normal spinal curvature
progressive scoliosis
tumor calcification
Myelography
Myelography has been superseded by MRI for the
diagnostic work-up of intradural spinal tumors.
CT and Myelo-CT
For whom MRI cannot be performed because of
contraindications
bony deformation such as destruction, scalloping, widening
of the spinal canal and/or the intervertebral foramen
calcification
contrast enhancement
spinal cord compression
expanding medullary mass
MRI
Meningiomas
Ependymomas
Astrocytoma
Angiography
Spinal angiography has a place in the
definitive diagnosis of
hemangioblastoma
(showing dense vascular stain and
prominent draining veins) and vascular
malformations
Treatment
Non-surgical Treatment
Recent developments in chemotherapy
and radiotherapy have made it possible
to apply these modalities, especially the
former for intramedullary gliomas of
children
Surgical Treatment
The goal of surgery for any benign intradural
neoplasms is gross total resection
The goal for a malignant glioma is debulking with
preservation of the function.
Recovery
Thank you