INTRADURAL SPINAL TUMOR

DR.MUMTAZ ALIResident Neurosurgeon

J

General information

• 15% of primary CNS tumors are intraspinal

• Most primary spinal tumors are benign• Most present by compression rather than

invasion

Types Of SCT

• extradural (ED) (55%) arise outside spinal cord outside of dura veretebral bodies epidural tissues

• Intradural (ID) (45%)• intradural extramedullary (ID-EM) (40%) in subarachnoid spaces leptomeninges or roots Meningioma Swhwannoma Neurofibroma Lipoma 4 % mets

• intramedullary spinal cord tumors(5 %) SC substance tracts and grey matter astrocytoma 30% ependymoma 30% miscellaneous 30% :malignant glioblastoma

,dermoid ,epidermoid ,teratoma mets : 2%

SPINAL MENINGIOMA

• Peak age: 40–70 years• Female:male ratio =4:1 overall, but the

ratio is 1:1 in the lumbar region. • 82% thoracic, 15% cervical, 2% lumbar.• 90% are completely intradural, 5% are

extradural, and 5% both• 68% are lateral to the spinal cord, 18%

posterior, 15% anterior.• Multiple spinal meningiomas occur rarely.

• Isointense to spinal cord T1/T2

• homogenous enhacement

• dural tail

• Dural tail• intensely

inhance with contrast

• calcification• cord

compression

Presentation

• 1. motor a) pyramidal signs only: 26% b) walks with aid: 41% c) antigravity strength: 17% d) flexion-extension with gravity removed:

6% e) paralysis: 9%

• 2. sensory a) radicular: 7% b) long tract: 90%• 3. sphincter deficit: 51%

Outcome

• Recurrence rate with complete excision : 7%

Spinal Schwannoma

• slow growing benign tumors• most (75%) arise from the dorsal

(sensory) rootlets• early symptoms are often radicular• recurrence is rare after total excision

(except in neurofibromatosis)

Incidence

• Incidence: 0.3–0.4/100,000/yr.• Most occur sporadically and are solitary• associated with neurofibromatosis

primarily type 2 (NF2)• can occur with type 1.

• Widened neural foramina

• VB scalloping• increased

intrapedicular distance

• Dumbel shaped

• T1WI:hypo/isointens• T2WI:hyperintense• Target sign:T1/T2• homogenous

enhancment• 40% cytic

Presentation

• Neurologic deficits develop late.• radiculopathy (from nerve root

compression),• myelopathy (from spinal cord

compression)• radiculomyelopathy (from compression of

both)• cauda equina syndrome (for tumors below

conus medullaris).

Histopathology

• Antoni A : (compact, interwoven bundles of long, spindly Schwann cells)

• Antoni B tissue : (sparse areas of Schwann cells in a loose eosinophilic matrix).

EPENDYMOMA

• the most common glioma of lower cord, conus and filum

• most ependymomas in conus and filum are myxopapillary ependymomas.• More common in adults• potential for seeding through CSF• associated cysts are common• surgical excision

Incidence

• Slow-growing• Benign • Slight male predominance• slight peak in 3rd to 6th decade• 50% in filum, next location is cervical.

• Sausage shaped

• intensely enhancing

• dorsal medulla to C5 level

• old hemosiderin

• central location

Histopathology

• papillary• cellular• epithelial• mixed • Cystic degeneration in 46%• papillary: highly vascular : SAH

ASTROCYTOMA

• Uncommon in first year.• Peak: 3rd – 5th decade.• Male:female =1.5:1• The ratio of low-grade:highgrade=3:1• thoracic > cervical.• 38% are cystic• cyst fluid usually has high protein.

Hemangioblastoma

• 1-3%• symptomatic in

5th decade• similar to glial

tumor• associated with

VHL

• Bright homogenous enhacement

• no more than 1 VB length

• 80% cystic tumor & serpengious vessel

• Angiogram & embolisation

Mets

• Most : extradural• rare : Intramedullary• metastatic spinal cord lesions:• small-cell lung Ca• breast Ca• malignant melanoma• lymphoma• colon Ca.

Presentation

1. Pain • the most common complaint• Almost always present in filum tumors • radicular ,local ,medullary : increases with

valsalva manuvre and spine movement.2. Motor disturbance : • weakness• gait disturbances : frequently in children

3. Sensory disturbance :•decreased pain and temperature•preserved light touch4. Sphincter disturbance :•usually urogenital•retention•incontinence•impotence

5 . Miscellenious :•scoliosis or torticollis• SAH• visible mass over spine

DIAGNOSIS

1. History•EMID: redicular symptoms early•IMID :sensory findings early 2. MRI :•mainstay of diagnosis•Ependymomas enhance intensely•often associated with hemorrhage & cysts•Cord edema may mimic a cyst.

3 . Plain radiograph :•vertebral body destruction• enlarged intervertebral foramina•increases in interpedicular distances4 . Lumbar puncture :• Elevated protein : 95 %•Glucose is normal except with meningeal tumor

5. SCT can cause complete block indicated :•Froin's syndome :clotting (due to fibrinogen) and xanthochromia of CSF•Queckenstedt’s test : failure of jugular vein compression to increase CSF pressure, which it normally does in the absence of block•barrier to flow of myelographic contrast media

6. Myelography :•fusiform cord widening•Meniscus sign :capping efect with a sharp cutt off•EDST (incomplete) : hourglass deformity•EDST(complete) : paintbrush effect7.Spinal angiography : hemangioblastoma

Managment

• Asymptommatic lesions are followed• Lesions with progressive neurologic

deficit • Low grade astrocytoma : Excision• High grade astrocytoma : Radiotherapy

& chemotherapy• Ependymoma : Excision• Meningioma : Excision• Scwannoma : excision

Surgery

1 . Position :•usually prone•lateral oblique•sitting2 . Cystic component : aspirate with 25 G3 . Intraoperative monitoring :•SSEP & MEP•ultasound (astrocytoma : isoechoic while ependymoma hypoechoic)

4.Myelotomy : midline/one side of the dorsal midline to avoid posteromedian vein.5.6–0 silk sutures : gently retract the spinal cord open6.copious irrigation : bipolar7.monopolar : should not be used8.debulking of tumor : laser or USA9.water tight dural closure

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