Osteoid osteoma small, night pain
Osteoblastoma large, lumbar
Aneurysmal bone cyst large lumbar
|| Giant Cell sacrum and vertebral body
|| Plasmacytoma pedicle and vertebral body
Ewings sarcoma sacrum
Surgery on the spinal cord is performed for lesions inside the spinal cord ( tumors, Infections, Vascular malformations) or for lesions causing pressure on the spinal cord from the outside (Tumors, infections, cysts, fractures)
Spinal cord tumors
Spinal cord tumors initially present with pain, followed by neurological symptoms. These tumors are usually benign and slow growing. The diagnosis therefore tends to be delayed. The common adult tumor is an Ependymoma. The tumor occurring commonly in children is an Astrocytoma.
Ependymoma is a benign tumor occurring in the spinal cord. These tumors are common in the adult patients and presents with pain initially and subsequently with neurological symptoms. On MRI the tumor is usually located in the center of the spinal cord with associated cysts at both ends of the tumor and brightly enhances with contrast.
Surgical removal should be undertaken early for best results. Though surgery can be performed at any stage of the disease, the best outcomes have been reported when they are undertaken with minimal neurological deficits at presentation. Radiation has no place in the treatment of Ependymomas unless in recurrence. These tumors can be removed completely, affording a cure.
Astrocytomas occur more commonly in younger patients and children. These tumors infiltrate into the surrounding spinal cord and unlike in the Ependymomas are difficult to remove completely. Early surgery is recommended and post-operative radiation when unresectable and with recurrences.
Removal of these tumors requires a team approach with a monitoring team and oncological teams to achieve best results.
Our monitoring team lead by Dr. Vedrun Deletis is one of the best in the country. We monitor the surface of the spinal cord with a grid electrode at the outset to determine the midline for opening into the cord. A contact Laser is used for opening into the spinal cord. During tumor removal Motor and Somatosensory evoked potential monitoring minimizes injury to the normal cord. Post-operatively patients undergo comprehensive physical therapy and are followed long term with frequent MRIs.
Dorsal Column Mapping in Spinal Cord
Surgery Case Presentation
Intramedullary Spinal Cord Tumor
Intramedullary spinal cord tumors comprise 4% of central
nervous system tumors and 20% of all intraspinal tumors (Fig. 2.1).
Traditionally, two types of tumors occur primarily in this location:
ependymomas and astrocytomas. Astrocytomas occur more frequently
in children, and ependymomas are more commonly found
in the adult population.
The vast majority of ependymomas are slow growing, welldemarcated
neoplasms. They produce symptoms by compression
of adjacent spinal cord tissue, as opposed to infiltration, as occurs in
astrocytomas. These tumors occur predominantly in the cervical
and cervico-thoracic regions. A group of these ependymal tumors
occurs in the filum terminale and conus of the spinal cord. Filum
ependymomas are papillary or myxo-papillary and are more benign
than the intramedullary and intracranial counterparts.
In terms of clinical presentation, most patients have pain either
in the neck or back as the predominant symptom. They can develop
any combination of numbness, weakness, gait imbalance, and finally
bowel or bladder dysfunction.
MRI scanning with and without gadolinium is the preferred
study for diagnosis. Ependymomas typically are well circumscribed,
located more centrally, enhance with contrast, and may have a rostral
and caudal associated cyst. Astrocytomas on the other hand may be
irregular, eccentric, and may or may not enhance with gadolinium.
Surgery is the treatment of choice once a definitive diagnosis of
intramedullary spinal cord tumor has been made. Biopsy is notoriously
unreliable, and observation for evidence of tumor growth is not recommended.
It is generally accepted that the most important factor in the
postoperative outcome after surgery, is the pre-operative neurological
status. Functional recovery is greatest in patients presenting with
minimal neurological dysfunction, and dramatic improvement should
not be expected in patients presenting with significant neurological
deficits. Secondly, the shorter the duration of symptoms, the better
the outcome after surgery and, thus the recommendation for early
surgery versus long-term observation is usually made.
Case Presentation 1
Other less common Intra-medullary spinal cord tumors include Hemangioblastomas, metastatic tumors, lipomas etc.
Other spinal cord and related conditions:
Benign cyst formation within the spinal cord either associated with a Chiari malformation, trauma or obstruction to the spinal fluid pathways in the sub-arachnoid space.
Occurs as a congenital anomaly but may present at anytime in life, with pain and bladder / bowel symptoms
Congenital anomaly with split spinal cord
Tumors Causing Pressure on the Spinal Cord From the Outside
- Nerve sheath tumors
These tumors arise within the lining layers of the spinal cord. The Schwannoma and Neurofibroma arise from the nerve sheath. In neurofibromatosis (Inherited disorder) tumors can arise in the head and anywhere in the spinal column.
Meningiomas arise from the lining of the spinal cord and cause spinal cord compression. Commonly occurs in older females and is slow growing.
These tumors can be removed completely, especially in Schwannomas and Meningiomas and can afford a cure.
Tarlov or Meningeal cysts
Occasionally can be symptomatic
Chordomas are low-grade primary malignant tumors arising
from notochordal remnants. They account for 1% to 4% of all
malignant bone tumors. These tumors invade the cancellous bone
and present as lytic lesions with areas of calcification. The tumor arises
most commonly in the clivus (50%), next in frequency is the sacrum
(35%), and less frequently in the spine (15%).
In the spine, the upper cervical spine and the lower lumbar
spine are more frequently involved, only rarely involving the thoracic
spine. Cervical spine involvement without involvement of the clivus is
relatively uncommon and often presents management problems. The
optimal management for chordomas of the spine with a contained
tumor would be en bloc resection.
Unlike sacral chordomas, in which en bloc resection is the
ultimate surgical goal, this may not be feasible in the cervical spine,
due to the complex local anatomy. Additionally, by the time these
tumors present clinically, they show spread into the epidural and
Cervical Chordoma Case Presentation
Sacral chordomas and Chodrosarcomas (discussed in spinal tumors)