INTRAMEDULLARY SPINAL CORD TUMORS K. Liaropoulos, P. Spyropoulou, N. Papadakis 3rd Neurosurgery...

INTRAMEDULLARY SPINAL CORD TUMORS

K. Liaropoulos, P. Spyropoulou, N. Papadakis3rd Neurosurgery clinic, Athens Euroclinic

EPIDEMIOLOGY

2-4% of tumors in the CNS inadults and children

Exception: the first year of life(Around 12%)

ORIGIN

Most tumors are of glial origin

Ependymoma (52%)Ependymoma (52%)Astrocytoma (46%)Astrocytoma (46%)

LOCALIZATION IN THE SPINAL CORD

cervicobulbar 11% cervical 24% cervicothoracic 25% thoracic 22% thoracolumbar 13% total 5%

SYMPTOMS

a) Pain (back or radicular)b) Paresthesiac) Scoliosis (in children)

CLINICAL PROFILE

TorticollisMotor deficitSphincter disorders

Neurological examination

HypoaesthesiaMotor deficitPyramidal syndrome

HISTOLOGICAL EXAMINATION

A) EPENDYMOMAAccording to the World Health Organization (WHO)

• of 2nd grade (90%)of 2nd grade (90%)

• rarely of 3rd graderarely of 3rd grade

B) ASTROCYTOMA

•most of 2nd grade most of 2nd grade • rarely of 3rd graderarely of 3rd grade

• glioblastomas very rareglioblastomas very rare

NEURORADIOLOGY

A) Radiography• Very limited contributionVery limited contribution

B) Myelography• Indirect diagnosis due to swelling ofIndirect diagnosis due to swelling of

the spinal cord• Does not indicate the characteristics of theDoes not indicate the characteristics of the

lesion• Invasive examinationInvasive examination

C) Computed tomography• Limited contributionLimited contribution

The MRI plays a dominant role in imaging

Advantages of MRI

In most cases it contributes to:

A) LocalizationB) SizeC) Solid - cystic componentsD) Composition some times(Lipoma, cavernous hemangioma)

MRI of grade II ependymoma

MRI of grade II conus astrocytoma

MRI in multiple sclerosis

MRI of grade II ependymoma

MRI of metastases

MRI of melanoma

MRI in lipoma

ATTENTION!

MRI can not distinguish between astrocytoma and

ependymoma with any degree of accuracy.

TREATMENT

The main treatment issurgery

SURGICAL TECHNIQUE

•Position: prone

• laminectomy / laminotomy

•Exposure of dura mater

•Exposure of arachnoid mater(With microscissors)

•Overview of the spinal cord(swelling - change in the color)

•Localization of posterior medianfissure (sometimes difficult)

•Overview of the spinal cord(swelling - change in the color)

•Localization of posterior medianfissure (sometimes difficult)

•Exposure of spinal cord•Biopsy•Ultrasound-guided resection•Detailed haemostasis•Suture

Surgical resection of grade II ependymoma

COMPLICATIONS

A) Sensory:Change little after the thirdmonth

B) Motor:Typically improve by1 ½ years

IMPORTANT

In the best case scenariothe long-term neurological condition will be

the same as the condition that first drove the patient to the doctor

RADIOTHERAPY

• We mention it last in order toemphasize that we do not believe there is any reason for this method,unless for treatment of malignanttumors, especially in children.•Even in these casesits value and safety have yetto be proved.

SUMMARY AND CONCLUSIONS

There is no pathognomonic profileof intramedullary tumors.However, pain in the back orneck or radicular pain or diffusedysesthesia, are always the firstsigns of an intramedullary tumor

The MRI is the preferredscreening test and shouldinclude full sections and the injection of contrast medium.Only the following cases presenta characteristic picture:Hemangioblastoma, dermoidcysts, epidermoid cysts andlipomas

2/3 of intramedullary tumorsare of glial origin. Sometimes thehistological verification isdifficult and requires additionalstaining and immunohistochemical

techniques

The operation of intramedullarytumors is guided by the anatomyand relies on the accessthrough the posterior median fissure.The main risk is lesion(Temporary or permanent) of the

posteriorcolumn in 70% of cases

The resection of intramedullarytumors is currently performed with

CUSA.Laser is not indicated becauseit blackens the surgical field and characteristics of the intramedullary tumor are lost

The main goal of the surgeryof intramedullary tumors is totalresection. This is possible only whenthere is a separating regionbetween the intramedullary tumor and the

spinal cord.In absence thereof, total resection is impossible andsuch attempt is dangerous and unnecessary.

If the tumor is astrocytoma,the prognosis is not necessarilyhopeless.Approximately 50% are totallyresectable

When the MRI indicatesthe presence of an intramedullary

tumor, surgeryis necessary since evencompletely benign tumors havebeen resected in patients wherethe MRI is referred to as invasive type of diagnostics

Radiotherapy is contraindicatedin dealing withintramedullary tumors

The low mortality,morbidity and recurrence ofintramedullary tumors constitutesurgery the onlyeffective treatment forintramedullary tumors.