Intramedullary Tumor Surgery When, Why, and How

Eric M. Massicotte, MD, MSc, FRCSCAssociate ProfessorUniversity of Toronto

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Thursday May 22nd, 2014

Today’s Objectives

• To understand different types of tumor

• To understand the function of the Spinal Cord

• To understand who might benefit from surgery for Intramedullary tumors

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Disclosure

Depuy-Synthes, Medtronic, Baxter, Stryker, Zimmer for Educational grant

AOSPINE North America Education Committee

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Cancer:the disease caused by an uncontrolled division of abnormal cells in a part of the body.a malignant growth or tumor resulting from the division of abnormal cells. plural noun: cancerssynonyms: malignant growth, cancerous growth, tumor, malignancy

Metastatic Cancer:Definitions of Metastatic cancer on the Web:Metastasis (Greek: displacement, μετά=next + στάσις=placement, plural: metastases), or Metastatic disease, sometimes abbreviated mets ...cancer that has spread from the place in which it started to other parts of the body. Cancer that migrates from a primary site to a secondary site(s).

Internet Definitions – Not the whole story4

Internet Definitions – Not the whole story

"A neoplasm is an abnormal mass of tissue, the growth of which exceeds and is uncoordinated with that of the normal tissues, and persists in the same excessive manner after cessation of the stimulus which evoked the change.”

• Neoplasia vs. tumor• Tumor (Latin for swelling,

one of the cardinal signs of inflammation) originally meant any form of swelling, neoplastic or not. Current English, however, both medical and non-medical, uses tumor as a synonym of neoplasm.[7]

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Types of Tumor

1. Classification of tumors based on tissue of origin

2. Grouping of tumors based on location

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Bone-forming tumor:‣ Benign: Osteoma, osteoid osteoma‣ Malignant: Osteosarcoma, Cartilage-forming tumor‣ Benign: Chondroma, osteochondroma‣ Malignant: Chondrosarcoma, chondroblastomaGiant-cell tumor (Osteoblastoma)Marrow Tumor‣ Ewing’s sarcoma‣ Malignant lymphoma‣ MyelomaVascular tumors‣ Benign: hemagioma, lymphangioma, glomus tumor‣ Malignant: angiosarcomaOther connective tissue tumor‣ Benign: Lipoma, desmoplastic fibroma‣ Malignant; Fibrosarcoma, liposarcoma, leiomyosarcomaOthers‣ Chordoma, neurofibroma

Types of Tumor – Based on tissue of origin

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Extradural:

‣ Metastatic lung, breast, prostate‣ Myeloma, lymphoma, leukemia‣ Primary vertebral tumors

Types of Tumor – Based on location

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Types of Tumor – Based on location

Intradural Extramedullary

‣ Meningioma ‣ Schwannoma‣ Nerve sheath tumour‣ Vascular malformation‣ Teratoma‣ Dermoid

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Types of Tumor – Based on location

Intramedullary

‣ Astrocutomas‣ Ependymomas‣ Oligodendroglioma‣ Teratoma‣ Hemangioma

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Types of Tumor – Examples

Schwannoma

ependymoma

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Function of the Spinal Cord

Communication– Connecting your brain

with the rest of your body

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• Understanding the level of the tumor becomes very important

• Pain, is much harder to use as localizer.

Function of the Spinal Cord13

Dorsal Column/Medial Lemniscus:

• discriminative touch,• joint position, • vibration

Function of the Spinal Cord – Specific Pathway14

Surgery – Comprehensive consent conversation

Why?How?What can go wrong?Alternatives

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Surgery – A case study

36 year-old mother of two boys presents with:• two month history of

progressive numbness and clumsiness in her hands.

• Difficulty with walking in the dark and on uneven surfaces.

• Physical exam reveal mild weakness in her hands, abnormal reflexes and unsteady gait.

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SurgeryKnife cutting the dura

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Surgery

Intra-operative Ultrasound

Free edge of dura

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Surgery

Blood vessels on the surface of the spinal cord

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Surgery

Instruments are in the spinal cord to reach the tumor

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Surgery

The difference between tumor and spinal cord is typically obvious in ependymoma

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Surgery22

Surgery

Post-Operative Status:• Hands stronger.

Pre-Operative Status:• Weakness in

hands• Difficulty

walking

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30 year-old lady with no symptoms

Surgery24

Today’s Objectives• To understand different types of tumor

– Using location

• To understand the function of the Spinal Cord– Connection between your brain and body

• To understand who might benefit from surgery for Intramedullary tumors– Make a definitive diagnosis– Remove tumor – Prevent further loss of Function

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