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Tumours of the SpineTumours of the Spine
Brad HoffmannMBBCh FRCS(Eng) FRCS(SN)
FCS(SA) Neurosurg
Brad HoffmannMBBCh FRCS(Eng) FRCS(SN)
FCS(SA) Neurosurg
Spinal TumoursSpinal Tumours
15% of primary CNS tumours are in the spine
Most are benign Mostly present with compression rather than invasion
15% of primary CNS tumours are in the spine
Most are benign Mostly present with compression rather than invasion
Spinal tumours-typesSpinal tumours-types Extradural-55% (probably higher) Arise in bone or extradural tissues.
Intradural extramedullary-40%.
Intramedullary-5%. Affect white matter tracts and grey matter
Extradural-55% (probably higher) Arise in bone or extradural tissues.
Intradural extramedullary-40%.
Intramedullary-5%. Affect white matter tracts and grey matter
Differential diagnosisDifferential diagnosis
• ExtraduralMetastatic-lymphoma, lung, breast, prostate
Primary spinal tumours- chordomas, osteoid osteoma, osteoblastoma, aneurysmal bone cyst, vertebral haemangioma
Occasionally extradural- meningiomas, neurofibromas, chloromas, angiolipoma
• ExtraduralMetastatic-lymphoma, lung, breast, prostate
Primary spinal tumours- chordomas, osteoid osteoma, osteoblastoma, aneurysmal bone cyst, vertebral haemangioma
Occasionally extradural- meningiomas, neurofibromas, chloromas, angiolipoma
Differential diagnosisDifferential diagnosis Intradural extramedullary
MeningiomasNeurofibromasLipomas (also intramedullary)Metastatic (only 4%)
Intradural extramedullaryMeningiomasNeurofibromasLipomas (also intramedullary)Metastatic (only 4%)
Differential diagnosisDifferential diagnosis Intramedullary
Astrocytoma-30%Ependymoma-30%Miscellaneous
Malignant glioblastomaDermoidEpidermoidTeratomaLipomaHaemangioblastoma
IntramedullaryAstrocytoma-30%Ependymoma-30%Miscellaneous
Malignant glioblastomaDermoidEpidermoidTeratomaLipomaHaemangioblastoma
Intramedullary tumours-Presentation
Intramedullary tumours-Presentation
Pain- radicular/ non radicular. Local pain/stiffness.NB- pain with recumbency. Often bilateral
Motor disturbance Other sensory disturbance Sphincter disturbance Other-scoliosis, cutaneous stigmata, visible mass
Usually insidious, progressive
Pain- radicular/ non radicular. Local pain/stiffness.NB- pain with recumbency. Often bilateral
Motor disturbance Other sensory disturbance Sphincter disturbance Other-scoliosis, cutaneous stigmata, visible mass
Usually insidious, progressive
Intramedullary tumours-TreatmentIntramedullary
tumours-Treatment
Surgery Radiotherapy (rare-glioma group)
Observation (“masterly inactivity”)
Surgery Radiotherapy (rare-glioma group)
Observation (“masterly inactivity”)
Intramedullary tumoursIntramedullary tumours
Intramedullary tumoursIntramedullary tumours
Intramedullary tumoursIntramedullary tumours
Spinal tumours-miscellaneous
Spinal tumours-miscellaneous
Spinal tumours-miscellaneous
Spinal tumours-miscellaneous
Spinal tumours-miscellaneous
Spinal tumours-miscellaneous
Spinal tumours-miscellaneous
Spinal tumours-miscellaneous
Spinal tumours-miscellaneous
Spinal tumours-miscellaneous
Spinal tumours-miscellaneous
Spinal tumours-miscellaneous
Thoracic meningiomaThoracic meningioma
Thoracic meningiomaThoracic meningioma
Spinal lipomaSpinal lipoma
Spinal lipomaSpinal lipoma
Intradural, extramedullary…Intradural,
extramedullary…
Spinal epidural metastases
Spinal epidural metastases
Suspect if history of cancer NB-pain at rest/ recumbency Occurs in 10% of cancer patients 80%-lung, breast, GI, prostate, melanoma, lymphoma
Routes-haematogenous Thoracic>cervical>lumbar Pain is first symptom in 95%, followed by neurological symptoms/ signs
Suspect if history of cancer NB-pain at rest/ recumbency Occurs in 10% of cancer patients 80%-lung, breast, GI, prostate, melanoma, lymphoma
Routes-haematogenous Thoracic>cervical>lumbar Pain is first symptom in 95%, followed by neurological symptoms/ signs
Spinal metastasesSpinal metastases
Primary site can be unknown/asymptomatic
15% present with paraplegia, but up to 75% have weakness at diagnosis
Symptoms to diagnosis-2 months Patients “triaged” according to severity of symptoms/signs
Primary site can be unknown/asymptomatic
15% present with paraplegia, but up to 75% have weakness at diagnosis
Symptoms to diagnosis-2 months Patients “triaged” according to severity of symptoms/signs
Spinal metastasesSpinal metastases
Most severe group- about 75% have abnormal Xrays:Pedicle erosionPedicle wideningCompression fractureScalloping of vertebral bodySclerosis, osteoblastic changes
Most severe group- about 75% have abnormal Xrays:Pedicle erosionPedicle wideningCompression fractureScalloping of vertebral bodySclerosis, osteoblastic changes
Spinal metastasesSpinal metastases
Further Ix:MRI +/- contrastRarely myelogramIsotope bone scan +ve in 66%Metastatic work-up
Further Ix:MRI +/- contrastRarely myelogramIsotope bone scan +ve in 66%Metastatic work-up
Spinal metastasesSpinal metastases
TreatmentIndividualisedUsually palliativeRadiotherapy most commonSurgeryDexamethasonePain control
TreatmentIndividualisedUsually palliativeRadiotherapy most commonSurgeryDexamethasonePain control
Other conditions to consider..
Other conditions to consider..
Osteoporotic fractures Disc lesions Infection-intra-osseous, epidural.. Haematomas-AVM, anticoagulation.. Facet joint cysts Demyelination, transverse myelitis Abdominal, renal, vascular pathology Paget’s disease Psychological factors
Osteoporotic fractures Disc lesions Infection-intra-osseous, epidural.. Haematomas-AVM, anticoagulation.. Facet joint cysts Demyelination, transverse myelitis Abdominal, renal, vascular pathology Paget’s disease Psychological factors
“Red flags”“Red flags”
Cancer or infection• Age >50 or <20• Hx of cancer• Unexplained weight loss• Immunosuppression• Drug abuse• UTI-fever, chills• Pain not relieved by rest
Cancer or infection• Age >50 or <20• Hx of cancer• Unexplained weight loss• Immunosuppression• Drug abuse• UTI-fever, chills• Pain not relieved by rest
“Red flags”“Red flags”Fracture
• Significant trauma• Prolonged use of steroids• Age >70
Cauda Equina Syndrome• Acute urinary incontinence, saddle anaesthesia
• Faecal incontinence, decreased anal tone
• Global / progressive weakness and numbness in legs (+ pain)
Fracture• Significant trauma• Prolonged use of steroids• Age >70
Cauda Equina Syndrome• Acute urinary incontinence, saddle anaesthesia
• Faecal incontinence, decreased anal tone
• Global / progressive weakness and numbness in legs (+ pain)