SPINAL CORD TUMORSBY : DR / AHMED MOHAMMED DEBES

NEUROSURGERY RESIDENT AT AHMED MAHER TEACHING HOSPITAL

CAIRO, EGYPT.

TUESDAY 09/10/2014

Spinal Cord Tumors

Intra-dural

Intra-medullary Extra-medullary

Extra-dural

Extra-medullary

Nerve Sheath Tumors

schwannomas neurofibromas

Meningiomas

Filum Terminale Ependymomas

• Gross

• Micro

• Asso.

Neurofibromas

• Fusiform

• Fibrous tissue + nerve fibers

• Neurofibromatosis type I

Schwannomas

• globoid masses, suspended eccentrically

• Antoni-A(elongated cells) Antoni-B(stellate-shaped

• schwannomatosis

• 4th – 6th decade , male = female

•Mostly affect dorsal root

most common

30%

(cervical)

10%

1%

arachnoid cap

cells

decade ,

•Mainly , upper

cervical spine and

foramen magnum

•ventral or ventrolateral,

may

•10%

•Do not penetrate the

pia

decade ,

•Myxopapillary

ependymomas

•Cuboidal cells surrounding a

vascularized core of

hyalinized connective tissue

•Benign

neural crest, benign,

neurosecretory granules

dumbbell tumors in

pediatric

thoracic spine

rarely

cause mass effect

CSF drop metastases,

direct penetration of the

dural root sleeve

•Depend on location

•Local back pain & radicular

pain

•Worsening pain on

recumbency

Signal abnormalities

CSF capping

cord/cauda displacement

•T1 iso/ slightly hypointense

•T2 hyperintense

•Contrast enhancement

benign,

excision, Recurrences are rare

-Posterior laminectomy

-unilateral facetectomy

-open dura

-Dorsal (visualized), Ventral

(dissect dentate ligament

-Cauterize tumor

-Neurostimulation

-Dumbbell shaped (resection of

both nerve roots)

-Surgical removal easy due to

- absence of bony involvement

- well-defined spinal epidural

space

- lack of venous sinus

involvement

-Recurrence 10 %

- Posterior laminectomy

- Anterior approaches for purely

ventral tumors

-Management of the dural base

• excision of the dural then graft

• extensive in situ coagulation

-Role of surgery depends on

size of the tumor and its

relationship

-Gross total en bloc resection

- Small, well circumscribed within

the fibrous coverings & easily

separable from the nerve roots

-Subtotal

-Radiation therapy

Intra-medullary

Astrocytomas Ependymomas

Hemangioblastoma

80% 8%

-First 3 decades of life

-Most common pediatric

intramedullary cord tumor

-60% of occur in the

cervical

-20% associated syringes

-Most are grade I or II

-Associated NF1

-Most common

intramedullary tumors in

adults

-Male = Female, middle

age

-65% have associated

cysts

-Associated NF2

-Cellular ependymoma

the most common

-Benign, unencapsulated,

circumscribed and do not

-Associated with von

Hippel-Lindau syndrome

(AD)

-At any age

-Associated syringes

-Benign tumors of

vascular origin

-Circumscribed, not

encapsulated

-located dorsally or

dorsolaterally

most

common dysembryogenic

lesion, increased fat

deposition in metabolically

normal fat cells, subpial

location.

The lung

and breast are the most

common primary tumor

sites

history of radiation

•Nonspecific

neurological deficit

can cause abrupt

deterioration

(ependymomas)

and

dysfunction occur early

Cord enlargement

Enhancement

•T1 iso/ slightly hypointense

•T2 hyperintense

-uniform contrast enhancement

-Polar cysts

-Heterogeneous contrast

enhancement

-Irregular margins

•Microsurgical removal is the

most effective treatment of

ependymomas &

hemangioblastomas.

•For astrocytomas are more

controversial.

•Resection should be limited to

tumor tissue

•Preservation of neurological

function rather than complete

tumor resection is paramount

• Preoperative steroids

and antibiotics

• General anesthesia,

intubated & prone

• Sensory and motor

evoked potentials

monitoring

• Midline skin,

subperiosteal bony

dissection

• Laminectomy extend

one segment above

and below the tumor

•The facets are

preserved.

• Strict hemeostasis before the

dura is opened

• The dura is opened in the

midline and tented laterally

with sutures

• Operating microscope

• The arachnoid is opened

• Cord inspected for surface

abnormalities ,U/S localize

tumor

• midline myelotomy through

the posterior median septum

• dorsal midline -- midpoint

between the dorsal nerve root

entry zones bilaterally

• Midline crossing vessels in

• Pia incised sharply with a

micro knife or scissors

• myelotomy extend over the

entire rostrocaudal extent of

the tumor

• Spreading the posterior

columns gently with micro

forceps

• Pial traction sutures are

placed

• Technique of tumor removal

is determined by the surgical

Objective (biopsy , removal)

• Internal decompression with

an ultrasonic aspirator or

laser

• The myelotomy is not closed

Q) WHAT TYPES OF NERVES DO NEUROFIBROMAS GENERALLY ARISE FROM?

•Dorsal root

•Ventral root

•Both of them

INTRADURAL SPINAL NERVE SHEATH TUMORS ARE TOTALLY MALIGNANT ( T ) OR ( F )

•False only 2.5 % are malignant

MENINGIOMAS USUALLY ARISE FROM WHICH TYPE OF CELLS ?

•Arachnoid cap cells

………. ARE BENIGN TUMORS OF VASCULAR ORIGIN ?

•Hemangioblastomas

Q) IN RESECTING AN INTRAMEDULLARY SPINAL CORD TUMOR, WHAT IS A SURE WAY TO RECOGNIZE THE MIDLINE IF THE TUMOR IS DEFORMING THE NORMAL SPINAL CORD ANATOMY?

•Midpoint between the dorsal nerve root entry zones

bilaterally

Q) WHAT IS THE MOST COMMON INTRAMEDULLARY SPINAL CORD TUMOR IN ADULTS?

•Ependymoma

•Meningiomas

•Astrocytoma

•Hemangioblastoma

Q) WHAT IS THE MOST COMMON INTRAMEDULLARY SPINAL CORD TUMOR IN PEDIATRIC ?

•Ependymoma

•Meningiomas

•Astrocytoma

•Hemangioblastoma

THE ENDTHANK YOU