This document discusses the radiological imaging and classification of spinal cord tumors. It describes how spinal cord tumors are classified as extra-dural, intra-dural extra-medullary, or intra-medullary. Common benign extra-dural tumors discussed include hemangioma, osteoid osteoma, osteochondroma, eosinophilic granuloma, and epidural lipomatosis. Imaging findings for diagnosing these tumors with x-ray, CT, and MRI are provided. Malignant primary tumors of the spine discussed include chordoma, lymphoma, osteosarcoma, and chondrosarcoma. Metastatic tumors to the spine are also mentioned.

1. Radiological imaging
of spinal cord tumour.
Dr/ ABD ALLAH NAZEER. MD.

3. Spinal Cord Tumours:
Extra-dural.
Intra-dural extra-medullary
Intra-medullary.
Spinal Cord Tumors are classified into:
Benign tumours.
Cysts, and other benign tumour like masses.
Malignant tumors.
Metastasis.

4. Extra-dural tumors:
. Occurs outside the spinal dura.
. Typically arises from the osseous spine,
intervertebral discs and adjacent soft
tissues.
. Imaging criteria. Focal displacement
of the theca away from the mass.

5. Diagnosis:
A thorough medical examination with emphasis on back pain and
neurological deficits is the first step to diagnosing a spinal tumor.
Radiological tests are required for an accurate and positive diagnosis.
X-ray: Application of radiation to produce a film or picture of a part of
the body can show the structure of the vertebrae and the outline of the
joints. X-rays of the spine are obtained to search for other potential
causes of pain, i.e. tumors, infections, fractures, etc. X-rays are not very
reliable in diagnosing tumors.
Computed tomography scan (CT or CAT scan): A diagnostic image
created after a computer reads X-rays, a CT/CAT scan can show the
shape and size of the spinal canal, its contents, and the structures
around it. It also is very good at visualizing bony structures.
Magnetic resonance imaging (MRI): A diagnostic test that produces
three-dimensional images of body structures using powerful magnets
and computer technology. An MRI can show the spinal cord, nerve
roots and surrounding areas, as well as enlargement, degeneration,
and tumors.

6. Extra-dural benign tumors:
-Hemangioma.
-Osteoid osteoma.
-Osteochondroma.

7. Hemangioma.
Slowly growing benign tumour of capillary,
cavernous or venous origin.
Most common benign spinal neoplasm and
approximately 50% of osseous hemangiomas
are found in the vertebral bodies (thoracic
especially). Most epidural hemangiomas occur
secondarily as extension of expanding intra-osseous
lesions.
Most hemangioma are asymptomatic and
discovered accidentally.

8. Radiological imaging of hemangiomas.
Plain film:
Findings include: prominent trabecular pattern, sclerotic vertebra
with vertical trabeculae: Corduroy sign lytic calvarial lesions with
spoke-wheel appearance irregular and lytic in long bones, with a
honeycomb appearance.
CT: Usually as an incidental finding, especially in the vertebrae.
Better visualization of thickened vertical trabeculation (polka-dot
appearance).
MRI: Signal intensity is somewhat variable, depending largely on
the amount of fat content.
T1: high is more common (fat rich).
intermediate to low signal intensity is seen in fat poor
hemangioma.
T2: high.
T1 C+ (Gd): enhancement is often present.

9. Hemangioma.

10. Hemangioma.

11. Hemangioma.

12. MRI: An epidural component of hemangioma of the LI vertebra with a
lesion of its arch pedicle (А); hemangioma of ThXI vertebra, spreading
paravertebrally and to the right pedicle of its arch (B).

13. Sagittal T2-weighted image showing a T3 haemangioma
with epidural extension compressing the spinal cord.

14. Osteoid osteoma is a small, benign osteoblastic tumor
consisting of a highly vascularized nidus of connective tissue
surrounded by sclerotic bone. The nidus is usually < 1.5 cm.
10% occur in the spine, usually at the site of neural arch. The
classical clinical presentation of spinal osteoid osteoma is that
of painful scoliosis. Other clinical features include nerve root
irritation and night pain. Osteoid osteoma has characteristic
computed tomography (CT) findings( dense sclerosis
surrounding a lytic lesion that has a central calcific nidus).
Because magnetic resonance imaging (MRI) findings of the
osteoid osteomas causing intense perinidal edema can be
confusing, these patients should be evaluated with clinical
findings and other imaging techniques. Nidus typically low to
intermediate signal at T1 and T2WI.
Bone Scan. Focal activity on both intermediate and delayed
images.

15. osteoid osteoma.

16. osteoid osteoma.

17. Osteochondromas are among the most frequent of
benign bone tumors. They occur either as solitary lesions or
as multiple osteochondromatosis, they arises through lateral
displacement of the epiphyseal growth cartilage, results in a
bony excrescence with cartilaginous –covered cortex and a
medullary cavity. However, the spine is affected by these
tumors in only 2% to 7%. Osteochondromas are commonly
seen in the second or the third decade of life.
Spinal osteochondromas present as asymptomatic palpable
masses or more unusually, with neurological deficit, because
the majority of the lesions grow out of the spinal canal and
usually do not cause symptoms. But nerve root compression
is an uncommon manifestation of exostosis developed within
the intra-spinal canal. Neurological compromise is more
common in the patient.

18. Radiological imaging of osteochondroma.
X-Ray films: A sessile or pedunculated bone like
projection.
CT Scan: The cortex of the parent bone flares into the
cortex of the osteochondroma with which it is
contiguous. The cartilaginous cap often contains
calcification.
MRI: Show mixed signal on both T1 and T2WI.
Cartilage in the cap has high signal intensity on T2-
weighted, spin-echo MRI scans. This characteristic
allows measurement of the cap, which is an
important consideration in malignant transformation.

19. Osteochondroma at upper cervical cord in a patient with multiple exostoses.

20. Osteochondroma of rib with neural foraminal extension and cord compression

21. T2W MRI cervical spine showing the C3 osteochondroma compressing the
cord, (b) CT axial section showing the pedunculated osteochondroma, (c) Post
op MRI T2WI showing the cord contusion, (d) Histopathological examination
showing cartilaginous cap with underlying irregular bony trabeculae.

22. Uncommon extra-dural masses.
Cysts, and other benign tumour
like masses.
-Eosinophilic granuloma.
-Epidural lipomatosis.
-Non-neoplastic cysts.
Synovial and arachnoid cyst.

23. Eosinophilic granuloma(EG)
Langerhans Cell Histiocytosis.
A benign non-neoplastic disorder, self limiting
process of well demarcated bone resorption.
1st- 2nd decade, Male to female ratio 2:1
Spine involvement in 10-15% of EG.
A classic cause of a single collapsed vertebral body
as a lytic lesion without surrounding sclerosis.
Associated with 2 systemic diseases:
-Hand-Schuller-Christian disease.
- Letterer-Siwe disease.

24. Radiological imaging finding:
X-Ray: Vertebral plana.
CT Scan: Lytic lesions or collapse of the
vertebral bodies(Vertebra plana).
MRI: decreased signal intensity on T1-
weighted images and high signal intensity
on T2-weighted sequences. The lesion may
enhance after the administration of a
gadolinium-based contrast agent.

25. Eosinophilic granuloma.

26. Eosinophilic granuloma.

27. Thoracic vertebral eosinophilic granuloma.

28. Epidural lipomatosis.
Epidural lipomatosis refers to excessive accumulation of fat within
the epidural space, such that the thecal sac is compressed.
Clinical presentation
Patients may present with back pain resembling that of a disc
herniation. In severe cases, symptoms of canal stenosis are
produced.
Radiographic features
MRI spine
There is a often generalized excess of fat seen in the extradural
space. As a result the dural sac can appear narrowed or even
resemble a "Y" shaped configuration.
Signal characteristics follow fat on all sequences:
T1 - high signal
T1 (FS) - shows fat suppression
T2 - high signal

29. Epidural lipomatosis.

30. spinal epidural lipomatosis. The thecal sac has the typical
"Y" configuration on axial section at the L5 level.

31. Epidural dorsal angiolipoma.

32. SYNOVIAL CYST.
A synovial cyst is a relatively uncommon cause of spinal
stenosis in the spine. It is a benign (noncancerous)
condition and the symptoms and level of pain and
discomfort can remain stable for many years. A synovial
cyst is a fluid-filled sac that develops as a result of
degeneration of the joints in the spine. Since it develops
as a result of the aging process, it is rarely seen in an
individual less than 45 years of age and is most commonly
seen in a person over the age of 65. The cyst causes
compression of the nerves in the spinal canal and this
causes the patient to experience symptoms of spinal
stenosis. Spinal stenosis is defined as narrowing of the
space for the spinal nerves.

33. Radiological imaging finding:
A synovial cyst is best visualized on an MRI scan of the spine. It
shows up as a bright signal on the T2 portion of the scan. It
often has the same appearance as the cerebrospinal fluid that
surrounds the nerves in your spinal canal.
Plain X-rays of the spine, including flexion/extension (bending)
X-rays of the spine, are also performed to rule out any
associated instability of the spine. It is very important to check
for spinal instability as the involved joint often has an
accompanying degenerative spondylolithesis. A spondylolithesis
is defined as a slippage of one vertebrae over another and it
indicates that the joint is unstable or incompetent.
CT Scan: Show hypo to hyperdense area compared to the
ligamentum flavum and these changes are associated with
facet joint degeneration.

34. Retrodental Cervical Synovial Cyst MRI.

36. Extradural arachnoid cyst.
CSF-filled outpouching of arachnoid that protrude through a
dural defect.
Spinal extradural arachnoid cysts are uncommon expanding
lesions. Idiopathic arachnoid cysts are not associated with
trauma or other inflammatory insults. If they enlarge, they
usually present with progressive signs and symptoms of neural
compression.
Spinal extradural arachnoid cysts are a rare cause of spinal
cord compression. These cysts most commonly occur in the
middle to lower thoracic spine (65%) but also have been
reported in the lumbar and lumbosacral (13%), thoracolumbar
(12%), sacral (7%), and cervical regions (3%). Cyst enlargement
can result in symptomatic spinal cord compression.

37. Radiological imaging finding:
MRI is considered the imaging study of choice in identifying
arachnoid cysts which appears CSF-equivalent extra-dural mass
that cause spinal cord compression. MRI provides better resolution
of tissue intensity, absence of bone interference, multiplanar
capabilities, and is noninvasive.
Plain films may show bony erosion of the spinal canal.
If MRI made with a contrast medium:
The signal in the cyst is the same as in the dural bag.
CT scan is another examination method often used for the
diagnosis of Tarlov cyst. Unenhanced CT scans may show widened
interpedicular distance, scalloping of vertebral bodies or pedicle
thinning and cystic masses that are have the same density with CSF.
CT Myelogram is minimally invasive, and could be employed when
MRI cannot be performed on patient.

38. Spinal extradural arachnoid cyst.

41. Spinal extradural arachnoid cyst

42. Primary Extradural Tumours and metastasis of the Spine.
Primary malignant tumour:
Chordoma.
Lymphoma.
Sarcoma.
Osteogenic sarcoma.
Chondrosarcoma.
Ewing sarcoma.
Plasmacytoma.
Multiple Myeloma.
Malignant Schwannoma.
Metastasis.

43. Chordoma
Chordoma is a rare slow-growing neoplasm thought to arise from
cellular remnants of the notochord. Grossly, locally invasive lobulated
gelatinous –appearing masses. Typically, arise in the midline of the
spinal column at any location from the clivus to the coccyx.
Radiographic features:
CT: Centrally located, well-circumscribed destructive lytic lesion,
sometimes with marginal sclerosis expansile soft-tissue mass (usually
hyper-attenuating relative to the adjacent brain, however inhomogeneous
areas may be seen due to cystic necrosis or hemorrhage; the soft-tissue
mass is often disproportionately large relative to the bony destruction)
MRI: T1 intermediate to low signal intensity, small foci of hyperintensity
(Intratumoral hemorrhage or a mucus pool).
T2: most exhibit very high signal.
T1 C+ (Gd): heterogeneous enhancement with a honeycomb appearance
corresponding to low T1 signal areas within the tumour.
GE (gradient echo): confirms hemorrhage if present with blooming.

44. Sacrococcygeal Chordoma.

45. Sacral
Chordoma.

46. Sacrococcygeal chordoma.

48. Lymphoma of the spinal cord:
Lymphoma of the spinal cord is an uncommon manifestation of lymphoma.
Although lymphoma more commonly involves the vertebral body (vertebral body
tumours) or epidural compartment, intramedullary lymphoma does rarely occur.
Radiographic features:
The most common intramedullary location is the cervical cord, followed by the
thoracic cord then the lumbar cord . Most are solitary lesions, however there may
be multiple lesions throughout the spinal cord.
MRI: Although spinal cord expansion is usually present, in some patients there is
relatively minimal enlargement of the cord. The lesions are generally poorly
defined and tumoural cysts are generally not a feature and secondary
syringomyelia is rare. Lymphoma usually does not have a hemorrhagic component
Reported signal characteristics include:
T1: isointense to spinal cord
T2: hyperintense (this is in contrast to the characteristic low T2 signal intensity
that is seen in intracranial lesions)
T1 C+ (Gd): usually solid and homogeneous enhancement.
CT: Non specific bone destruction and hyperostosis.

49. Lymphoma of the spine

50. Arrows point to lymphoma
causing epidural compression. Lymphoma of the spines.

51. Osteosarcoma:
Osteosarcomas are malignant bone forming tumours and the
second most common primary bone tumour after multiple
myeloma. They account for ~20% of all primary bone tumours.
primary osteosarcoma: typically occurs in young patients (10-
20 years) with 75% occurring before the age of 20; which is
logical because the growth centers of the bone are more active
during the puberty to adolescence time period. Therefore the
epidemiology can be easily understood. For less clear reasons,
there is a slight male predominance.
secondary osteosarcoma: occurs in the elderly, usually
secondary to malignant degeneration of Paget's disease,
extensive bone infarcts or post radiotherapy for other
conditions.

52. Radiographic features
Plain film: Conventional radiography continues to play an important role
in diagnosis. Typical appearances of conventional high grade
osteosarcoma include: medullary and cortical bone destruction wide zone
of transition, permeative or moth-eaten appearance aggressive periosteal
reaction, sunburst type .
CT: The role of CT is predominantly in assisting biopsy and staging, but
adds little to plain x-ray films.
MRI:
T1: soft tissue non-mineralized component: intermediate signal intensity
mineralized/ossified components: low signal intensity, peri-tumoural
edema: intermediate signal intensity scattered regions of hemorrhage
will have variable signal (see ageing blood on MRI) enhancement:
solid components enhance
T2: soft tissue non-mineralized component: high signal intensity
mineralized/ossified components: low signal intensity peri-tumoural
edema: high signal intensity.

53. Telangiectatic osteosarcoma.

54. Osteosarcoma of the Spine:

55. osteosarcoma of the sacrum.

56. Chondrosarcoma.
Chondrosarcoma is a malignant tumor that produces
cartilage matrix. Primary chondrosarcoma is very uncommon,
arises centrally in the bone, and is found in children. Secondary
chondrosarcoma arises from benign cartilage defects such as
osteochondroma or enchondroma.
Imaging show lytic lesions with sclerotic and variable matrix
calcification occurring in rings and arc.
CT scanning may be useful for detecting subtle calcifications
in the matrix when the diagnosis is in doubt.
MRI: The investigation of choice for assessing the extent of a
chondrosarcoma Helps delineate the extent of soft-tissue
involvement Important for preoperative planning and for
confirming or diagnosing recurrence at a surgically treated site

57. Chondrosarcoma
along the left
posterior
paraspinal
location.

58. Spinal Chondrosarcoma.

59. Chondrosarcoma of the lower cervical spine.

60. Plasmacytoma and multiple myeloma.
Multiple myeloma is the most common primary
malignant bone neoplasm in adults, and results in a wide
range of radiographic abnormalities.
Four main patterns are recognised:
disseminated form: multiple defined lesions:
predominantly affecting the axial skeleton
disseminated form: diffuse skeletal osteopenia
solitary plasmacytoma: single large/expansile lesion most
commonly in a vertebral body or in the pelvis
osteosclerosing myeloma.
The spine is the most common location.

61. Radiographic features:
X-Ray Films: The vast majority of lesions are purely lytic,
sharply defined/punched out with endosteal scalloping when
abutting cortex. In only 3% of patients are the lesions sclerotic.
CT: CT does not have a great role in the diagnosis of
disseminated multiple myeloma, however it may be useful to
determine the extent of extra-osseous soft tissue component in
patients with a large disease burden.
MRI: MRI is generally more sensitive in detecting multiple
lesions compared to the standard plain film skeletal survey.
Infiltration and replacement of bone marrow is exquisitely
visualized, and newer scanners are able to perform whole body
scans for this purpose which has been shown to be superior to
both CT and skeletal surveys.

62. Multiple myeloma.

63. Two cases of multiple myeloma.

64. Spinal metastases:
Spinal metastases is by far the most common extra-dural
malignant neoplasm. Metastatic disease have any of the
following:
vertebral metastases (94%)
may have epidural extension
intradural extramedullary metastases(5%)
intramedually metastases (1%).
In adults, the initial site is the vertebral body, usually the
posterior aspect.
Most metastasis arises from the, breast: 22%, lung: 15%,
prostate: 10%, lymphoma: 10%, kidney: 7%, gastrointestinal
tract: 5%, melanoma: 4%, unknown: 4%, others: 24%.

65. Radiographic features.
Plain radiography is used to show erosion of the pedicles or the
vertebral body. Owl-eye erosion of the pedicles in the
anteroposterior (AP) view of lumbar spine is characteristic of
metastatic disease and is observed in 90% of symptomatic patients.
However, radiologic findings become apparent only when bone
destruction reaches 30-50%. Osteoblastic or osteosclerotic changes
are common in prostate cancer and Hodgkin disease; they are
occasionally seen in breast cancer and lymphoma.
CT scanning is useful in determining the integrity of the vertebral
column.
MRI- Is very sensitive in detecting vertebral metastasis. The most
common pattern is multifocal lytic lesions characterized by low
signal at the T1WI and of high signal at the T2WI.
Scintigraphy- Very sensitive although non-specific in detecting bone
metastasis.

66. Spine metastasis.

67. Spinal metastases.

68. C2 metastasis in a 60-year-old male patient with renal cell carcinoma.

69. Intradural extramedullary spinal tumours.
Intradural extramedullary neoplasms are located outside the spinal cord
but within the dural sheath.
Schwannomas are the most common intradural extramedullary spinal
lesions (30% cases), followed by meningiomas (25% cases).
In the pediatric population, the most common intradural extramedullary
neoplasms are leptomeningeal metastases resulting from primary brain
tumours.
Benign tumours: spinal schwannoma, spinal meningioma, spinal
neurofibroma spinal paraganglioma and myxopapillary
ependymoma
Cysts and other benign tumourlike masses:
spinal lipoma, intradural spinal lipoma, spinal epidermoid cyst,
spinal dermoid cyst spinal neurenteric cyst and spinal arachnoid
cyst.
Malignant tumours:
spinal leptomeningeal metastases.

70. Spinal schwannoma and neurofibroma:
Spinal schwannomas are schwannomas arising from nerves within the spinal
canal. They are the most common intradural extramedullary spinal tumours,
representing 30% of such lesions. They are most frequently seen in the
cervical and lumbar regions, far more frequently than in the thoracic spine.
In general schwannomas appear as rounded lesions, often with
associated adjacent bony remodelling. when large they may either
align themselves with the long axis of the cord, forming sausage
shaped masses which can extend over several levels, or may protrude
out of the neural exit foramen, forming a dumb-bell shaped mass.
Plain X-Ray film: Show erosions of the pedicle with enlarged neural
foramina.
CT Scan: Shows bone erosion, and the density is hypo to slightly
hyperdense.
MRI: T1 - 75% are isointense, 25% are hypointense.
T2 - more than 95% are hyperintense, often with mixed signal.
T1 C+ (Gd) - virtually 100% enhance.

71. Spinal schwannoma.

72. Cervical Spinal schwannoma.

73. Spinal neurofibroma.

74. Spinal neurofibroma.

75. Spinal meningioma.
Meningiomas arising from the coverings of the spinal cord
represent a minority of all meningiomas (approximately 12%5)
but are the second most common intradural extramedullary
spinal tumour representing 25% of all such tumours. Despite
usually being small, due to the confines of the spinal canal they
can result in significant neurologic dysfunction.
spinal meningiomas are also not distributed evenly along the
canal: cervical spine - 15%
thoracic spine - 80%
lumbosacral spine: uncommon.
Meningiomas are often located posterolaterally in the
thoracic region and anteriorly in the cervical region.
Most meningiomas are solitary lesions (98%). Multiple
meningiomas are most often associated with NF2.

76. Radiographic features.
Plain film: usually normal, rarely bone erosion or calcification
CT (non-contrast)
Isodense or moderately hyperdense mass hyperostosis may be seen
but is not as common as in the intracranial forms.
calcification may be present
MRI: well-circumscribed, broad-based dural attachment dural tail
signs
They share similar signal characteristics to intracranial meningiomas:
T1
isointense to slightly hypointense.
may have a heterogenous texture.
T2 - isointense to slightly hyperintense.
T1 C+ (Gd) - moderate homogeneous enhancement.
Occasionally, densely calcified meningiomas are hypointense on T1
and T2, and show only minimal contrast enhancement.

77. Spinal meningioma.

78. Upper cervical spinal meningioma.

79. Spinal paraganglioma.

80. Spinal myxopapillary ependymoma.

81. Intradural spinal lipoma.

82. Spinal epidermoid cyst.
Spinal epidermoid cysts are cystic tumours lined by squamous
epithelium. Unlike dermoid cysts, they do not contain skin appendages
(hair follicles, sweat glands, sebaceous glands).
They are usually extramedullary but rarely can be intramedullary . They
may be congenital or acquired.
Plain film: In advanced cases, there may be scalloping of the vertebral
bodies or a scoliosis.
CT: well circumscribed mass hypodense (similar to CSF), minimal to no
enhancement calcification is rare
MRI: well-defined lesion, generally no perilesional edema,
Although variable, typical signal characteristics include:
T1: hypointentse (similar to CSF)
T2: hyperintense (similar to CSF)
FLAIR: hyperintense compared to CSF
T1 C+ (Gd): no enhancement or a thin rim of capsular enhancement
DWI: bright (with corresponding low intensity on ADC map).

84. Spinal dermoid cyst.
Spinal dermoid cysts are uni or multilocular cystic tumours lined by squamous
epithelium containing skin appendages (hair follicles, sweat glands, sebaceous
glands) . They are congenital in origin.
Forty percent are intramedullary, and 60% are extramedullary .
Radiographic features: Spinal dermoid cysts are most often located in the lumbosacral
region (60%) and cauda equina (20%) . They are rarely found in the cervical or thoracic
spine. They have variable imaging appearances, but commonly appear as a mass of CSF
density/intensity with fat density/intensity components .
CT: well defined mass, isodense to CSF, often with hypodense components (fat)
calcification may be present minimal enhancement may be demonstrated widening of the
spinal canal, flattening of the pedicles and laminae and osseous erosions may be
demonstrated
MRI: Signal intensity may be homogeneous or heterogeneous. Typical signal characteristics
include:
T1: hypo or hyperintense
hypointense: water content
hyperintense: due to the presence of fatty secretions of sebaceous glands
T2: hyperintense
FLAIR: hyperintense compared to surrounding CSF
T1 C+ (Gd): no enhancement or mild rim enhancement
DWI: less likely to show diffusion restriction than epidermoid.

85. Spinal dermoid cyst.

86. Spinal arachnoid cyst:
Spinal arachnoid cysts are relatively uncommon and may be either intra-dural
(type III meningeal cyst) or extra-dural (type IA meningeal cyst).
Radiographic features
General: Most primary intradural spinal arachnoid cysts are dorsal to the
cord.
They occur at the following locations:
thoracic: 80%, cervical: 15%, lumbar: 5%
Secondary spinal arachnoid cysts can be located anywhere.
MRI: As the cysts follow the intensity of CSF and their walls are generally
not visible, they may not be identified unless the cord is displaced.
T1: CSF intensity
T2: CSF intensity, may even be brighter than CSF on account of no signal
loss from pulsation/flow
T1 C+ (Gd): no contrast enhancement
phase-contrast imaging: decreased CSF flow within the cyst.
DWI: No evidence of restricted diffusion

87. Intra-dural Spinal arachnoid cyst.

88. Intra-dural Spinal arachnoid cyst.

89. Intradural lymphoma.

90. Intradural extramedullary metastases:
Intradural extramedullary metastases are rare and only accounts for
approximately 5% of spinal metastases. Presentation is highly variable. As the
most commonly affected site is the lumbosacral spine symptoms and signs include
back or radicular pain, weakness, paresthesia, gait disturbance, cauda equina
syndrome and symptoms/signs of meningeal irritation.
Radiographic features:
Plain films and CT are inadequate for the assessment of possible leptomeningeal
metastatic disease, and in these cases, MRI is required.
MRI
MRI without contrast may be normal, and thus when suspected contrast should be
administered. Typical signal characteristics include:
T1: thickened nerve roots or nodular lesions that are isointense with the spinal
cord may be seen.
T2: cord edema may be seen with more extensive disease, especially if there is an
intramedullary component.
T1 C+ (Gd)
enhancing tumour nodules on the spinal cord, nerve roots or cauda equina.
“sugar coating” of the spinal cord and nerve roots.

91. Multiple intramedullary extradural spinal cord metastases.

92. Multiple intramedullary extramedullary spinal cord metastases.

93. Intramedullary spinal tumours.
Intramedullary spinal tumours are rare, representing 4-10% of all CNS tumours.
They account for 20% of all intraspinal tumours in adults and 35% of all intraspinal
tumours in children .
Classification: They can be classified according to many ways:
intramedullary neoplastic lesion:
glial neoplasms: 90-95% of all intramedullary tumours
spinal ependymoma: 60% of all glial spinal cord tumours
spinal astrocytoma: 33% of all glial spinal cord tumours
spinal ganglioglioma: 1% of all glial spinal cord tumours
non-glial neoplasms:
highly vascular lesions
spinal hemangioblastoma and spinal paraganglioma
other rare lesions
intramedullary metastasis
primary lymphoma of the spinal cord
spinal primitive neuroectodermal tumour
solitary fibrous tumour
intramedullary benign masses: Syringohydromyelia, MS , transverse myelitis
arachnoid and ependymal cyst.

94. Syringohydromyelia.
Syringohydromyelia refer to any pathologic CSF-containing cord
cavity and can mimic spinal cord tumour.
Imaging shows focal or diffuse cord expansion.
CT Scan: Show distinct area of low density within the cord
without enhancement at the post-contrast study.
MRI: Cystic area within the cord which appears of low signal at
the T1WI and of bright signal at the T2WI. No enhancement seen
within the lesion at post-contrast study.

95. Two cases of Syringohydromyelia.

96. Multiple sclerosis.
Spinal cord may be the earliest affected by MS
plaques.
Plaques occur preferentially in the dorsolateral cord
and do not respect boundaries between grey and
white matter.
More predominant on the female.
Early there is a predilection for the cervical cord.
MRI: The most common finding on T2WI of one or
more elongated, poorly marginated, hyperintense
intramedullary lesions. The foci may has mass effect
and enhance at the post-contrast study. Focal or
generalized mild cord atrophy may be present.

97. Multiple Sclerosis.

98. Multiple Sclerosis with disease activity.

99. Transverse Myelitis (TM).)
Focal inflammatory disorder of the spinal cord resulting in
motor, sensory and autonomic dysfunction.
Imaging findings:
More than 2/3 of the cross sectional area is involved.
Focal enlargement.
T2WI hyperintensity
Enhancement + / -
Two forms of TM:
Acute partial transverse myelitis - APTM
Lesions extending less than two Segments.
These patients are at risk of developing MS.
Acute complete transverse myelitis - ACTM
Lesions extending more than two Segments

100. ATM on T2WI, CE-T1WI and STIR.

101. Spinal Intramedullary Neuroepithelial (Ependymal) Cyst.

102. cystic intramedullary arachnoid cyst.

104. Spinal ependymoma.
Spinal ependymomas are the most common intramedullary neoplasm in
adults, comprising 60% of all glial spinal cord tumours. They are the
second most common intramedullary neoplasm in the pediatric
population, representing 30% of pediatric intramedullary spinal
neoplasms.
Peak incidence is in the fourth decade, with 39 years being the mean age
at presentation. Males are more commonly affected than females.
There is an increased incidence with neurofibromatosis type 2. 6
histological subtypes are recognised:
cellular (the most common intramedullary type).
Papillary.
clear cell.
Tanycytic.
Myxopapillary.
virtually always located along the filum terminale with occasional
extension into the conus medullaris
melanotic (the least common type).

105. Radiographic features:
CT:
CT may demonstrate non-specific canal widening
isodense or slightly hyperdense compared with normal spinal cord
intense enhancement with iodinated contrast.
MRI: Typical signal characteristics:
T1: most are isointense to hypointense; mixed signal lesions are seen
if cyst formation, tumour necrosis or hemorrhage has occurred
T2: hyperintense
peritumoural edema is seen in 60% of cases
associated hemorrhage leads to the “cap signs” (a hypointense
hemosiderin rim on T2 weighed images) in 20-33% of cases. The
cap sign is suggestive of but not pathognomonic for ependymoma
as it may also be seen in hemangioblastomas & paragangliomas.
T1 C+ (Gd): virtually all enhance strongly, somewhat
inhomogeneously.

106. An ependymoma of the cervical spine on MRI T2 image (left) and
T1 with contrast (right). Note the associated syrinx seen on T2,
contrast enhancing mass on T1, and overall expansion of the cord.

107. Large filum terminalis
ependymoma (arrows).
Intramedullary cervical
ependymoma (red arrows).

108. Spinal astrocytoma.
Spinal astrocytomas are the second most common spinal cord
tumour overall, representing 40% of intramedullary tumours . They
account for 60% of pediatric intramedullary tumours, making them
the most common spinal cord tumour in children Spinal cord
astrocytomas generally have a lower histologic grade than
astrocytomas in the brain. In adults, 75% are low-grade neoplasms.
Up to 25% are anaplastic astrocytomas. Glioblastoma multiforme
represent only 0.2-1.5% of spinal cord astrocytomas. In children
younger than 3, 80% are either grade I or II. All astrocytomas are
characterised by hypercellularity and the absence of a surrounding
capsule. In contrast to cord ependymomas, a cleavage plane is not
present in most intramedullary spinal astrocytomas. Most common
at cervical cord. High grade tumours are more likely to demonstrate
extensive leptomeningeal spread seen in up to 60% of spinal cord
glioblastomas.

109. A fibrillary astrocytoma of the cervical spine on T2 (left)
and T1 with contrast (right). Note the indistinct cord
edema, expansion and partial contrast enhancement

110. Spinal astrocytoma.

111. Spinal ganglioglioma are rare, comprising 1.1% of
all spinal cord neoplasms . They are more frequent
in children, representing 15% of intramedullary
neoplasms in the pediatric age group.

112. Spinal hemangioblastoma.
Spinal hemangioblastomas are the third most common intramedullary
spinal neoplasm, representing 2-6% of all intramedullary tumours.
Angiography: A densely enhancing nidus with associated dilated arteries and
prominent draining veins is characteristic for a hemangioblastoma.
CT: On non-contrast CT They may be seen as a soft tissue nodule often with a
prominent hypodense cyst-like component. Contrast administration results in vivid
enhancement of the solid component.
MRI: Although they usually appear as discrete nodules, there can be diffuse cord
expansion. An associated tumour cyst or syrinx is common (50-100%) .
T1: variable relative to normal spinal cord.
hypo-isointense most common, and difficult to identify
hyperintense (25%)
T2: iso-hyperintense
focal flow voids especially in larger lesions
surrounding edema and associated syrinx are usually seen
hemosiderin capping may be present
T1 C+ (Gd): the tumour nodule enhances vividly.

113. A hemangioblastoma of the thoracic spine on T1 with contrast in sagittal (left) and
axial sections (right). Note the enhancing tumour nodule with associated cyst.

114. Spinal cord hemangioblastoma is seen at L1-2 (arrowed).

115. Lymphoma of the spinal cord.
Lymphoma of the spinal cord is an uncommon manifestation of lymphoma.
Radiographic features
The most common intramedullary location is the cervical cord, followed
by the thoracic cord then the lumbar cord . Most are solitary lesions,
however there may be multiple lesions throughout the spinal cord.
MRI:
Although spinal cord expansion is usually present, in some patients there
is relatively minimal enlargement of the cord. The lesions are generally
poorly defined and tumoural cysts are generally not a feature and
secondary syringomyelia is rare. Lymphoma usually does not have a
hemorrhagic component .
Reported signal characteristics include:
T1: isointense to spinal cord
T2: hyperintense (this is in contrast to the characteristic low T2 signal
intensity that is seen in intracranial lesions)
T1 C+ (Gd): usually solid and homogeneous enhancement

116. Primary intramedullary spinal cord lymphoma.

117. Intramedullary spinal metastasis.
Intramedullary spinal metastases are rare, occurring in 0.9-2.1% of
autopsied cancer patients. They represent 8.5% of central nervous system
metastases and account for 5% of all intramedullary lesions. They are less
common than leptomeningeal metastases.
Radiographic features:
CT (contrast enhanced)
Hypervascular metastases may rarely be seen as enhancing intraspinal
lesions.
MRI
Lesions are usually well-defined and typically produce cord expansion over
several segments. In contrast to primary intramedullary neoplasms,
associated cysts are rare.
Typical MRI signal characteristics are:
T1: hypointense
T2: hyperintense
prominent edema commonly surrounds the tumour nodule
T1 C+ (Gd): avid homogeneous enhancement.

118. Intramedullary spinal metastasis.

119. Intramedullary spinal metastasis.

120. Thank You.