脊髓內轉移癌

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脊髓內轉移癌

  1. 1. 單元十二:脊椎脊髓系統 王駿瑋醫師 Intramedullary Spinal Cord Tumors APRIL 2| MONDAY 2012 Speaker: 林品慶 1
  2. 2. Spinal cord anatomy - meninges Protective Sheath  Duramater  Arachnoid  Piamater Potential Space  Subdural Space • Located between the Dura & Arachnoid  Subarachnoid Space • The CSF flows between the Arachnoid & Piamater in the space. 2
  3. 3. Spinal cord anatomy Begins  Foramen Magnum as a continuation of the Medulla Oblongata Terminates  Conus Medullaris • Adult: Lower Border of L1 • Young child: Upper Border of L3 Filum Terminale  Prolongation of the piamater  Attaches to the spinal cord at the coccyx Dural sac  Ends at the level of the second sacral vertebra 3
  4. 4. Spinal cord anatomy Gray Matter  Ventral Horns  Dorsal Horns White Matter  Anterior Columns  Lateral Columns  Posterior Columns 4
  5. 5. Spinal cord anatomy 31 pairs of spinal nerves (Each formed by 2 roots) The spinal nerves exit through the intervertebral foramen  8 cervical • 1st exits through the occipital bone and C1 • 8th exits between C7 & T1  12 thoracic • Distal to T1 each spinal nerve exits below its corresponding vertebra  5 lumbar  5 sacral  1coccygeal 5
  6. 6. Motor impairment related to Spinal Cord Injury 6
  7. 7. Dermatome 7
  8. 8. Spinal cord cross section: Fiber tracts 8
  9. 9. Spinal cord anatomy: Vasculature Upper Cervical Spine  Vertebral artery: • One anterior spinal artery • Two posterior spinal arteries 9
  10. 10. Spinal cord anatomy: Vasculature Lower Third of C- Spine  Anterior segmental medullary (radicular) arteries: • Vertebral artery • Ascending cervical artery • Deep cervical artery 10
  11. 11. Spinal cord anatomy: Vasculature1. Post. Spinal vein2. Ant. Spinal vein3. Posterolateral spinal vein4. Radicular (or segmental medullary) vein5. Post. Spinal arteries6. Ant. Spinal artery 117. Radicular (or segmental medullary) artery
  12. 12. Spinal cord anatomy: Vasculature Below C-Spine  Continuous anastomoses with the radicular arteries. • Aorta • Intercostal arteries • Spinal arteries • Ant. & post. Radicular arteries 12
  13. 13. Spinal cord anatomy: Vasculature Thoracic/Lumbar Spine  Anterior segmental arteries alternate sides of cord  Artery of Adamkiewicz • Major blood supply to lower thoracic & lumbar spine • Arises on the left ~78% • Enters single intervertebral foramen between T8 & L3 13
  14. 14. Spinal cord anatomy: Vasculature Batson’s plexus:"In brief, the vertebral veins area valveless plexiform networkwith a longitudinal pattern.They parallel and communicatewith the superior and inferiorvenae cavae. The plexus extendsthe entire length of the vertebralcolumn and finds a cranialterminus in the duralsinuses.“Batson Multiple anastomoses with:  Azygous system  IVC  Pelvic plexus  Prostatic plexus 14
  15. 15. Spinal cord anatomy: Vasculature Batson’s plexus:"In brief, the vertebral veins area valveless plexiform networkwith a longitudinal pattern.They parallel and communicatewith the superior and inferiorvenae cavae. The plexus extendsthe entire length of the vertebralcolumn and finds a cranialterminus in the duralsinuses.“Batson Multiple anastomoses with:  Azygous system  IVC  Pelvic plexus  Prostatic plexus 15
  16. 16. Classification of spinal cord lesions Extradural  Outside the thecal sac (including vertebral bone lesions) Intradural/extramedullary  Within thecal sac, but outside the cord Intramedullary  Within cord 16
  17. 17. Classification of spinal cord lesions 4-6% of pediatric CNS Neoplasms Astrocytomas  60% of all pediatric IMSCTs  10-15% are High Grade Ependymomas Miscellaneous  Teratomas  Dermoid  Epidermoid cysts  Oligodendrogliomas  Schwannomas  Neurofibromas  Neurocytomas  Metastases 17
  18. 18. Presentation Low grade  High grade  Asymptomatic  Symptoms to diagnosis  Subtle presentation • 7 weeks to 4 months  Symptoms to diagnosis • 9.2 months 18
  19. 19. Presentation Back or neck pain  Dysesthesias  Dull  20%  Aching  Usually asymmetrical in glial  Diffuse tumors  Referable to spinal axis involved  Sphincter dysfunction  Worse at night  Bowel/bladder dysfunction is • Venous congestion & dural rare unless late in clinical course distension caused by  Exception: conus medullaris recumbent position lesions • Meningeal irritation  Motor Weakness  Delar in milestones Paraesthesias  Motor regression Spinal deformity  Gait abnormality Slow neurologic deterioration  Frequent falls 19
  20. 20. Kyphoscoliosis 20
  21. 21. Torticollis 21
  22. 22. Hydrocephalus Associated with 15% of children with IMSCTs  Substantially higher in patients with malignant IMSCTs (35%) • Increase concentration of protein in the CSF • Arachnoidal fibrosis • Subarachnoid dissemination • 4thventricle outlet obtruction 22
  23. 23. Work-up MRI  With and with gadolinium Plain radiographs  Scoliosis  Post-op deformity CT  Bony involvement is rare  Only obtained to follow spinal deformity or if MRI is contraindicates 23
  24. 24. Intramedullary Spinal Cord Metastases 3-5% of cases of myelopathy in patients affected by cancer Found 0.9-2% of cancer patients at autopsy 3.4% symptomatic metastic spinal cord lesions Primaries:  Small cell lung cancer  Breast cancer  Malignent melanoma  Lymphoma  Colon cancer  Rarely present initially with intramedullary spinal metastases 24
  25. 25. Intramedullary Spinal Cord Metastases: clinical presentation Early in the course  Later in the course  Local back pain  Transverse myelopathy  Radicular or referred pain in a  Brown-sequard syndrome limb  Ascending myelopathy or  Aggravation of pain with descending myelopathy • Cough  Signs of leptomeningeal • Straining of stool metastases • Deep inspiration • Straight leg raise  Vertebral percussion tenderness • Dorsal horn  Weakness in one arm or leg • Medical portion of the lateral column or in the ventral horn. 25
  26. 26. Intramedullary Spinal Cord Metastases 26
  27. 27. Intramedullary Spinal Cord Metastases 27
  28. 28. Intramedullary Spinal Cord Metastases 28
  29. 29. Intramedullary Spinal Cord Metastases 29
  30. 30. Prognosis & Complication Median survival with intramedullary spinal cord metastases 7 months (Range 2 weeks to 2 years) Favorable prognostic factors  Breast > Lung  Surgery > Radiation Cause of death is usually widespread systemic and CNS metastatic disease 30
  31. 31. Management Radiation therapy  Stabilization of spinal cord function  Not short-lived Lasts for as long as the patient survives Response to therapy depends on extent & duration of neurological deficit and less on radiosensitivity of the tumor 31
  32. 32. Thanks for your attention 32

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