Vertebral Column Tumors Primary tumors: These tumors occur in the vertebral column, and grow either from the bone or disc elements of the spine. They typically occur in younger adults. Osteogenic sarcoma (osteosarcoma) is the most common malignant bone tumor. Most primary spinal tumors are quite rare and usually grow slowly. Metastatic tumors: Most often, spinal tumors metastasize (spread) from cancer in another area of the body , These tumors usually produce pain that does not get better with rest, may be worse at night, and is often accompanied by other signs of serious illness (such as weight loss, fever/chills/shakes, nausea or vomiting).

1. Dr.SAYF ALDEEN HUSSAM
ORTHOPEDIC DEPARTMENT
BAGHDAD MEDICAL CITY

2. Prevalence and
characteristics
■Of all primary benign bone tumors, 8% occur in
the spine or sacrum.
■Benign primary tumors most commonly occur
during first 3 decades of life
■Spine metastasis most often occur in patients
older than 40
■Benign tumors most frequently involve the
posterior elements, but malignant tumors have a
predilection for the vertebral bodies.

3. Prevalence and
characteristics
■ Most common symptom of a spine tumor is pain,
which occurs in 76% of benign and 95% of malignant
tumors.
■ Carcinomas of the breast, prostate, kidney, and
thyroid gland account for 80% of all skeletal
metastasis, with the spine as the most common
site.
■ Malignant tumors occur more frequently in the lower
(lumbar > thoracic > cervical) spinal levels

4. classification of sPinal tumors
Primary: benign & malignant
Metastatic: The most common tumour of the
spine is metastatic

6. Back Pain with following
characteristics :should Be
considered susPicious
1-Prolonged back pain
2-Slow and insidious onset (with or
without trauma)
3-Does not improve with rest
4-Wakes the patient from a sleep

7. evaluation 1
■Presence of a vertebral fracture after a relatively
minor trauma.
■Recent-onset of back pain in a patient with
previous malignancy should be considered a
recurrence or metastasis.
■History of exposure to potential carcinogenic
agent.

8. evaluation 2
■A review of systems is important and should
focus on constitutional symptoms such as
weight loss, mood changes, and chronic fatigue
■Inspection of patient general posture, gait, and
balance, Palpation of the entire spine, and
Percussion of affected areas should be done.
■Assessment of range of motion of the spine.
■Careful neurologic examination of motor
strength, sensation, and tendon reflexes.

9. Diagnostic Work-up
Laboratory studies:
Laboratory testing is among the first step in the
evaluation of a patient with a suspected spine
tumor
F.B.C (Anemia, lymphoma, multiple Myeloma(●
Erythrocyte sedimentation rate (nonspecific(●
Renal function test (BUN, creatinine(●
●Serum Electrolytes

10. Parathyroid hormone●
Alkaline phosphatase (elevated in osteosarcoma(
●
●Urine protein electrophoresis (multiple myeloma,
solitary plasmacytoma(
Thyroid hormones (thyroid malignancy(●
Prostate specific antigen (prostate cancer(●
●Liver function test (gastrointestinal malignancy(

11. imaging stuDies
:Plain radiographs
The first step imaging for a suspected spine tumor is
plain radiographs
■A tumor is detectable on plain radiographs only if
30%to 40% of vertebral body is involved
■Extension of tumor into surrounding soft tissue may
appear as widening of paraspinal soft tissue
■Neoplasms in the vertebrae can present as osteolytic
osteoblastic or mixed

13. The most classic early sign of vertebral
involvement by malignant lesions is Lytic
destruction of pedicles with the (winkingowl
sign ) seen on an anteroposterior view

15. MRI show Progressive metastatic disease to the spine

16. Computed Tomography:
In general, CT is more reliable in demonstrating the
cortical outlines of bone
and calcification in comparison to MRI. It can better
show the extent of the tumor destruction

17. CT scan of the lumbar spine showing destruction of the right
pedicle, occur in aneurysmal bone cysts

19. :Radionuclide Studies
A technetium-99m bone scan is widely used in the
initial diagnosis and follow-up of bone tumors.
Technetium scans are sensitive to any area of
increased osteoid reaction to destructive
processes in bones
They can detect lesions as small as 2 mm, and as
little as a 5–15% alteration in local bone turnover.
They can identify changes in osteolytic or
osteoblastic disease 2–18 months sooner than
radiographs

20. Vertebral metastases in breast cancer

21. Biopsy
●Diagnosis of a tumor is not considered definitive
until a tissue sample obtained and histologically
evaluated
●Histologic type and grade of tumor can influence
treatment decision making

22. Biopsy methods include percutaneous needle biopsy,
open incisional biopsy, and open excisional biopsy.
CT guided biopsy

23. staging

25. treatment
Non-operative Treatment
For benign lesions, there are only rare indications for non-
operative treatment, such as hemangioma or Langerhans
cell histiocytosis.
For malignant lesions, non-surgical treatment generally is
an adjunct to surgery and consists of:
pain management: like NSAIDs ,Opioid drugs , epidural
and intrathecal administration of local anesthesia
chemotherapy
Radiotherapy

26. operative Treatment:
the ultimate goal must be a “wide” and preferably an en
bloc resection of the primary tumor in combination with a
spinal reconstruction which allows for early mobilization.
The surgical techniques are classified by the tissue planes
and approach as:
curettage
intralesional resection: is only used for benign tumors or
for debulking of inoperable primary or metastatic lesions.
en bloc resection

27. Curettage and intralesional resection describe a
gradual removal of the tumor.
En bloc resection indicates the attempt to remove
the whole tumor in one piece together with a
layer of normal tissue.

28. En bloc resection pathological specimen is
histologically analyzed, and further classified into:
1-intralesional
2-marginal
3-wide
The term “intralesional” is used when the tumor mass
is violated; marginal is appropriate when the surgeon
dissects along the pseudocapsule,
and “wide” is appropriate if surgical separation has
occurred outside the pseudocapsule,

29. Surgical treatment indicationS
spinal instability due to bony destruction
progressive neurologic deficit
radioresistant tumor that is growing
the need for open biopsy
intractable pain unresponsive to non-surgical treatment