Spinal Tumors

1. Spinal Tumors
Dina Feras Haddad

2. Anatomy review:
• Spinal cord:
-Extends from foramen magnum to L1/L2 in adults, and
≈L3/L4 in pediatrics.
- In tapers off into the conus medullaris.
- From the apex of the conus a prolongation of the pia
matter (filum terminale) descends to be attached to
the back of the coccyx.

4. • Denticulate ligaments: Thin extensions of the
pia matter attach to the dura, which help
centralize and suspend the cord in the middle
of the canal.

5. -The spinal cord, like the brain, is surrounded by three
meninges, dura, arachnoid, and pia.

6. -The Dura (most external part), encloses spinal cord and cauda
equina, it extends inferiorly and ends at the lower border of S2
at the filum terminale.

7. -The dura is separated from the walls of the
canal by the epidural/extradural space. (contains
loose tissue and internal vertebral venous
plexus)

8. -The Arachnoid is separated from pia by the subarachnoid space,
which contains the CSF.
- Pia: closely related to the spine.
- arachnoid + pia  leptomeninges

9. Blood supply:
• Arises from the vertebral arteries:
-Two posterior arteries
-One anterior
-Radicular arteries reinforce the cervical region’s blood supply at
C3,C6,C8
-Artery of Adamkiewicz most commonly supplies the area
between T8-L1
-this leaves the area around T4/T5 were the blood supply is a
little less (watershed Area), more prone to vascular insult, and
tumor formation.

11. Spinal Tumors
• Most primary spinal tumors are benign
• Most common spinal tumors in general are mets
from other areas. (secondary/extradural)
• Most present with compression rather than
invasion
• Classification:
• Extradural (55%): arise outside the cord, in
vertebral bodies or epidural tissue.
• Intradural extramedullary (40%): in
leptomeninges or roots
• Intramedullary tumors (5%): in spinal cord itself

15. Presentation:
• Since spinal tumors’ primary effects are a result of
compression, therefor the presentation in all typs is
similar:
- Pain  most common complaint,
- Nocturnal pain is characteristic
(a differential diagnosis could be herniated disc, however,
pain from disc is usually worse during day with activity,
and gets better with rest, while tumor pain might be
absent during the day, and gets worse at night
- increase with Valsalva maneuver
(local, radicular, medullary)

16. • Sensory disturbance
• Motor disturbances
• Sphincter disturbance (retention
(especially conus lipomas early presentation)

17. Diagnosis:
• X-ray:
- vertebral body destruction
- enlarged intraventricular foramina (dumbbell)
- increase in interpeduncular distances
• MRI (most imp)
• Bone scans

18. Extradural spinal tumors:
• Majority are mets
• Most are osteolytic
• Confined, don’t exceed the disk space (due to
lack of blood supply in discs, differentiates it
from infections)
• Most common site thoracic region
• Most Common Presentation  Pathological
Fracture
-Lung
-Breast
Prostate
Lymphoma

19. Case:
• A 52-year old woman has constant, severe back pain for 2
weeks. While working in her yard, she suddenly fell and
couldn’t get up again, when brought to the hospital she was
paralyzed below the waist. Two years ago she had a
mastectomy for cancer of the breast.
Diagnosis: spinal extradural metastatic tumor
Management: xray shows bony mets and the pathological
fracture
MRI  shows the state of the cord, compressed or transected
If compressed we perform an urgent decompression
If transected surgery could be delayed since the cord isn’t
salvageable, and the goal is fixation only

21. Notice the multiple affected vertebrae with intact discs
in-between

22. Notice how
in extradural
tumors, the
CSF is
tapered
(gradually
narrowed)

23. Intradural extramedullary tumors:
Spinal Meningioma:
• 40-70 years
• More in females
• Chronic, slow growing, erode bone and compress
the cord
• Base attached to dura give the appearance of
dural tail on MRI
• Typical patient: elderly lady with back pain over
years with progressive weakness and sensory
defects over the past months

24. Notice how in extramedullary tumors, csf is wide
(not tapered) above and below the tumor

25. Dural tail:

26. Drop mets:
• Spinal mets that arise from intracranial
regions and travel with csf towards the spine.
• That’s why in those brain tumors we should
always check the spine as well.
• Could occur with posterior fossa tumors such
as medulloblastomas and ependymomas.

27. All yellow arrows are pointing towards multiple
small drop mets

28. Neural sheath tumors:
• Compress nerve roots
• Neurofibroma: infiltrates, multiple, associated
with NF1
• Shwannomma : no internal extension, not
radiosensitive, solitary, associated with NF2
• Most are intradural but rarely it could occur
extradurally

29. Intramedullary:
• Astrocytoma:
-most common intramedullary tumor in
pediatrics
–more on thoracis region
-more in males
-less enhancing that ependymoma

30. Ependymoma:
• Most common primary tumor of the spinal
cord (glioma)
• More in adults/middle-aged, more in males
• Most in conus and filum terminale
(myxopapillary type)
• Usually encapsulated and minimally vascular
(sausage-like)

32. Hemangioblastoma
• Benign, uncommon
• Not encapsulated
• Associated with polycythemia