Spinal tumor

1. Spinal tumor

2. CLASSIFICATION OF SPINAL TUMOR
The classification is based on the anatomic location
Intramedullary Extramedullary Intradural Extradural
Spinal cord Dura ,
Arachnoid,
Nerve sheath
Bone, Discs
Paraspinal soft
tissues

3. INTRADURAL(40%) EXTRADURAL(60%)mc
INTRAMEDULLARY
Adults(4-10%)
Children(35%) mc
EXTRAMEDULLARY
(20-30%)2nd mc
METASTASIS(90%)
mc
PRIMARY
VERTEBRAL
TUMOR(10%)
90% GLIOMA
EPENDYMOMA(60%)
ASTROCYTOMA(30%)
HEMANGIOBLASTOMA
GANGLIOGLIOMA
LYMPHOMA
METASTASIS
MENINGIOMA(50%)
PERIPHERAL NERVE SHAETH
TUMOR (50%)
SCHWANOMA
NEUROFIBROMA
METASTASIS

4. PRIMARY VERTEBRAL TUMOR
BENIGN LOCALLY AGGRESSIVE MALIGNANT
HEMANGIOMA
OSTEOID OSTEOMA
OSTEOBLASTOMA
ANEURYSMAL BONE CYST
EOSINOPHILIC GRANULOMA
CHORDOMA
GCT
MULTIPLE MYELOMA
PLASMACYTOMA
CHONDROSARCOMA
EWING SARCOMA
OSTEOSARCOMA

5. CLINICAL PRESENTATION
SIGNS INTRAMEDULLARY EXTRAMEDULLARY
Radicular Pain unusal common
Vertebral pain unusal common
Funicular pain common Less common
UMN Sign late early
LMN Sign Diffuse Unusal , Segmental
Sensory inv Descending Ascending
Sphincter Early Late

6. INVESTIGATIONS
Plain radiographs : First imaging study in evaluation of
patients presenting with back pain
CT :evaluation of cortical bone destructions & calcifications
MRI : imaging technique of choice
 d/t better evaluation of spinal cord & nerve roots
 lesion extension
 specific imaging features

7. INTRAMEDULLARY TUMOR
EPENDYMOMA(CENTRAL)
ASTROCYTOMA
(ECCENTRIC)
HEMANGIOBLASTOMA
(DORSAL SUBPIAL)

8. EPENDYMOMA
 MC in adults
 2nd MC in children
Peak incidence 4th -5th decade
Male >Female
Increase incidence with NF2
Location – MC Cervical >Upper thoracic>Conus
Epidemiology
Pathophysiology
Cell of origin : ependymal lining of the spinal cord
central canal
WHO Grade –II low tendency to infiltrate

9. Imaging
Plain radiographs & CT
Non specific finding
Scoliosis & spinal canal widening
Vertebral body scalloping
MRI( IOC)
Central location ,well circumscribed
Symmetric cord expansion
Involve avg 4 vertebrae
60-90% a/w cysts
Syrinx occurs in cervical ependymomas

10. T 1: Isointense to Hypointense
T2 : Hyperintense
Cap sign deposition of hemosiderin in rostral &
caudal margins d/t chronic hemorrhage.
T1 C+(gd) : Well defined margins with a homogenous
pattern
DWI : Don’t restrict
DTI : Displace the white matter track
MRS :Choline & Lipid

12. Differential diagnosis
Spinal astrocytoma
Spinal cavernous malformation
Thoracic cord
more than half cord
on MRI heterogeonous signal intensity
d/t different ages of blood products
Popcorn appearnce

13. MYXOPAPILLARY EPENDYMOMA
Epidemiology
Predominantly in children & young adults
Male >Female
Location : conus medullaris & filum terminale
Very slow growing ,so very large before
diagnosis
 More prone to hemorrhage
Pathophysiology
Same as ependymoma

14. Imaging
MRI
Well defined
T1: Isointense to hyperintense (d/t prescence of mucin)
T2 :Hyperintense
T1c+(gd) : Homogenous
Diffential diagnosis
Schwannoma
Paragnglioma

15. ASTROCYTOMA
Epidemiology
Mc intramedullary tumor in children
2nd mc intramedullary tumor in adults
Peak incidence 4th decade in adults
Pilocytic astrocytoma age 1to 5yr
Fbrillary astrocytoma age app. 10yr
Male > Female
Associated with NF1
Location mc Thoracic > cervical
Pathophysiology
Arises from astrocytic glial cell
Pilocytic astrocytoma WHO grade I don’t infiltrate
Fibrillary astrocytoma WHO grade II infiltrate

16. Imaging
MRI
Eccentrically located
Assymetric & fusiform cord expansion
About 4 vertebrae segment involvement .
however holocord involvement may occurs in children
& early adolescent
T1: Hypointense
T2 : Hyperintense , Hemorrhage is not commonly seen
T1 c+(gd) : Enhances inhomogenously in a nodular &
patchy manner

17. DWI : No restrictions
DTI : Diffuse infiltration of the cord with disruption of
white matter tracts
MRS : Elevated choline & decrease NAA

19. ASTROCYTOMA VS EPENDYMOMA
Long segment Short segment
Infiltrative border well defined border
Heterogenous enhancement Homogenous enhancement
Eccentric Central
a/w NF1 a/w NF2
Children Adults
Differential diagnosis

20. HEMANGIOBLASTOMA
Epidemiology
3rd MC tumor
Peak incidence 4th decade
Male > Female
70% sporadic 30% a/w VHL
Location sporadic disease has single lesion
thoracic> cervical
but in VHL multiple lesion
Pathophysiology
Arise from non glial mesenchymal cells
WHO Grade I tumor

21. Imaging
MRI
 Well demarcated hyperenhancing nodular masses
T1 : isointense
T2 : Hyperintense
T1 c+(gd): vividly enhances
DTI : White matter tracts wrapped around the tumor
without infiltration

23. GANGLIOGLIOMA
Epidemiology
 Very rare in adults
15% of intramedullary tumor in pediatrics
Children between 1-5 yrs
 Slightly female predominant
Location : cervicothoracic >thoracic>cervicomedullary
>cervical>conus
Pathophysiology
Arises from ganglion cells & glial cells
WHO Grade I&II

24. Imaging
Scoliosis & Bone remodelling is common
MRI : Long tumor length on an avg 8 vertebral bodies
tumoral cyst
absent of edema
mixed signal intensity on T1 ( d/t dual celluar
component)
eccentric location
patchy tumor enhancement
Hemorrhage & calcifications rare

26. EXTRAMEDULLARY INTRADURAL

27. SCHWANOMA
 AKA Neurinomas /Neurilemmomas
 Mc extramedullary intradural tumor in adults.
 Multiple schwannomas occurs in children in NF2 a/w
higher risk of malignant transformation.
Location cervical & lumbar region.
MRI : well encapsulated tumor with cystic components
T1 : Iso to hypointense
T2 : Hyperintense
T1+C(gd) : varry intense & homogenous
D/D : Myxopappilary Ependymoma of filum
pushes the nerve roots to the periphery where
as schwannoma of the cauda pushes the roots in
an eccentric fashion

29. NEUROFIBROMA
A/W NF 1 & NF2
 NF 1 , Multiple plexiform neurofibroma
MRI : Not well encapsulated , ill defined , multiple
if solitary not able to differentiate between
schwannoma & neurofibroma.
Target sign : Hyperintense rim with low centre

31. MENINGIOMA
 Mainly Dural based tumor
Peak age 5th -6th decade
A/w NF 2
Female predominance
Location : Thoracic > cervical
CT : Iso to Hyperattenuating
with calcifications
MRI : T1 : Hypointense
T2 : Hyperintense
T1 C +(Gd) : strong homogenous enhancement
except for the calcified areas.
Dural tail sign less commonly seen as compared to
intracranial meningioma

33. METASTASIS
Leptomeningeal spread
NON CNS CNS
Breast Drop Metastasis
Lung Meduloblastoma
Ependymoma
Choroid plexus Carcinoma
Pineloblastma
Germinoma
Older patients younger patients

34. MRI : on MRI Leptomeningeal metastasis demonstrates
3 patterns
1. Diffuse CE along the pia & nerve roots
Sugar coating pattern / Zukerguss pattern
2. Multiple small CE nodules in subarchnoid space
3 .Single CE mass

35. EXTRA DURAL TUMOR
 Mc spinal tumor
 Local pain is the Mc presenting features
Draped curtain sign
Extension of the tumor in the ant epidural space
displaces the lateral aspect of PLL d/t strong medial
Fixation by medial menigovertebral ligament
( Ligament of Trolard & Hofmann )

36. METASTASIS
Spine is the 3rd MC site of metastasis following Lung &
Liver
MC primary malignancies are Breast, Prostate, Lung
Peak incidence 40-65 yr
MC location Thoracic > Lumbar > Cervical
Most frequently , metastasis occurs in vertebral body.
Plain Radiographs : Pedicle erosion Winking owl sign
f/b vertebral compression fracture.
CT :Osteolytic Multiple lytic lesions with irregular non
sclerotic margins.
Osteoblastic increased density & sclerosis “ Ivory
Vertebrae

37. MRI :
T1 : Any lesion of Spinal marrow hypo to muscle &
disc abnormal
T2 : Hyperintense to bone marrow

38. OSTEOBLASTIC MIXED OSTEOLYTIC
Prostate Breast Lung
Osteosarcoma Lymphoma RCC
Medullary thyroid Ca Malignant melanoma
Multiple Myeloma

39. Tumor Age Sex
Osteoid osteoma 10-20 M>F
osteoblastoma 10-20 M>F
Eosinophilic Granuloma 10-20 M>F
ABC <30 F>M
Ewing Sarcoma 10-30 M>F
GCT 20-40 F>M
Osteosarcoma >40 M>F
Chondrosarcoma >40 M>F
Multiple myeloma >50 M> F
Chordoma 50-60 M>F
PRIMARY VERTEBRAL TUMOR

40. HEMANGIOMA
Mc benign tumor of spine in adults
Vertebral body involvement is mc
Most are asymptomatic discovered accidentally
PLAIN RADIOGRAPHS : Corduroy cloth appearance
CT : Polka Dot sign
MRI : T1 : Hyperintense d/t prescence of fat
d/d : Metastatic melanoma, Exostosis
T2 : Hyperintense
T1 C +gd : Enhancement

42. OSTEOID OSTEOMA
Mc benign vertebral tumor in children
Lumbar > cervical > thoracic
CT : Calcified / non calcified Small circumscribed area of
osteolysis ( radioluscent) with surrounding reactive
sclerosis
MRI : T1 : low
T2 : High with marked edema in the surrounding
bone marrow

44. OSTEOBLASTOMA
 Spine is the MC site
Equally distributed vertebral column
CT : Expansile lytic lesion with multiple small
calcifications & peripheral sclerotic rim
MRI : similar to osteoid osteoma

46. ANEURYSMAL BONE CYST
 Lumbar > Thoracic =Cervical
CT : Lytic mass with multifocal matrix mineralization
multicystic architecture with fluid fluid levels
MRI : well defined low signal rim with differernt ages of
hemorrhage within the cystic component

48. EOSINOPHILIC GRANULOMA
Most benign form of Langerhans cell histiocytosis
Primarily affect children < 15yr
Mc thoracic > lumbar> cervical
Mc part vertebral body
A/W 2 systemic disease
Hand schuller christian disease
Letterer siwe disease
X RAY : Vertebra plana
CT : Lytic lesion /collapsed vertebral bodies without
surrounding sclerosis.
MRI : Non specific

50. CHORDOMA
 MC primary bone tumor of sacrum
Sacrum> base of skull
Plain Radiographs : Midline destructive bone lesions
CT: Expansile midline lytic lesion with irregular
borders & infiltration of surrounding tissues
calcifications & bone sclerosis are frequently
present
MRI : T1 : Hypointense with areas of hyperintense
d/t hemorrhage & mucin
T2 : Hyperintense
T1+c(gd) : Varriable homogenous to peripheral
septal enhancement

52. GIANT CELL TUMOR
 2nd MC primary tumor of sacrum
 Mc sacrum > Thoracic > cervical> Lumbar
Increases size during pregnancy
Plain radiographs : well defined lytic & expansile
lesion crosses the midline
CT : Absence of mineralisation & lack of sclerotic rim
MRI : T1 : Hypointense
T2 : Hypointense

54. MULTIPLE MYELOMA
 MC malignant vertebral tumors
Commonly occurs in thoracic spine
Vertebral body is the mc site of involvement
Plain radiographs : multicystic expansile lytic
lesion with thickened trabeculae
CT : Hollow vertebral body
MRI : T1 : Hypointense
T2 : Hyperintense
T1C +(gd) : Homogenous vivid enhancement

56. CHONDROSARCOMA
 2nd mc primary malignant tumor of spine
Thoracic & Lumbar spine most frequently involved
CT : Large calcified mass with bone destructions
MRI :T1 : Hypointense
T2 : Very high signal d/t water content of
hyaline cartilage
T1+C (gd): Ring & Arcs d/t lobulated growth
pattern cartilaginous tumors

58. OSTEOSARCOMA
 3rd Mc primary malignant tumor excluding non
lymphoproliferative tumor
Thoracic = Lumbar segment> Sacrum> Cervical
Most osteosarcomas osteoblastic type .
CT :Cortical destruction,expansile aggressive remodelling,
Matrix mineralisation
MRI :T1 : low to intermidiate
T2 : High
Areas of mineralisation are low in all sequences

60. EWING SARCOMA
 Mc Primary malignant tumor in children excluding
non lymphoproliferative tumor
Location Sacrum > Lumbar spine > Cervical
Typically centred vertebral body
CT : Lytic bone destruction
MRI : T1 : Intermediate
T2 : Hyperintense
T1+C(Gd) : Homogenous enhancement

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