spinal neoplasm with physiotherapy treatment plan

1. SPINAL
NEOPLASM
SAYALI GUJJEWAR
MPT II

2. QUESTIONS
PAPER VI – CLINICAL CONDITIONS
– Classify Spinal Neoplasms. Elaborate on clinical features,
diagnositic procedures & treatment options. (20 marks)

3. DEFINITION
A spinal tumor is an abnormal mass of tissue within or surrounding
the spinal cord and/or spinal column. These cells grow and multiply
uncontrollably, seemingly unchecked by the mechanisms that control
normal cells.

4. INTRODUCTION
– In the CNS tumours, 15% are spinal.
– Majority of intraspinal tumours are benign.
– Produces effects mainly by compression of the spinal cord rather than by invasion.
– Primary tumors of the spinal cord are considerably less frequent.
– Compression of the spinal cord by a metastatic tumor in the vertebral column is a common
occurrence in many types of cancers.
– Both sexes are equally liable.
– May develop at any age, but in over 80% cases symptoms first appear between the ages of
20 and 60.

5. CAUSES & RISK FACTORS
– The cause of intraspinal neoplasm is unknown.
– Development of the spinal tumours is linked to inherited syndromes, such as
A. Neurofibromatosis
 Autosomal-dominant disorder.
 Two subtypes: NF-1 and NF-2.
 19% of subjects diagnosed with NF-1 develop intramedullary spinal cord tumour.
 Due to the genetic activity if the disease there is increased cellular division and proliferation
and eventual tumor development.

6. B. Von Hippel-Lindau disease
 Rare autosomal-dominant disease
 Due to the genetic activity at the cellular level tumour formation occurs.
 Characterized by widespread formation of both benign and malignant tumors throughout
the body.
 Multisystem disorder associated with blood vessel tumors (hemangioblastomas) in the
brain, retina and spinal cord and with other types of tumors in the kidneys or adrenal
glands.

7. CLASSIFICATION
INTRASPINAL
NEOPLASM
INTRADURAL:
Part of the dura
INTRAMEDULLARY:
- Inside the spinal cord
- 5%
EXTRAMEDULLARY:
- Inside the dura, but
outside the spinal cord
- 40%
EXTRADURAL:
- Outside the dura
mater lining
- 55%
A. Based on location

8. INTRASPINAL
NEOPLASM
BENIGN:
Non-cancerous
MALIGNANT:
Cancerous
B. Based on being cancerous/
non-cancerous
INTRASPINAL
NEOPLASM
PRIMARY:
Originate in the
spine or spinal cord
SECONDARY/
METASTATIC:
Result from cancer
spreading from
another site to the
spine.
C. Based on origin

9. PATHOPHYSIOLOGY
– Metastatic spinal cord compression usually follows hematogenous dissemination of
malignant cells to the vertebral bodies, with subsequent expansion into the epidural space.
– Spread into the epidural space may occur by means of tumor extension through the
intervertebral foramina or hematogenous spread by way of the Batson venous plexus.
– Most frequently, metastatic seeding appears in the thoracic spine (accounting for about 70%
of cases), with the lumbar spine being the next most involved site (20% of cases). The
cervical spine is affected in approximately 10% of cases. Multiple spinal levels are affected in
about 30% of patients.

10. – Systemic cancers with a tendency for spinal cord metastasis are breast cancer, prostate
cancer, renal cancer, lung cancer, lymphoma, sarcoma, multiple myeloma.
– Gastrointestinal and pelvic malignancies tend to affect the lumbosacral spine.
– Lung and breast cancers are more likely to affect the thoracic spine.
– Metastases to the substance of the cord (intramedullary) are relatively rare.
– Leptomeningeal metastases spread by means of diffuse or multifocal seeding of the
meninges from systemic cancer (eg, lung or breast cancer, melanoma, lymphoma).

11. – Intradural extramedullary tumors, including schwannomas, neurofibromas, and
meningiomas, that affect the paravertebral area may spread and compress the cord through
expansion.
– Additionally, an enlarging cancerous lymph node may compress the cord.
– Neoplasms may compromise the vascular supply, causing edema or ischemia.
– Less frequently, tumors may induce cyst formation or cavitation within the spinal cord.

12. CLINICAL FEATURES
Patients with spinal cord tumors are likely to present with one of
three clinical syndromes:
(1) sensorimotor spinal tract syndrome
(2) painful radicular-spinal cord syndrome
(3) intramedullary syringomyelic syndrome

13. SENSORIMOTOR SPINAL TRACT
SYNDROME
The clinical picture is related predominantly to compression and less often to invasion and
destruction of spinal cord tracts.
The signs of compression consist of a combination of
 An asymmetrical spastic weakness of the legs with thoracolumbar lesions and of the arms
and legs with cervical lesions.
 A sensory level on the trunk below which perception of pain and temperature is reduced
or lost.
 Posterior column signs
 A spastic bladder under weak voluntary control.

14. – The onset of the compressive symptoms is usually gradual and the course progressive over
a period of weeks and months, frequently with back pain.
– The initial disturbance may be of motor or sensory function and the distribution may be
asymmetrical.
– With thoracic lesions, one leg usually becomes weak and stiff before the other one.
– Subjective sensory symptoms of the dorsal column type (tingling paresthesias) assume
similar distributions. Pain and thermal senses are more likely to be affected than tactile,
vibration, and position senses.

15. – The posterior columns are frequently involved as the process progresses.
– Initially, the sensory disturbance is contralateral to the maximum motor weakness.
– The bladder and bowel usually become paralyzed coincident with paralysis of the legs.
– If the compression is relieved, there is recovery from these sensory and motor symptoms,
often in the reverse order of their appearance; the first part affected is the last to recover,
and sensory symptoms tend to disappear before motor ones.

16. PAINFUL RADICULAR-SPINAL
CORD SYNDROME
– Here the syndrome of spinal cord compression is combined with radicular pain, i.e., pain in
the distribution of a sensory nerve root.
– The discomfort is described as knife-like or as a dull ache with superimposed sharp stabs of
pain, which radiate in a distal direction, i.e., away from the spine, and are intensified by
coughing, sneezing, or straining.
– Segmental sensory changes are paresthesias, impaired perception of pinprick and touch
– Motor disturbances are cramp, atrophy, fascicular twitching, and loss of tendon reflexes

17. – Ache in the spine
– Tenderness of the spinous processes over the tumor is found by percussion in about half the
patients.
– The segmental changes, particularly the sensory radicular ones, often precede the signs of
spinal cord compression by months if the lesion is benign.

18. INTRAMEDULLARY
SYRINGOMYELIC SYNDROME
– Rare
– No single symptom is unique to the intramedullary tumors .
– Some degree of pain, sometimes minor, is common and is almost invariably present with
tumors of the filum terminale.
– The main features are segmental or dissociated sensory loss, amyotrophy, early
incontinence, and late corticospinal weakness.
– Sacral sparing of sensation may be found.

19. – A dissociation of thermal pain and tactile sensory loss over several contiguous segments on
the trunk is a more dependable sign of an intramedullary lesion.
– Rarely, an extramedullary tumor may give rise to a syringomyelic sensory syndrome,
possibly by causing vascular insufficiency in the central portion of the cord.

20. Special Spinal Syndromes
Tumors in the region of the foramen magnum
– They produce quadriparesis with pain in the back of the head and stiff neck, weakness and
atrophy of the hands and dorsal neck muscles, marked imbalance, and variable sensory
changes or, if they spread intracranially, there may be signs of cerebellar and lower cranial
nerve involvement.
– Slowly growing tumors in this region, such as meningiomas, characteristically produce an
"around the clock" progression of weakness beginning in one limb and proceeding to the
adjacent one in a clockwise or counterclockwise direction.

22. Lesions of the cauda equina
– Always difficult to separate from the lesions of the lumbosacral plexuses and multiple
nerves.
– Sciatic and other root pain and lumbar ache.
– Bilaterally asymmetrical, atrophic, areflexic paralysis, radicular sensory loss, and
sphincteric disorder.

23. Lesions of the conus medullaris
– Early disturbances of the bladder and bowel (urinary retention and constipation).
– Back pain
– Symmetrical hypesthesia or anesthesia over the sacral dermatomes
– A lax anal sphincter with loss of anal and bulbocavernosus reflexes, impotence, and
sometimes weakness of leg muscles.
– Sensory abnormalities may precede motor and reflex changes by many months.

24. TYPES

25. INTRADURAL INTRAMEDULLARY SPINAL NEOPLASM
– Comprise 20 to 30% of all primary spinal cord tumors
– Metastatic intramedullary tumors are rare but present in 2% of all
intramedullary tumors.
– Mostly found in the thoracic region, followed by the cervical and
then lumbar spine.

26. CLASSIFICATION OF INTRADURAL INTRAMEDULLARY SPINAL
NEOPLASM
ASTROCYTOMAS
– Red, gray, glossy tumors that are characterized by a poorly defined plane and are generally
infiltrative in nature.
– The second most common IMSCT in adults at 30 to 35% of tumors and the most common
in children at 90% of tumors.
– Of all astrocytomas arising in the CNS, 3% occur in the spinal cord.
– They primarily occur in the cervical spine, and they often involve multiple spinal segments
due to the expansive nature of these tumors
– Nearly 20% of such lesions are associated with syrinx formation.

27. – Astrocytomas have an association with NF-1, occur predominantly in males, and rarely
manifest in patients over the age of 60.
– Adults mainly exhibit highgrade lesions, whereas low-grade lesions are associated with the
younger population.
– Malignant degeneration develops in 25% of adult astrocytomas.
– Astrocytomas average five to six vertebral body extensions.

28. EPENDYMOMAS
– Soft, encapsulated, reddish gray or yellow tumors with modest vascularity that present in
the third or fourth decade of life.
– Half of all ependymomas are located in the region spine and a slight majority are located
in the cord (55%), relative to the cauda equina (45%).
– They are not sex discriminant.
– The majority of them are classified as benign tumors, and ependymomas have a
propensity to grow slowly.
– Spinal ependymomas are primarily present in the cervical or cervicothoracic region.

29. – The cysts associated with these tumors are predominantly found in the superior margin of
the tumor and have an increased incidence in the cervical region
– Approximately 65% of these tumors are associated with syrinx formation.
– Originating from ependymal cells, ependymomas are more centromedullary located as
compared with astrocytomas, and they tend to blend with the cord.
– They appear as a focal enlargement within the spinal cord.
– Ependymomas have a mean extension of three to four vertebral bodies.
– Abnormalities of chromosome 22 are associated with ependymomas, and this leads to
their association with NF-2.

30. TYPES OF EPENDYMOMAS
– The most common is the cellular variant or the “typical” form, which is WHO grade II
tumor that is well circumscribed. Pathologic analysis reveals both true ependymal rosettes
and more commonly perivascular pseudorosettes.
– Tanycytic ependymomas are also WHO grade II, are less common overall, and are found
more commonly in the spinal cord than in the brain. Histologically, tanycytic
ependymomas lack ependymal rosettes and their pseudorosettes are vaguely apparent,
which can lead to misdiagnosis as pilocytic astrocytoma (WHO grade I)
– Rarely anaplastic ependymomas, WHO grade III, can be encountered, which develop
more rapidly than lower grades, can occasionally develop from malignant degeneration,
and have an overall poor prognosis.
– Subependymomas (WHO grade I), which may be histologically related to ependymomas,
have also been reported as rare IMSCT.

31. HEMANGIOBLASTOMA
– Small, benign, richly vascularized solitary neoplasms that rarely extend beyond one or
two segments.
– Found in the spinal cord, predominantly located at the posterior or posterolateral region
of the spinal canal.
– Most hemangioblastomas develop sporadically but, they are associated with VHL.
– They constitute between 2 and 8% of all IMSCTs.
– Commonly, they are located in the cervical spine but may be found in any portion of the
neuroaxis.

32. – Cyst formation is evident within 50 to 70% of tumors, and the tumors have an association
with syrinx.
– Hemangioblastomas are more commonly found in men.
– Although hemangioblastomas are not age discriminant, most occur during the fourth
decade of life.
– It is possible that individuals with a hemangioblastoma can remain asymptomatic
throughout life, with tumor only apparent at autopsy.
– Composed of a dense network of vascular capillary channels containing endothelial cells,
pericytes, and lipid-laden stromal cells.

33. – The cells of origin remain unknown, but based on the genetics of VHL and mutations
found in sporadic lesions, they are likely vascular endothelial growth factor-secreting
undifferentiated mesenchymal cells.
– Two histologic forms exist: reticular and cellular.
– The former is composed of irregular nuclei with conspicuous vessels.
– Conversely, the cellular form exhibits fewer conspicuous vessels with varying stromal
cells; this form bears a similarity to astrocytomas and may be difficult to discriminate
from these lesions.
– Hemangioblastomas are well-demarcated tumors that are amenable to resection.

34. – With complete resection, the prognosis is excellent.
– Pain and sensory changes are the most frequent presenting complaints.
– Imaging is a crucial factor in surgical planning and should be thoroughly evaluated.
– An associated cord widening is commonly found adjacent to the tumor, possibly attributed
to edema related to increased blood flow in surrounding draining veins or within the tumor
creating vascular congestion.
– After tumor removal, widening regresses.
– In addition, spinal angiography is recommended to delineate the characteristics of the
spinal draining veins.

35. OTHER RARE IMSCTs
– Cavernomas are rare vascular lesions that may hemorrhage repeatedly during the lifetime
of an individual, and they can have associated syringes.
– Intramedullary lymphomas may occur in isolation or with other central nervous system
lesions. They respond to chemotherapy.
– Gangliogliomas are benign tumors consisting of glial and neuronal cells that are estimated
to comprise 3.8% of CNS tumors found in the upper cervical cord.
– Oligodendrogliomas possess ill-defined borders and less extensive cord growth compared
with other IMSCTs; fewer than 50 cases have been literature reported.
– Melanocytomas, melanomas, fibrosarcomas, peripheral neuroectodermal tumors,
amyloid angiopathies

36. INTRADURAL EXTRAMEDULLARY SPINAL NEOPLASM
– 70 to 80% of primary intradural tumors are intradural
extramedullary tumors.
– Thoracic region of the cord is the most commonest site, followed
by the cervical and then lumbar spine.
– Approximately two-third of these tumours are situated on the
dorsal or dorsolateral aspects of the cord and approximately one-
third on the ventral or ventrolateral aspects.

37. CLASSIFICATION OF INTRADURAL EXTRAMEDULLARY SPINAL
NEOPLASM
MENINGIOMAS
– Arise from arachnoid cap cells embedded in dura near the spinal nerve root sleeve.
– Second most common
– Their predominant spinal canal location is lateral.
– Other cells of origin may be fibroblasts associated with the dura or pia. In this case the
tumor has a ventral dural origin. Frequently the attachment to dura is broad based.
– Most common patients’ age interval is between 50 & 70 years although any age group
may be involved.

38. – More common in women (75-85%) and in the thoracic location (80%).
– In 75% of meningiomas, calcifications were registered.
– Most commonly they are solitary although 1-2% may be multifocal, particularly in
neurofibromatosis-I (NF I) patients.
– Majority of spinal meningiomas are intradural, although 10% may involve extradural
location.

39. NERVE SHEATH TUMORS
– Most frequent EISTs.
– Spinal nerve sheath tumors (SNSTs) include Schwannomas (neuromas, neurinoma,
neurilemmomas) and neurofibromas.
– Schwannmomas are composed of Schwann cells with fibrous tissue. These tumors may
show cystic degeneration and hemorrhage. They usually displace nerve roots. If they are
multiple, they may be associated with NF II patients.
– Neurofibromas are composed of Schwann cells, fibroblasts, and nerve fibers in a matrix
of mucopolysaccharides, fluid and fibrous material.

40. – Typically SNSTs are found on the dorsal sensory roots which they encase.
– There is no gender predilection.
– Most commonly they are seen in cervical and lumbar regions; less frequently in the
thoracic spinal segment.
– Predominantly they have an intradural location but 25% are completely extradural and
15% are intra/extradural.
– Their peak incidence is fourth decade of life.
– 90% of these tumors are benign.

41. – Multiple tumors are typical for NF I patients.
– If they reach a large size, they may remodel intravertebral foramen or even erode or
cause scalloping of the posterior aspect of the vertebral body

42. FILUM TERMINALE EPENDYMOMAS
– Fifty percent of all ependymomas are spinal.
– Within spinal ependymomas, 50% are intramedullary and another 50% are located
within terminal filum.
– Despite the neuroectodermal origin of filum terminale, from anatomical and a surgical
perspective it is appropriate to group them with IESTs.
– Filum terminale ependymomas arise from ependymal rests in filum terminale and are
of myxopapillary histologic variant.
– They can occur at any age but most commonly between 3rd and 5th decades.

43. – These tumors are well circumscribed and seldom infiltrate the dura.
– After radical resection recurrence is generally rare although subarachnoid seeding is
possible.

44. LIPOMAS
– Lipomas are rare congenital tumors that constitute 1% ofmintraspinal tumors.
– Commonly found in the cauda equina and conus medullaris, these tumors tend to violate
the posterior cord and are usually extramedullary.
– Lipomas are commonly associated with spinal dysraphism and are thought to arise from
premature disjunction of the cutaneous ectoderm from the neural ectoderm prior to
neural tube closure, allowing mesenchymal cells to infiltrate into the neural groove.

45. – These tumors possess a higher water content than other intramedullary tumors and
tend to attach firmly to the dura; their cellular content is indistinguishable from normal
adipose tissue.
– These tumors are slow-growing, and they become symptomatic due to focal mass
effect.
– They present no cleavage plane from the surrounding cord with blending of the neural
and fatty tissue. As a result, complete tumor resection is extremely difficult, and some
neurologic damage may be expected when attempting resection.

46. – Although little is known about these tumors, patients tend not to improve from their
baseline neurologic state but the long-term prognosis is excellent with 90% progression-
free survival at 16 years following total or near total excision and 35% progression-free
survival at 10 years following a debulking procedure.
– Developmentally, these tumors prevent normal maturation of the surrounding neural
tissue.

47. EXTRADURAL SPINAL NEOPLASM
– Extradural tumors are the most common spinal tumors and are
usually of metastatic origin.
– Thoracic region of the cord is the commonest site.

48. CLASSIFICATION OF EXTRADURAL SPINAL NEOPLASM
CHORDOMAS
– Chordomas are slow growing, locally aggressive lesions that can occur anywhere along
the axial skeleton, but are most commonly found at the craniocervical junction and the
sacrum.
– Sacral chordomas are often associated with large, exophytic soft tissue masses that
can contribute to a neurogenic bladder and obstipation.

49. GIANT CELL TUMORS
– GCTs comprise 5% of all adult primary bone tumors and occur most frequently at the
epiphyseal–metaphyseal junction of long bones.
– They most commonly involve the sacrum, followed by the cervical and thoracic
regions.
– Although they are aggressive benign tumors, their size and vascularity make resection
difficult; therefore, patients may require preoperative embolization to decrease
intraoperative blood loss.

50. DIAGNOSTIC PROCEDURES
PLAIN RADIOGRAPHS
– Plain radiographic findings are present in 40% of patients with spine metastasis.
– At least 50% loss of the trabecular bone is required for a destructive spine lesion to be
visualised on plain radiographs.
– In many hematological malignancies, plain radiographic findings may not be seen until
the advanced stages of disease.
– Plain radiographic characteristics of metastatic lesions can be osteoblastic, osteolytic or
mixed.
– Spine metastases of prostate and breast carcinomas are generally osteoblastic or mixed-
type lesions, but lung and thyroid carcinomas as well as renal cell carcinoma are usually
in the form of lytic metastatic lesions.

51. – Radiopaque lesions which extend outside of the rectangle that draws the boundaries of
the vertebral body generally indicate primary malignant lesions of the spine.
– Radiographic sign known as “winking owl sign” can be defined as a faint shadow
obscuring the visibility of one pedicle on anteroposterior radiograph, indicates extending
of the tumor mass from vertebral body to paraspinal area.
– Winking owl sign is generally accepted as the earliest direct radiographic sign of a
metastatic lesion.
– Another plain radiographic finding for spine tumors is presence of one or more lytic
lesions. Lytic lesions indicate bone destruction.

52. – However, destruction pattern gives information about nature of the tumor in the spine as
well as in all bone tumors.
– Geographical destruction suggests that tumor is slowly progressive, moth-eaten lesions
suggest that tumor grows faster, and permeative destruction suggests that tumor is very
rapidly progressive.
– Another plain radiographic finding is collapse of the vertebral body that can be called
compression fracture. It is not easy to distinguish pathological compression fractures from
benign osteoporotic ones.

53. WINKING OWL SIGN
INTRAOSSEOUS MALIGNANT PERIPHERAL NERVE
SHEATH TUMOR OF THE THORACIC SPINEOSTEOCHONDROMA OF
THE CERVICAL SPINE

54. BONE SCINTIGRAPHY
– Bone scintigraphy is the most helpful diagnostic procedure in cases whose plain
radiographs are negative or suspicious.
– Bone scintigraphy is a diagnostic procedure performed by radioisotopes.
– Even though bone scintigraphy has a low specifity except in some tumors such as osteoid
osteoma, it is a useful tool for diagnosis because of its high sensitivity and the ability to
scan the entire body that is not found in other diagnostic tools.
– It is also useful in terms of recognizing the primary disease in metastatic tumors which
have unknown primary origins and guiding biopsy.

56. COMPUTED TOMOGRAPHY (CT)
– Most advantageous method in examination of mineralized
tissues.
– Even complex anatomical structures like the spine could be
evaluated by CT, which is superior to plain radiographs with
regards to its ability of 3 plane examination.
– However, poor affinity and efficacy of CT in soft tissue lesions are
disadvantages of this method .

57. MAGNETIC RESONANCE IMAGING (MRI)
– Magnetic resonance imaging (MRI) is superior to all
diagnostic procedures in spine tumors, especially in the
evaluation of bone marrow and spinal canal, relationship of
the tumor with neurovascular structures and tumor
vascularity.
– Gadolinium contrast enhanced MRI can also distinguish
intra and extra-dural tumors and also intra and extra-
medullary tumors.

58. BIOPSY
– Biopsy in spine tumors can be performed as fine needle aspiration,
tru-cut biopsy, incisional or excisional biopsy.
– Fine needle biopsy and tru-cut biopsy are percutaneously applied
procedures.
– It should be kept in mind that biopsy tract is contaminated by
tumor cells, and biopsies must be performed far from the
neurovascular structures by small incisions which could then be
removed with tumor mass in definitive surgical procedure.
FINE NEEDLE ASPIRATION
BIOPSY

59. TREATMENT
CHEMOTHERAPY
– Chemotherapy can be divided into antitumor drugs and drugs that prevent or improve the
effects of tumor.
– Antitumor chemotherapy currently plays a relatively limited role in the treatment of spinal
metastases.
– Dexamethasone reduces vasogenic edema of acute spinal cord compression to stabilize or
improve neurologic status in some patients and relieve tumor related pain.
– Doses range from moderate (16 mg/day in divided doses) to high (96 mg/day in divided
doses) with a 10 to 100 mg load. It is unclear whether higher dose steroids improve
neurologic outcomes compared to moderate dose, but significantly more complications
result from the higher doses.

60. – Side effects seen in the moderate and high-dose steroids are 8% and 29%, respectively.
– Complications from steroids include hyperglycemia, gastrointestinal hemorrhage, intestinal
perforation, and avascular necrosis of the hip.
– Biphosphonates are drugs that inhibit osteoclastic acitivity, suppress bone resorption, and
are effective in the treatment of malignancy-associated hypercalcemia.
– Pamidronate is the most commonly used biphosphonate for cancer patients.
– In combination with systemic antitumor therapy, pamidronate has been shown to reduce or
delay skeletal events, such as pathologic fractures.

61. – The most significant side effects are febrile reactions, often in combination with myalgias
and lymphopenia.
– Other side effects include transient neutropenia, thrombophlebitis, hypocalcemia, and
rarely, ocular complications (uveitis).
– Antitumor chemotherapy has an important role in the treatment of chemosensitive
tumors, such as neuroblastoma, Ewing’s sarcoma, osteogenic sarcoma, germ cell tumors,
and lymphoma.

62. RADIATION THERAPY
– Radiation therapy is a therapy using ionizing radiation, to control or kill malignant cells.
– It is an important means of managing spinal tumors.
– In particular, RT is considered superior to surgery when tumors affect more than one
vertebra or the surrounding soft tissues.
– Its effectiveness is determined by the sensitivity of the tumor cells and the affected
region(s) of the vertebra(e).
– Rapid pain relief and neurologic improvement can be expected in most radiosensitive
tumors, such as myeloma, lymphoma and breast cancer, that affect the spine.

63. – In particular, external beam radiotherapy (EBRT) and brachytherapy are used to treat
spinal tumors.
– However, the main limitation of EBRT is the radiosensitivity of the spinal cord.
– Selective internal radiotherapy is also used to treat some types of spinal tumors, such as
metastatic tumors from the thyroid gland or liver.
– Exposure of the spinal cord to the free radicals caused by RT often limits the treatment
dose to surrounding spinal column tumors to below the optimal therapeutic dose. Large-
dose and single-fraction RT tend to cause radiation-induced toxicity and may result in
spinal injury.

64. – Single dose RT is better than conventional fractionated RT in the context of Stereotactic
Body Radiation Therapy (SBRT).
– Single dose RT tends to decrease the volume of the tumor by killing tumor cells at one time,
whereas fractionated and hyper-fractionated RT tend to increase the sensitivity of tumor
cells, thus making it easier to eradicate them.
– SBRT is found to be effective for treating metastatic spinal tumors and sarcomas.
– Other types of RT like three-dimensional conformal radiotherapy (3-DCRT), intensity-
modulated radiation therapy, helical tomotherapy, proton-beam therapy and carbon ion
radiotherapy (CIRT), are also recommended for managing spinal tumors.
– Proton-beam therapy benefits patients with spinal chordomas.

65. – However, RT is associated with some serious, even life-threatening, complications, such as
deep infection and edema of the nerve root; additionally, mechanical structural changes in
the spine after RT can result in vertebral fracture.
– Furthermore, RT, including some advanced RT therapies, is considered to be linked to
radiation-related sarcoma.
– Additionally, bone construction following RT is slower than normal.
– Notably, RT has long been considered a dangerous treatment for spinal tumors in children
and pregnant women.
– Nonetheless, RT alone seems less satisfactory than a combination of radiation and surgical
therapies for spinal cord decompression and tumor management.

66. – Surgery and RT can often be used cooperatively in the management of spinal tumors.
– Preoperative, postoperative and intraoperative RT and brachytherapy such as radiation seed
implantation are the most widely used measures.
– Preoperative RT is often used to reduce the volume and viability of a tumor prior to surgical
excision.
– Postoperative RT is often administered to patients after margin-positive surgery or when the
tumor is adherent to the soft tissues around it. It is aimed at reducing the risk of local
recurrence, is considered routine after debulking or piecemeal surgery. It is the most widely
used way of combining surgery and RT to treat spine tumors. Because, little tumor tissue and
few tumor cells usually remain after surgery, very precise lower dose fractionated or hyper-
fractionated RT is appropriate.

67. SURGERY
– The main objectives of the surgical procedure are decompress the spinal cord and prevent
recurrence by removing the tumor as completely as possible and achieving a tumor-free
margin.
– The main surgical procedures are:
Percutaneous Vertebroplasty (PVP) is a spinal procedures in which bone cement is injected
through a small hole in the skin into a fractured vertebra to try to relieve back pain caused by
a vertebral compression fractures.
Debulking Surgery is the reduction of as much of the bulk (volume) of a tumour as possible.
Piecemeal Resection is the removal of tumor in small bits or stages.

68. Total en bloc Spondylectomy (TES) is the complete removal of vertebra(e).
Gross Total Resection is resection without visual residual enhancing tumor.

69. PHYSIOTHERAPY TREATMENT
Role of Rehabilitation
– Functional mobility
– Pain management
– Bracing
– Neuromuscular re-education
– ROM/flexibility
– Strengthening
– Bowel/bladder management

70. FUNCTIONAL MOBILITY
PT interventions
– Positioning
• For skin and joint integrity
– Bed mobility
– Functional transfers
– Gait training
– Adaptive equipment, assistive devices, DME
– Patient and caregiver education

71. PAIN MANAGEMENT
PT interventions
– Positioning
• For comfort
– Postural bracing
– Modalities
• Heat, cold
• TENS
– Manual therapy
• Soft tissue massage

72. BRACING
Indications
• Flexible, supportive, or rigid
bracing for
 Postural correction
 Stretching
 Proprioceptive awareness
 Stabilization of fractures
– Cervical collars
• Soft cervical collar
• Hard cervical collar
– Clavicle strap
– TLSO
– Multipodusboot
– AFO
– Additional support
• Abdominal binder
• Compression stockings

74. NEUROMUSCULAR RE-EDUCATION
Postural re-education
• Addressing missing components during functional activities
 Facilitating neutral alignment
 Facilitating trunk and pelvic control
 Progressing from static mobility to dynamic activity
• Sitting - standing - functional
• Pre-gait training

75. Balance
– Manipulating proprioceptive input
– Supported - unsupported activities
– Stable - unstable surfaces
– Altering BOS
– Removing visual input
– Compression/bracing/weights to assist in controlling movement

76. ROM/FLEXIBILITY
Selective passive stretching & free exercises for limbs to improve:
– Muscle tightness
– Spasticity
– Joint ROM

77. STRENGTHENING
Post-surgical patients
– No spinal muscle or core strengthening
x 5-6 weeks post-op
– Mild LE strengthening
– After 5-6 weeks – cleared for gradual
strengthening
• Isometric - Progressive Resistive
Exercises
•No heavy weight recommended
 Progressive resistive exercises
– Upper and lower extremities
– Scapular/shoulder girdle
 Core –often most important to improve
pain, posture, and diminish bracing needs
– Abdominal muscles
– Paraspinal muscles
– Pelvic floor muscles ( Kegel’s exercises)
 Progress level of difficulty by altering
position, BOS, and/or surface

78. BOWEL/BLADDER MANAGEMENT
Pelvic Floor Therapy (PFT)
Re-educating pelvic floor muscles to contract and relax to void and
defecate efficiently.
– UMN – relax muscles
• Diaphragmatic breathing
• Positioning
• Gentle selective stretches
– LMN – strengthen muscles
• Muscle power
• Muscle endurance

79. REFERENCES
– Brain’s Diseases of the Nervous System. 10th edition.
By - John Walton
– Adams and Victor's Principles of Neurology. 10th edition.
By – Allan H. Roper, Martin A. Samuels, Joshua P. Klein
– Intramedullary Spinal Cord Tumors: Part I—Epidemiology, Pathophysiology, and
Diagnosis. Global Spine Journal. Samartzis et al. 2015.
– Spinal Cord Neoplasms. Medscape. J Stephen Huff et al. 2018.
– Extramedullary Intradural Spinal Tumors: A Review Of Modern Diagnostic And
Treatment Options And A Report Of A Series. Bosnian Journal Of Basic Medical
Sciences 2009; 9 (Supplement 1): S41-S45. Kenan Arnautovic, Aska Arnautovic.

80. – Tumors of the spine. Ciftdemir M et al . World Journal of Orthopaedics. 2016;
7(2): 109-116
– Epidemiology of Spinal Cord Tumors. Y. Ş. Çağlar and İ. Doğan. Springer Nature
Switzerland AG 2019.
– The Diagnosis and Treatment of Metastatic Spinal Tumor. Bilsky, Lis, Raizer et al.
The Oncologist 1999;4:459-469.
– Surgery Combined with Radiotherapy to Treat Spinal Tumors: A Review of
Published Reports. Chong Bian et al. Orthopaedic Surgery 2016;8:97–104.