8% of all bone tumors present in spine 25-30% of bone tumors are benign Peak age: 2-3rd decade Posterior element involved: osteoid osteoma, osteoblastoma, aneurysmal bone cyst Anterior element involved: giant cell tumor, hemangioma, eosinophilic granuloma

1. Bony tumors of Spine
Dr Abhinav Agrahari
19.3.18

2. • Benign lesions
– Hemangioma
– Chondroma
– Giant cell tumors
– Osteoma
– Fibroma
– Aneurysmal bone cyst
– Chondromas
– Chondromyxoid fibroma
• Primary malignant lesions
– Chordomas
– Solitary plasmacytoma
– Sarcoma
• Secondaries (breast, lung, thyroid, prostate, lymphoma,
multiple myeloma)
• Intraspinal extension of paravertebral tumor
– Neuroblastoma, Ewing’s, Lymphosarcoma, Hodgkin’s

3. Benign tumors
• 8% of all bone tumors present in spine
• 25-30% of bone tumors are benign
• Peak age: 2-3rd decade
• Posterior element involved: osteoid osteoma,
osteoblastoma, aneurysmal bone cyst
• Anterior element involved: giant cell tumor,
hemangioma, eosinophilic granuloma

4. • Clinical presentation of benign lesions
– Pain: focal radicular, night pains
– Myelopathy
– Sphincter involvement
– Scoliosis

5. • Investigations
– Plain radiographs
• Sclerotic changes
• Expansile lytic lesions
• Vertebra plana
• Trabeculae
– MRI is investigation of choice for soft tissue and
cord involvement
– CT for bony details
– Bone scan
– CT guided biopsy

6. • A thorough systemic exam is also required,
including CT Chest and Abdomen and pelvis
• Can include a PET scan
• Tissue diagnosis is also required
• Enneking classification

10. Surgery
• The goals :
– to establish a definitive diagnosis,
– decompress the neural elements,
– maintain or achieve spinal stability, and,
– if possible, cure the patient.
• Cure can often be achieved if proper
consideration is given to size, extent, and
location of the benign tumor.

11. • Indications of surgery
– Acute neurological deterioration
– Progressive deterioration on conservative
treatment
– Persistent unbearable pain
– Extensive lesions with instability
– Radio-resistant lesions
• Aims
– Debulking of tumor
– Restoration of stability

12. • Spine tumor resection can be en bloc or intra--
lesional.
• En bloc resection, or spondylectomy, is the
resection of the entire tumor in one piece.
– Marginal resection dissects through the
pseudocapsule of the tumor, and
– Wide resection provides a cuff of normal tissue
(>2 mm of healthy bone, reactive periosteum, or
pleura) with a margin of healthy surrounding
tissue
• Intralesional resection is the incision into the
tumor, and debulking from within.

13. • Intra-lesional resection has good neurologic
outcomes, but local recurrence rates remain high
• Marginal en bloc resection or intralesional
resection with an adjuvant (e.g., phenol, liquid
nitrogen, methyl methacrylate) may be curative
• Wide en bloc resections may effect a longer
disease-free interval and a potential cure
• High morbidity and recurrence rates, can be
reduced if treatment from biopsy to resection
occurs at the same institution by a dedicated
multidisciplinary team*
* En bloc resections in the spine: the experience of 220 patients over 25years. Stefano B,
Alessandro G, Bandiera S, Ghermandi R, Lador R. WNS, Oct 2016

14. • When the biopsy is performed prior to the
definitive procedure, the biopsy path should
be well marked and the soft tissue along the
biopsy path should be resected
• Avoid contamination of surrounding tissues
with tumor cells.
• Resecting the dura as a margin may increase
the risk of intradural seeding.
• When a fusion is planned, bone graft should
be obtained through a separate surgical setup

15. Radiation
• Neoadjuvant or postop adjuvant regimes
• Benign tumors (e.g., osteoid osteoma,
osteoblastoma, osteochondroma) have a poor
response rate
• Post radiation sarcomas
• Challenge in radiation therapy is that the dose
the spinal cord can tolerate is significantly
lower than the dose required to achieve local
tumor control

16. • With gross residual disease after resection, 70
Gy is typically delivered in 200-cGy fractions
• The spinal cord is thought to tolerate no more
than 50 Gy when delivered in 200-cG fractions
• Advances include
– intraoperative radiation therapy,
– brachytherapy,
– proton beam therapy,
– high-dose conformal photon therapy, and
– stereotactic radiation

17. • IORT:
– Custom brachytherapy
– Lead shield, gold foils used to shield the cord
– Labor intensive
– Difficult calculations
• Brachytherapy
– Iodine 125
– Yttrium 90
• Proton beam therapy
– Geometric advantage
– Better results
– Paucity of centers
– 3D CRT
• IMRT

18. Chemotherapy
• No major benefit
• 3-year event-free survival rates of 71% and
78% for patients with Osteogenic Sarcoma
treated with either Cisplatin, Doxorubicin, and
Methotrexate versus muramyl tetrapeptide
following resection
• Chordoma, generally chemoresistant, has also
been shown to be sensitive to tyrosine kinase
inhibitors (Imatinib mesylate)

19. Avoidance of complications
• Knowing the preop extent of the tumor is imp
• Periop angio and embolisation
• Proper planning of surgical incision in post-
radiation status
• As much as possible removal in the first
surgery
• Correction of spinal instability

20. Management of complications
• Avoid making complications
• Inadequate wound healing
• Csf leak
• Deep infections
• Inadequate stabilisation

21. Hemangioma
• Commonest benign
• Mostly incidental
• Females> males
• Enlarge in pregnancy, resolve post delivery,
recur in next pregnancies
• Pain. Most sympt in thoracic region
• Honeycomb appearance and gadolinium
enhancement

23. • Laminectomy without radiation therapy for
subtotal tumor resections resulted in tumor
control rates of 70% to 80%
• Postoperative irradiation reduces the risk of
tumor recurrence in patients after subtotal
tumor removal
• Vertebroplasty and kyphoplasty have also
been advocated

24. Eosinophilic Granuloma
• 10-15% of LCH
• Generally in less than 10yrs
• Self-limiting, benign lesions cause bony
destruction secondary to the local
proliferation of histiocytes.
• Occasionally, multiple levels are involved
• Destructive bony lesions with well-
demarcated borders and no evidence of a soft
tissue mass

25. • In many cases, symptoms will resolve over
time, and a conservative approach should
always be considered first.
• The vertebral body height can be restored
spontaneously if the areas of endochondral
ossification were preserved and the child is
young
• Treatment is generally conservative with
activity limitations and bracing
• If the bony destruction leads to instability that
persists despite a course of conservative
management, arthrodesis is required

27. Aneurysmal bone cysts
• benign, proliferative nonneoplastic lesions
that may occur in any part of the skeleton
• Young pts
• Slow growing, but sudden enlargements
reported in past
• ABCs are characterized by spaces separated by
septa that contain fibroblasts and giant cells.
Reactive new bone is usually present

28. • Lytic and expansile, and they extend to the cortex
and occasionally violate the periosteum.
Hemorrhage is common.
• When discovered incidentally, conservative
• When a biopsy is required, an open biopsy is
preferred
• Treatment options for ABCs include percutaneous
injection of a fibrosing agent, arterial
embolization, radiation therapy, curettage with or
without bone grafting, or resection
• Injection of zein alcohol (Ethibloc) with histoacryl
glue or of methylprednisolone with calcitonin has
been shown to lead to successful destruction of
the lesion with low recurrence rates

29. • Complete surgical resection is often considered
the treatment of choice.
• The approach (ventral, dorsal, or dorsolateral)
depends on the exact location and extent
• An eggshell-thin cyst of subperiosteal new bone
that is continuous with adjacent cortex is
observed at surgery
• This delineates the extent of the lesion, and its
removal often results in intense bleeding
• The core of the tumor consists of soft, fleshy,
vascular tissue, as well as a cystic trabeculation of
the interior of the mass containing unclotted
blood

31. • Prognosis is excellent with complete excision
and recurrence rates are rare in most series.
• Subtotal surgical excision, conversely, is
followed by a high incidence of recurrence,
which is usually rapid (within 1 year, and often
within 4 months).
• Curettage and bone grafting is associated with
a 20% or greater recurrence rate.

32. Giant cell tumor
• Locally aggressive
• Mean age around 30yrs
• Pain, neuro deficit
• 10% malignant transformation
• Destructive expansile lesion, generally in sacrum
• MRI reveals a heterogeneous, cystic
compartmentalized mass that may contain blood
degradation product

34. • Radiation therapy may be considered with
subtotal surgical excision.
• Giant-cell tumors can recur relatively early after
even the most radical surgical excision
• The 10-year success rate of radiation alone was
69% compared with 83% for postoperative
radiation therapy.
• Progression to a high-grade sarcoma occurs in 5%
to 15% of cases following radiation treatment.
• Radiation therapy should be reserved for
patients with recurrent or residual lesions

35. Osteoid osteoma
• Relatively common benign neoplasm
• 21% of surgically managed benign lesions.
• Central nidus of interlacing osteoid and woven
bone within a loose vascular stroma, surrounded
by an osteosclerotic rim
• Sharply demarcated from surrounding bone
• The nidus is rarely greater than 1.5 cm in
diameter
• Lesions larger than this are categorized as
osteoblastomas.

36. • Young males
• Second decade
• Neural arch elements are affected, most
commonly in the lumbar spine
• Pain, which increased with exercise
• Classically relieved with aspirin
• Fifteen months appears to be the critical cut-
off point after which spontaneous correction
of scoliosis does not occur after surgery.

38. • NSAIDs for pain relief
• Side effects
• Definitive treatment is surgical excision
• In more than 95% of cases, resection results in
almost immediate pain relief.
• When a complete resection is not achieved and
the lesion recurs, reoperation is recommended.
• Radiation is not recommended, either alone or
following surgery

39. Osteoblastomas
• Osteoblastomas represent a histologic
continuum of osteoid osteoma
• Difference being the size of the lesions.
• Osteoblastomas are lesions that are greater
than 1.5 cm in diameter
• Throughout spine
• Two-thirds are confined to the dorsal
elements.

40. • Well-defined, lobulated, lytic, expansile mass
• Involves the neural arch structures.
• Fifty percent of lesions are radiolucent with a
sclerotic rim
• Osteoblastomas should be treated surgically
with total resection
• Approximately 10% of lesions recur after
surgery

41. Osteochondroma
• Rare in spine
• Cartilage-covered cortical bone with
underlying medullary bone, both types of
bone being contiguous with their counterparts
in the parent bone
• Lesions affect the transverse or spinous
processes, and half of all lesions occur in the
cervical spine
• Surgical resection is the treatment of choice

42. Malignant primary tumors

43. Plasma cell tumors
• Mutliple myeloma and solitary plasmacytoma
• Most common primary malignant tumors of the
spine
• multiple bony lesions, infiltration of the bone
marrow by plasma cells, and a marked reduction
of normal immunoglobulins
• Up to 50% of plasmacytomas occur in the spine
and most commonly occur in the thoracic spine
• Fifty percent of patients diagnosed with
plasmacytoma ultimately develop multiple
myeloma, most commonly within 2 years

44. • Pain and myelopathy
• Symptoms for 6-12 months before presentation
• Definite diagnosis by needle biopsy
• In plasmacytoma, the bone marrow is negative for
plasma cell infiltrates, and serum protein
electrophoresis results are normal
• Multiple myeloma is usually diagnosed definitively by a
bone marrow biopsy, the presence of multiple bony
lesions on bone survey, and an abnormal monoclonal
immunoglobulin spike on serum or urine
electrophoresis

45. • Treatment of choice for solitary plasmacytoma in
the absence of instability or rapid paralysis is
radiation therapy.
• The dose of radiation to the spine for
plasmacytoma varies from 35 to 50 Gy
• Local control rates of up to 96% and survival rates
of up to 11 years have been reported
• Chemotherapy is generally withheld until
progression to multiple myeloma is documented

46. • When the diagnosis of multiple myeloma is
established, chemotherapy is indicated
• Prognosis is poor, with a median survival rate
thereafter of 2 years an a 5-year survival rate
of 18%
• Vertebroplasty can help relieve pain and
improve the quality of life in patients without
neurologic deficit
• Surgical decompression and fusion are
generally reserved for patients with
progressive neurologic deficit and deformity

47. Indications of surgery
• Patients with osteolytic lesions involving
greater than 50% of the vertebral body are
likely to require instrumentation.
• It has been recommended that surgical
intervention be considered when the
likelihood of future instability exceeds 50%,
• Local kyphosis is greater than 20%, or
• there is translational deformity

48. Chordoma
• Arises from notochord remenants
• 5th-7th decade
• 50% are sacrococcygeal
• 40% are sphenooccipital
• 10% other regions
• Lowgrade malignancy,
• Extremely difficult to resect because of their
proximity to the spinal cord and cauda equina.
• In 5% to 10% of cases, they tend to metastasize
within 1 to 10 years of the diagnosis

50. • Pain: local/ radicular
• Weakness
• Arising from sacrum: rectal dysfunction,
including constipation, tenesmus, or bleeding
hemorrhoids
• Palpable tumor on rectal examination can be
identified in most patients

51. • Consist of two cell types: a small, compact
stellate cell that is considered to be the precursor
of the more prevalent and larger physaliferous
cell containing mucinous vacuoles.
• Characteristic lobular appearance on MRI
• Generally avascular
• Often gray or partially translucent
• Consistency varies from firm and focally ossified
to a soft, myxoid, or semifluid material
• Pseudocapsule separating the tumor from
adjacent soft tissue
• Tumor is diffusely invasive within adjacent bone
without clear margins

52. • Percutaneous CT-guided biopsy
• Optimal treatment of chordomas is wide en
bloc resection
• Staged approach
– first a posterior approach is performed to mobilize
the posterior elements, free the dura from the
tumor pseudocapsule, and place posterior
instramentation, followed by
– an anterior approach to perform an en bloc
vertebrectomy

53. • Sparing the S3 nerve root on either side may
be sufficient to preserve bladder and fecal
continence.
• Loss of sexual function needs to be discussed
with the patient preoperatively.
• Local recurrence in patients undergoing en
bloc resection was 28%.
• Local recurrence in those where the tumor
capsule was violated was 64%

54. • Chordomas are not generally radiosensitive
• However, because of the high risk of recurrence,
postoperative radiation therapy is often
recommended
• 5-year survival rate has ranged, depending on the
source, from 50% to 77%,
• 10-year survival rate of 50%
• 30% of spinal chordomas develop metastases
• Chemo resistant. Imatinib, good results recently

55. Ewings sarcoma
• Males
• >80% second decade
• Frequency decreases from caudal to rostral
direction
• Pain, deficits, rectal mass
• Lytic masses on plain xrays and CT
• Paravertebral masses
• Infiltrating sheets of small, round to oval cells
with a scant amount of cytoplasm that tests
positive for glycogen

56. • Grossly, these tumors are gelatinous in
consistency and gray-white in color. Lesions
are poorly outlined, with extension into the
bony trabeculae as well as into the
paravertebral soft tissues
• Very vascular

57. • Optimal treatment : combination of radiation
therapy and chemotherapy
• Local radiation therapy to the spine is usually
given at a dose of 50 to 55 Gy, with inclusion of
an adequate margins
• Higher doses: postradiation myelopathy
• Local recurrence occurs in 22% of patients
receiving radiation alone and 18.7% of those
receiving surgery and radiation
• surgical debulking prior to radiation did not
improve outcomes
• Surgery should be performed only if a wide
resection is possible

58. • Accepted chemotherapy protocol developed by
the Intergroup Ewing’s Sarcoma Study (IESS)
consists of cyclophosphamide, vincristine,
dactinomycin, and doxorubicin
• More intense chemotherapeutic and radiation
therapy protocol (the IESS-II protocol) was
developed for the treatment of pelvic and sacral
Ewing sarcoma.
• Consisting of four-agent chemotherapy before
and after high-dose local irradiation
• Role of surgery in the treatment of spinal Ewing
sarcoma remains controversial
• Best performed after initial treatment with
chemotherapy and radiation

59. Prognostic factors
• Survival is improved in patients with
– local disease,
– tumors less than 500 mL in volume,
– peripheral involvement only, and
– who undergo gross total resection
• Poor prognosis
– Metastatic involvement,
– tumor volume greater than 500 mL,
– Central involvement, and
– who do not undergo resection.
• Aggressive surgery with radiation therapy might be an
important prognostic factor.
• The best prognosis is provided by local irradiation and
chemotherapy

60. • Osteosarcoma
• Chondrosarcoma

61. Metastatic spine disease
• Most common site of skeletal mets
• Sites of primary: breast, thyroid, kidney, lungs,
prostate, GIT

62. Surgical outcome assessment
• Overall neurologic status
• Ambulation
• Sphincter control
• Pain and suffering
• Survival rates
• Local recurrences
• Complications (including immediate
postoperative mortality)
• Reoperation rate
• Overall patient satisfaction

63. Prognostic factors
• Site of primary: aggressiveness of cancer can also
be classified as
– Slow growth (breast, thyroid, prostate),
– moderate growth (kidney, uterus), and
– rapid growth (lung, stomach, liver, colon, unknown)
• Concurrent mets
• Location of lesion
• Number of vertebra affected
• Age of patient

64. Prognostic factors contd
• Neurologic deficits : ambulation, sphincter
control, rate of neuro deterioration
• Timing of surgery: the effectiveness of
decompression undertaken < 48 hours after
the development of symptoms, was
significantly better for neurologic recovery
• Compounding effect

65. Outcome assessment tools
• Evaluation of patient functional status should
be based on (1) pain assessment, (2) profile of
mood states, and (3) overall performance
status

66. Surgical guidelines
Tokuhashi System for Preoperative Evaluation
of Metastatic Spine Tumors
Parameter Score
1 General condition (performance status) 0,1,2
2 Extraspinal bone metastatic foci 0,1,2
3 Number of metastases in the spine (vertebrae) 0,1,2
4 Metastasis to major internal organs 0,1,2
5 Spinal cord palsy 0,1,2
6 Primary site of the cancer (histopathology 0,1,2
Indication of surgery: score >9: excisional surgery
<5: palliative surgery

67. • For general condition 0 for poor condition (PS values, 10–40%); 1 for
moderate (PS values, 50–70%), and 2 for good (PS values, 80–100%).
• For extraspinal bone metastatic foci more than three, the score is 0;
between one and two metastatic foci, the score is 1; and for
nonmetastatic lesions, 2.
• For the number of metastases in the spine, the score is 0 for more than
three vertebrae; 1 for two metastases; and 2 for no more than one
vertebra.
• For metastasis to a major internal organ, the prognosis depends on the
resectability of the tumor: 0 for unremovable lesions; 1 for removable
lesions, and 2 for no metastasis.
• For the primary site of the cancer, the score is: 0 when the expected
survival is less than 3 months (lung and stomach); 1 for expected survival
rate of 3 to 12 months (kidney, liver, uterus, others, unidentified), and 2
for expected survival rate of more than 12 months (thyroid, prostate,
breast, rectum).
• Finally, the severity of spinal cord palsy was rated as 0 for Frankel grade A
and B (complete paraplegia) 1 for Frankel C and D (incomplete paraplegia),
and 2 for Frankel E (no paraplegia), respectively.

68. Harrington classification
Neuro status Structural defect
1 Not significant No vertebral collapse
2 Not significant Vertebral involvement without collapse or instability
(lytic or blastic lesion)
3 Major (sensory/motor) No significant bone destruction or instability (lytic
Tumor)
4 Not significant Mechanical pain from vertebral collapse ± Instability
5 Major (sensory/motor) Retropulsion of hard discovertebral elements ± kyphotic
deformity
surgical intervention for class IV and V lesions and conservative treatment for class I and
II, For Harrington category III lesions, with a neurologic deficit in the absence of major
destruction of bone or spinal instability, surgery should not be entertained unless the
tumor is radioresistant or unresponsive to chemotherapy

69. Assessment
Tokuhashi score: 9
- General condition: 2
- Extraspinal bone
metastases: 1
- No. of vertebrae: 1
- Major organ metastases: 2
- Origin: 2
- Spinal cord palsy: 1
A. Lateral roentgenogram of the thoracic spine of
a 72-year-old man with metastasis to the T7 vertebra
from cancerof the prostate and incomplete paraplegia
(ASIA C). B, AxialCT revealed osteolytic lesion in the
vertebral body. C, Tokuhashiscore was 9. The patient
was treated with corpectomy, reconstructionwith mesh
cage, and posterior stabilization (D). This resultedin
improvement of pain and neurologic rate in 15 months.

70. Treatment guidelines
Class 1 Chemotherapy or hormonal treatment or radiation
Class 2 Chemotherapy or hormonal treatment or radiation
± cement augmentation (for lytic lesions)
Class 3 Radiation ± cement augmentation (for lytic
lesions)
Class 4 Surgery, tokuhasi <5: palliative stabilisation
Surgery, Tokuhasi >9: radical excision with recon
Class 5 Surgery, tokuhasi <5: palliative stabilisation
Surgery, Tokuhasi >9: radical excision with recon

71. THANK YOU