Spinal tumors can be primary tumors arising from the spine or metastatic tumors from other parts of the body. Metastatic tumors are far more common, accounting for 97% of spinal tumors. Common symptoms include back pain, weakness, and neurological deficits. Imaging techniques like plain radiography, CT, MRI, and bone scans are used to identify and characterize tumors. Biopsy is needed to determine if a tumor is benign or malignant. Management depends on the type and extent of tumor and may involve surgery, radiation, chemotherapy, or observation. Prognosis is based on scoring systems that consider primary tumor type, extent of metastasis, neurological function, and other factors.

1. Spinal Tumor
Consultant :
Dr. dr. Agus Hadian Rahim, Sp.OT(K), M.Epid., MH.Kes
Dr. dr. Ahmad Ramdan, Sp.OT(K), M.KM
dr. Abdul Kadir Hadar, Sp.OT(K)
Reza Devianto Hambali, dr
Referat 2 – Spine Division

2. BACKGROUND
• may arise from local lesions, adjacent or from distant malignancies by
hematogenous or lymphatic routes.
• metastatic tumors are far more common than primary lesions in the spine,
accounting for 97%
• location of the lesion within the vertebra is important prognosticator for
benign or malignant disease.

3. EPIDEMIOLOGY
• Vertebral column is the most common osseus site for secondary
malignancy (>90.000 new cases in US)
• Primary tumors of the vertebral column : relatively rare (2.5 to 8.5 cases
per year
• Hemangioma : most common benign tumor (20%–30%)
Plasmacytoma : most common malignant primary spinal (30%)

4. SYMPTOMS
• Pain (85%) → 20% Radicular symptoms
• Weakness (40%)
• Objective neurologic deficits (35% benign tumors & 55%
malignancies)
• A palpable mass (16%)
• Bowel and bladder dysfunction

5. IMAGING TECHNIQUE
1. Plain radiograph
 should be the first test in any case
 early lesions may be hard to detect : is not apparent
until 30-50% the trabecular bone destroyed
 classic early sign : winking owl

6. IMAGING TECHNIQUE
2. Bone Scan (99mTechnetium)
 ideal to detect in symptomatic patients
with negative or equivocal radiographs
 poor specificity

7. IMAGING TECHNIQUE
3. CT Scan
 improved specificity : detection of spinal neoplasms.
 lesions may be visualized at an earlier time
 only effective when the right area is studied

8. IMAGING TECHNIQUE
4. MRI
 the only reliable way  assess spinal cord and nerve root compression

9. BIOPSY
Three forms of biopsy
• excisional
• incisional
• needle biopsy or aspiration

10. BIOPSY
Basic principles
• incision should be placed with the tumor during the definitive procedure
• should be approached in the most direct manner possible
• tissues should be handled carefully & hemostasis should be meticulous
• bone should not be removed or windowed unless absolutely necessary
• specimen should be large enough  histologic, ultrastructural analysis,
immunologic stains.

11. PRIMARY TUMORS of BONE
BENIGN
Osteochondroma
• the most common benign tumor of bone
• usually asymptomatic
• second and third decades
• spinal cord compression : 56% cervical, 38% thoracic, 6% lumbar

12. PRIMARY TUMORS of BONE
Aggressive “Benign”
1. Osteoblastoma & Osteoid osteoma
• Show a propensity for spinal involvement, usually the posterior elements
• Osteoblastomas become considerably larger than osteoid osteomas
• Painful scoliosis (78% & 54 %)
• Treatment : excision
• Aggressive osteoblastoma : borderline or intermediate osteoblastic tumor

13. PRIMARY TUMORS of BONE
Aggressive “Benign”
2. Hemangioma
• common lesions, + 10% of all patients, rarely
symptomatic
• occur in the vertebral body, extend to the posterior
• Radiosensitive
• Alternative : ethanol injection/traditional embolization

14. PRIMARY TUMORS of BONE
Aggressive “Benign”
3. ABC
• expansile lesions, thin-walled, blood-filled cystic cavities  bone
destruction
• rare lesions, at any level
• involve the posterior elements ~ 100%
• involve adjacent vertebrae (3-4)
• Treatment : simple curettage + bone grafting, complete excision,
embolization, and radiation, reconstruction + stabilization

15. PRIMARY TUMORS of BONE
Aggressive “Benign”
4. GCT
• slow-growing, locally aggressive, do not metastasize
• geographic lytic appearance & marginal sclerosis
• CT : evaluation preoperatively  complete resection
• CT : crucial in the early identification of recurrences
• poor prognosis : locally invasive & difficulty in
obtaining a wide margin  high local recurrence
rates

16. PRIMARY TUMORS of BONE
MALIGNANT
1. Osteosarcoma
• 2% : primary osteogenic sarcoma, 95% :
anterior elements
• pain & often with neurologic compromise
• outcome : has traditionally been poor (6-10
months)
• neoadjuvant chemotherapy & extent of
surgical resection

17. PRIMARY TUMORS of BONE
MALIGNANT
2. Ewing Sarcoma
• 3.5% of all Ewing tumors arise in the spinal
column
• majority originating in the sacrum
• multiagent chemotherapy, high-dose
radiotherapy, surgical extirpation

18. PRIMARY TUMORS of BONE
MALIGNANT
3. Chordoma
• relatively rare
• Predominantly : fifth or sixth decade of life

19. PRIMARY TUMORS of BONE
MALIGNANT
4. Chondrosarcoma
• 7-10% of chondrosarcomas arise in the spinal column.
• Most of these tumors are low grade → grow slowly
and are relatively resistant to radiotherapy and
chemotherapy.
• A high propensity for local recurrence leads to the
poor prognosis of spinal chondrosarcoma.

20. PRIMARY TUMORS of BONE
MALIGNANT
5. Solitary Plasmacytoma
• manifestations in a continuum of B-cell lymphoproliferative diseases.
• treatment : radiation.
• Although radiotherapy is effective in local control, it is not effective in
restoring spinal stability.
• Fractures and progressive vertebral collapse may occur.

21. PRIMARY TUMORS of BONE
MALIGNANT
6. Lymphoma
• systemic disease with skeletal manifestations or as an isolated bony tumor
referred to in the past as a reticulum cell sarcoma.
• treatment : radiation therapy with or without chemotherapy.
• surgical treatment is primarily limited to biopsy, cord decompression, or
stabilization of pathologic fractures, though some recurrences after radiation
treatment may need to be surgically resected.

22. METASTATIC TUMORS
• Skeletal metastases are produced by almost all forms of malignant disease
but are most commonly secondary to carcinomas

23. METASTATIC TUMORS
PATHOPHYSIOLOGY
• Tumor emboli → the bloodstream tend to lodge in the natural filters of
the vascular tree (the capillary beds of the liver, lungs, and bone marrow)
→ bypass the capillary beds of the liver and lungs
• Tumors of the lung → segmental arteries → the vertebral column directly
• Breast tumor → azygous vein communicates with the paravertebral
venous plexus → thoracic region

24. TUMOR CLASSIFICATION
 tried to classify metastatic tumors according to symptomatic, anatomic &
prognostic data and results of treatment strategies were obtained

25. TUMOR CLASSIFICATION
1. Tomita Anatomical Surgery Classification
• described the tumoral involvement of the vertebra
• allows for easily memorable tumor spreading as it follows
a systematic description

26. TUMOR CLASSIFICATION
2. The Weinstein-Boriani-Biagini (WBB)
• involvement of a specific vertebra
• arranged clockwise in 12 sectors on an axial
• confined to five layers of tissue penetration : A–E

27. TUMOR CLASSIFICATION
2. The Weinstein-Boriani-Biagini (WBB)
a. Vertebrectomy
 zones 4–8, or 5–9 with at least one
pedicle free of tumour
b. Sagital resection
 zones 2–5 or 8–11, with the lesion
possibly involving the pedicle or
transverse process

28. TUMOR CLASSIFICATION
2. The Weinstein-Boriani-Biagini (WBB)
c. Posterior arch resection
 lesions restricted to zones 10–3.

29. MANAGEMENT
• Not all patients with spine tumors require surgery
• Benign tumors, those with diffuse metastases in whom the primary is known
: can simply be observed.
surgical indications
1. an isolated primary or metastatic lesion or a solitary site of relapse;
2. pathologic fracture or deformity with bony impingement
3. radioresistant tumors—metastatic or primary
4. tumor progression despite or following radiotherapy
5. Segmental instability with significant pain or impending neurologic injury
6. inability to obtain tissue diagnosis by other means.

30. MANAGEMENT

31. PROGNOSIS
1. Karnofsky Performance Status (KPS)
• quantify patients' general well-being and activities of daily life.
• used to compare effectiveness of different therapies and to assess the prognosis

32. PROGNOSIS
2. Tokuhashi Score
• scoring system for the preoperative
evaluation of a patient’s prognosis with a
metastatic spinal tumor

33. PROGNOSIS
2. Tomita Score

34. PROGNOSIS
3. Baur scoring system
• analysis of prognostic factors: the site of
the primary tumor, metastatic load, and
pathologic fracture
• useful until 4 years after treatment

35. ALGORITHM

36. TAKE HOME MESSAGE
1. Metastatic tumors account for 97% of all spinal column tumors. (adenocarcinoma of lung,
breast, prostate, kidney, gastrointestinal tract, and thyroid )
2. Pain and weakness are the most common presenting complaints
3. The most classic radiographic “winking owl” sign on AP view
4. Goals of treatment :
• obtain a definitive diagnosis through biopsy or primary Excision
• institute appropriate surgical or medical treatment according to tumor type and the patient’s
condition at presentation
• preserve neurologic function & maintain spinal column stability
5. Radiotherapy is the initial treatment
6. Not all patients with spine tumors require surgery
7. Classification, evaluation, and scoring systems  useful in the selection of suitable treatment
strategies

37. THANK YOU