spinal tumors

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.
END OF SPINAL CORD
END OF DURA

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 met 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. • 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
-Lung
-Breast
-Prostate
-Lymphoma
• 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

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: x-ray 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
EXTRADURA
L 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. • 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.
DROP METS

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