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Fifth stage
Surgery
Lec-2
د
.
ياسر
طاقة
1/1/2014
Tumours of the Spines (Spinal Tumors)
As in the brain, any space occupying lesion around the soft encaged spinal cord will
produce the same symptoms, signs and even radiological appearance of a tumour.
15 % of primary CNS tumors are intraspinal.
Most of the primary CNS spinal tumors are benign.
Most present by compression rather than invasion.
Sites of Spinal Tumours:
Spinal tumours may be:
A. Extradural
B. Intradural: which may be either:
I.
Extramedullary (i.e. outside the cord)
(meningioma, neurofibroma), arise from
leptomeninges and nerve root.
II.
Intramedullary (i.e. inside the cord):
arise from cord substance including
astrocytoma, ependymoma, dermoid, epidermoid, teratoma, lipoma.
A. Extradural Tumours:
Pathological Types:
1. Metastatic tumours (secondary deposits): these are the most common tumours of
the spine, accounting for 98% of all spine lesions.
Although metastatic lesions may be found in each group, they are usually
extradural.
Areas involved in frequency are dorsal, cervical, lumbar and sacral.
These are also the commonest extradural tumours.
The most common sites of origin usually from the following organs in order of
frequency:
a. Breast (21%)
b. Lung (14%)
c. Prostate (7.5%)
d. Renal (5%)
e. Gastrointestinal (5%)
f. Thyroid (2.5%)
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Methods by which metastatic disease spreads to the spines:
a. Embolisation through the venous system (Batson's plexus): this is the most
frequent pathway.
b. Embolasation through the arterial system.
c. Direct extension.
d. Lymphatic spread.
2. Sarcoma
3. Chordoma
4. Neurofibroma: a neurofibroma may be "dumb-bell" in shape, the smaller part lies
within the neural canal while the larger part projects through an intervertebral
foramen and encroaches on the thorax.
Clinical Features of Extradural spinal tumours:
These tumours present with symptoms and signs of irritation of nerve roots preceding the
signs of pressure on the cord.
Differential diagnosis:
Prolapsed intervertebral disc in the lumbar and less commonly in the cervical regions, may
produce identical symptoms.
B. Intradural Tumours:
I. Intradural Extramedullary Tumours:
Pathological Types: the most important are
1. Meningiomas
2. Neurofibromas
Clinical Features of Extramedullary Tumours:
1. Sensory and motor weakness. The anterior or posterior roots tend to be involved
first; the proximal level of the sensory and motor changes depends on the site of the
tumour.
2. Symptoms due to pressure on the cord itself occur later, there may be the Brown-
Sequard hemisection phenomenon, with weakness and loss of vibration sense on
the same side as the lesion and loss of pain on the opposite side. Paraplegia will
follow if pressure is not relieved.
II. Intradural Intramedullary tumours:
Pathological types: Intramedullary tumours are usually:
1. Ependymomas.
2. Astrocytomas (Gliomas).
Clinical features of Intramedullary Tumours:
1. Cord signs present first, while root pains tend to occur later.
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2. Paralysis may occur on both sides, or sometimes may be of the crossed type,
where there is anaesthesia on one side and paralysis and hyperaesthesia on the
other.
3. Dissociated sensory loss may occur.
4. Urinary incontinence usually appears early.
Investigations of Spinal Tumours:
1. Plain X-ray of the spines should be done in anteroposterior, lateral and oblique
views.
Erosion of bone or some other bony abnormalities is seen nearly 50% of patients
with spinal tumours.
2. CT scan and MRI of the spines will show the lesion clearly.
3. Myelography has been largely superseded by CT scan and MRI.
Treatment of Spinal Tumours:
Laminectomy is performed and if possible the tumour is removed.
Removal of the tumour and laminectomy help in decompression of the cord.
Acute paraplegia demands an emergency operation.
If the vertebral body pathology with anterior compression, a corpectomy done
with fusion and fixation.