Spinal cord tumors [extra-medullary , intra-medullary]

1. SPINAL CORD TUMORS
BY : DR / AHMED MOHAMMED DEBES
NEUROSURGERY RESIDENT AT AHMED MAHER TEACHING HOSPITAL
CAIRO, EGYPT.
TUESDAY 09/10/2014

2. Spinal Cord Tumors
Intra-dural
Extra-dural
Intra-medullary Extra-medullary

3. Extra-medullary
Nerve Sheath
Tumors
Meningioma
schwannomas neurofibromas
s
Filum Terminale
Ependymomas
• Gross
• Micro
• Asso.
Neurofibromas
• Fusiform
• Fibrous tissue +
nerve fibers
• Neurofibromatosis
type I
Schwannomas
• globoid masses,
suspended eccentrically
• Antoni-A(elongated
cells) Antoni-B(stellate-shaped
• schwannomatosis

4. • 4th – 6th decade , male = female
•Mostly affect dorsal root
most common
30%
(cervical)
10%
1%

5. arachnoid cap
cells
decade ,
•Mainly , upper
cervical spine and
foramen magnum
•ventral or ventrolateral,
may
•10%
•Do not penetrate the
pia

6. decade ,
•Myxopapillary
ependymomas
•Cuboidal cells surrounding a
vascularized core of
hyalinized connective tissue
•Benign

7. neural crest, benign,
neurosecretory granules
dumbbell tumors in
pediatric
thoracic spine
rarely
cause mass effect
CSF drop metastases,
direct penetration of the
dural root sleeve

8. •Depend on location
•Local back pain & radicular
pain
•Worsening pain on
recumbency

9. Signal abnormalities
CSF capping
cord/cauda displacement
•T1 iso/ slightly hypointense
•T2 hyperintense
•Contrast enhancement

10. benign,
excision, Recurrences are rare
-Posterior laminectomy
-unilateral facetectomy
-open dura
-Dorsal (visualized), Ventral
(dissect dentate ligament
-Cauterize tumor
-Neurostimulation
-Dumbbell shaped (resection of
both nerve roots)

11. -Surgical removal easy due to
- absence of bony involvement
- well-defined spinal epidural
space
- lack of venous sinus
involvement
-Recurrence 10 %
- Posterior laminectomy
- Anterior approaches for purely
ventral tumors
-Management of the dural base
• excision of the dural then graft
• extensive in situ coagulation

12. -Role of surgery depends on
size of the tumor and its
relationship
-Gross total en bloc resection
- Small, well circumscribed within
the fibrous coverings & easily
separable from the nerve roots
-Subtotal
-Radiation therapy

13. -First 3 decades of life
-Most common pediatric
intramedullary cord tumor
-60% of occur in the
cervical
-20% associated syringes
-Most are grade I or II
-Associated NF1
Intra-medullary
Astrocytomas Ependymoma
s
Hemangioblasto
ma
80% 8%

14. -Most common
intramedullary tumors in
adults
-Male = Female, middle
age
-65% have associated
cysts
-Associated NF2
-Cellular ependymoma
the most common
-Benign, unencapsulated,
circumscribed and do not

15. -Associated with von
Hippel-Lindau syndrome
(AD)
-At any age
-Associated syringes
-Benign tumors of
vascular origin
-Circumscribed, not
encapsulated
-located dorsally or
dorsolaterally

16. most
common dysembryogenic
lesion, increased fat
deposition in metabolically
normal fat cells, subpial
location.
The lung
and breast are the most
common primary tumor
sites
history of radiation

17. •Nonspecific
neurological deficit
can cause abrupt
deterioration
(ependymomas)
and
dysfunction occur early

18. Cord enlargement
Enhancement
•T1 iso/ slightly hypointense
•T2 hyperintense
-uniform contrast enhancement
-Polar cysts
-Heterogeneous contrast
enhancement
-Irregular margins

19. •Microsurgical removal is the
most effective treatment of
ependymomas &
hemangioblastomas.
•For astrocytomas are more
controversial.
•Resection should be limited to
tumor tissue
•Preservation of neurological
function rather than complete
tumor resection is paramount

20. • Preoperative steroids
and antibiotics
• General anesthesia,
intubated & prone
• Sensory and motor
evoked potentials
monitoring
• Midline skin,
subperiosteal bony
dissection
• Laminectomy extend
one segment above
and below the tumor
•The facets are
preserved.

21. • Strict hemeostasis before the
dura is opened
• The dura is opened in the
midline and tented laterally
with sutures
• Operating microscope
• The arachnoid is opened
• Cord inspected for surface
abnormalities ,U/S localize
tumor
• midline myelotomy through
the posterior median septum
• dorsal midline -- midpoint
between the dorsal nerve root
entry zones bilaterally
• Midline crossing vessels in

22. • Pia incised sharply with a
micro knife or scissors
• myelotomy extend over the
entire rostrocaudal extent of
the tumor
• Spreading the posterior
columns gently with micro
forceps
• Pial traction sutures are
placed
• Technique of tumor removal
is determined by the surgical
Objective (biopsy , removal)
• Internal decompression with
an ultrasonic aspirator or
laser

24. Q) WHAT TYPES OF NERVES DO
NEUROFIBROMAS GENERALLY ARISE
FROM?
•Dorsal root
•Ventral root
•Both of them

25. INTRADURAL SPINAL NERVE SHEATH TUMORS
ARE TOTALLY MALIGNANT ( T ) OR ( F )
• False only 2.5 % are malignant

26. MENINGIOMAS USUALLY ARISE
FROM WHICH TYPE OF CELLS ?
•Arachnoid cap cells

27. ………. ARE BENIGN TUMORS OF
VASCULAR ORIGIN ?
•Hemangioblastomas

28. Q) IN RESECTING AN INTRAMEDULLARY SPINAL
CORD TUMOR, WHAT IS A SURE WAY TO
RECOGNIZE THE MIDLINE IF THE TUMOR IS
DEFORMING THE NORMAL SPINAL CORD
ANATOMY?
• Midpoint between the dorsal nerve root entry zones
bilaterally

29. Q) WHAT IS THE MOST COMMON
INTRAMEDULLARY SPINAL CORD TUMOR IN
ADULTS?
•Ependymoma
•Meningiomas
•Astrocytoma
•Hemangioblastoma

30. Q) WHAT IS THE MOST COMMON
INTRAMEDULLARY SPINAL CORD TUMOR IN
PEDIATRIC ?
•Ependymoma
•Meningiomas
•Astrocytoma
•Hemangioblastoma

31. THE END
THANK YOU