This presentation prepared based on the Orthopedic Knowlege update spine 4 chapter 43

1. Spinal Tumors
Chapter 43
Page 509-514

2. Introductions
 The advent of MRI has led to widespread recognition of
interadual lesion.
 It can be difficult to distinguish as interdural lesion from
transverse myelitis, demyelinating condition or other lesion
not suitable for surgery.
 A carful physical exam can isolate the level of involvement
along the spinal cord.
 The risk of surgical damage to critically important regions
surrounding a lesion must be weighted against risks
associated with nonsurgical.

3.  Primary CNS tumor are more common intracranially,
2% to 4% such tumor occur in the spine.
 Primary CNS tumor of the spine is classified as;
- Exteradural
- Interadural exteramedullary
- Interdural interamedullary.
• an exteradural tumor typically represents a metastasis or
lymphoma.
Primary Spinal Tumors

5. Interadural Exteramedullary Tumor
 Its account for 60% to 70% of all primary spinal cord
tumors.
 Most of this tumor are nerve sheet tumor or
meningioma.
 Patient usually have symptoms related to cord
compression, including local or radicular pain.
 Patient often report deep seated pain in the back.

6. Schwannoma
 Is a type of nerve sheath tumor.
 Usually is benign, although malignant subtype is exist.
 Commonly originate from dorsal nerve root.
 The peak incidence is during the forth and fifth decades
of life.
 They occur equally among male and female.
 The tumor may be associated with neurofibromatosis
type II

7. MRI Appearance
 On MRI, a schwannoma appears as a lesion arising from
the dorsal root.
 Some time as dumbbell lesion with both interadural and
exteradural components.
 T1 weighted MRI image show isointensity
 T2-weighted image show marked hyperintinsity.
 The contrast enhancement is variable

10. Other Characteristics
 Tumor that have existed for long period of time can erode
the neural foramina and scalloping of posterior vertebral
body.
 Schwannoma occur: 31% in cervical spine 24% in cauda
equina, 22% in thoracic spine, 16%upper cervical spine,
and 7%. conus medullaris
 It can be difficult to distinguish a schwannoma from a
neufibroma.

11. Neurofibroma
 It originate in the peripheral nerve and tend to favor the
ventral root.
 They are classified as general of plexiform.
 A solitary general neurofibroma is a discrete well-
circumscribed lesion with a fusiform or globular
appearance.
 The peak incidence is during the fourth and fifth decades of
life.
 Equal distribution among men and women.

12.  The presence of multiple neurofibromas can suggest
neurofibromatosis.
 50% of patients with neurofibromatossi type I have a
malignant peripheral nerve sheath tumor
 Like schwannoma, a neurofibroma appears as a well-
circumscribed, rounded or fusiform lesion that may be
dumbbell shaped.
 The imaging characteristics also are similar
 Isointensity on T1W-MRI and marked hyper intensity on T2
w-MRI.
 With intense contrast enhancement.

13. T1: hypointense
T2: hyperintense
T1 C+ (Gd): heterogenous
enhancement

14. Meningioma
 Is a dura-based benign tumor that accounts for 25% of all
primary spinal cord tumors.
 More than 80% of spinal meningiomas are diagnosed in
women
 Most tumor occur in thoracic spine.
 In men, meningiomas occur with equal in the cervical and
thoracic.
 The peak incidence of these tumors is during the fifth and
sixth decade of life.
 94% of meningiomas are interadural and 6% are
exteradural.

15. MRI Appearances
 It appear as a well circumscribed, dura based lesion.
 Tumor is isointense or hypointencse on T1w-MRI
 On T2 w-MRI slightly hyperintense.
 Homogenous intense in contras enhancement.
 Calcification sometimes are present.
 In contrast with neurofibromas meningiomsa usually are
entirely intradural or exteradural.
 Multiple meningiomas are particularly associated with
neurofibromatosis type II

17. Meningeal
hemangiopericytoma Is an exteremely rare tumor with only a few incidences.
 Malignant feature are more common than in other types of
intradural exteramedullary tumor.
 The lesion has lobular appearance on MRI
 Heterogeneity on T1 and T2 MRI angiogram reveals
corkscrew vessels with an associated tumor blush.

18. Dermoid and Epidermoid
Cysts They arise from abnormal heterotopic presence of
ectodermal cells in the neural tube during embryogenic
development.
 Approximately 40% of epidermoid cysts in the spine are a
late complication of lumbar puncture in which tissue was
implanted in the thecal sac.
 These lesions usually are found in the lumbosacral spine,
although they also can appear in the thoracic region.

19.  Epidermoid cyst typically appear during the fourth decade
of life.
 Dermoid appear during the third decade.
 If the lesion rupture chemical meningitis can ensue.
 An epidermoid cyst can be difficult to see on MRI because it
consistency is similar to that of cerebrospinal fluid.
 Diffusion-weighted MRI can be useful for distinguishing
an epidermoid cyst from an arachnoid cyst.
 Dermoid cyst contain solid cholesterol, and their signal
intensities can be similar to those of fat.

20. Lipoma
 Intradural extramedullary lipomas are congenital.
 The typical regions of involvement are the lower thoracic
and lumbosacral spine.
 A lipoma in the region of the cauda equina can cause
tethered cord syndrome.
 On MRI Lipoma is hyperintence on T1 and hypointence on
T2

21. T1: hyperintense T2: hypointense
fat-suppressed
sequences:

22. Paraganglioma
 Is a nonsecrating tumor derived form paraganglion cell of
the autonomic nervous system.
 These tumor are considered benign.
 The mean age of patinas is 48 years.
 More men than women are affected.
 Typically involves the conus medullaris, cauda equina or
filum terminale.

24. MRI Appearance
 The signal is hypointense or isointense on T1-weighted MRI
and heterogeneous on T2
 Hemosiderin deposits on the periphery of the tumor can
appear as a rim of T2-weighted or gradient echo
hypointensity.
 The infusion of contrast can produce the classic salt-and-
pepper appearance.

25. Intradural Inramedullary
Tumors Intramedullary tumors represent 20% to 30% of all
intradural tumors in adults and 50% of intrdural tumors in
children.
 More than 80% of intramedullary tumors are classified as
gliomas.
 30% to 40% of intramedullary tumors are classified as
astrocytoma's.
 60% to 70% are classified as ependymomas.
 Astrocytoma are more common in children and
ependymomas are more common in adults.

26.  Hemangioblastoma accounts for 3% to 8% of primary
intramedullary tumors
 This tumor is associated with von Hippel-Lindau disease in
15% to 20% of patients.
 Only 2% of intramedullary tumors are of metastatic origin.
 The symptoms of the tumor vary with its location.
 Local or radicular pain is common.
 Motor deficits occur in 50% to 69%. Sphincter dysfunction
occur in 64% to 65%
 Sphincter dysfunction is the initial symptoms in 14% to
38%

27. Ependymoma
 Is the most common intramedullary tumor.
 Typically classified as cellular or myxopapillary.
 Myxopapillary ependymoma accounts for approximately
40% to 50% of spine ependymomas.
 Clear-cell, papillary, anaplastic, and mixed variant subtypes
also exist.

30.  The incidence of cellular ependymoma peaks during the
fourth and fifth decades of life.
 Cellular ependymoma represents 40% to 60% of all
intramedullary tumors in adult and 16% to 23% in children.
 Myxopapillary and cellular ependymoma are histologically
distinct.
 Cellular ependymoma appear as a focal enlargement of the
spinal cord.
 The cervical spine affected in 42% of patients
 On MRI is diffuse heterogeneous contrast enhancement
with isointensity or hypointensity on T1 and hyperintesity
on T2

31. Astrocytoma
 75% of astrocytomas are benign.
 They typically occur during the third decade of life.
 No preference for men or women.
 In children represents as many as 80% to 90% of
intramedullary tumors.

32. MRI Appearances
 This tumor have fusiform appearance on MRI with
irregular margins.
 Intratumoral, caudal or rostral cysts can evolve into
syringomyelia.
 The appearance is hypointense to isointense on T1
 On T2 is hyperintense, with variable contrast enhancement.
 In high grade lesion, there is more prominent enhancement
intratumoral cysts can appear and surrounding edema and
necrosis become more obvious.
 The tumor is more common in the cervical spine of adults

34. Hemangioblastoma
 Is a benign vascular tumor.
 10% to 25% are associated with von Hippel-Lindau disease.
 Sporadic tumors occur predominantly in men typically
during the fourth decade of life.
 The tumor favor the dorsal location and thus tends to affect
sensation.
 Most of this lesion are solitary and are found in cervical of
thoracic spine.

35. MRI Appearances
 MRI reveals a homogeneously enhancing nodule
accompanied by a cyst and sometimes by peritumoral
edema or syringomyelia.
 Small lesion appears isointense on T1and hyperintense on
T2
 Large lesion appears isointense to hypointese with T1 and
hetrogeneous with T2
 Heterogeneous contrast enhancement is seen within the
nodule.

37. Sub Ependymoma
 Fewer than 50 incidence of subependymoma have been
reported.
 Predominantly in men in their fourth or fifth decade of life.
 Is located in cervical spine and less commonly in the
thoracic spine.
 A subependymoma mimics a spine ependymoma on MRI

38. Other Interadural Intermedullary
Tumors
 Oligodendrogalioma 2% located on spine.
 Ganglioglima
 Lymphoma
 Germinoma
 Melanoma
 Lipoma is a congenital lesion
 Teratoma
 Intamedulary metastasis
References: 1- Orthopedic knowledge update spine chapter 43
2- radiopaedia.org/articles/spinal-nerve-sheath-tumours.
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