Neurosurgical Consultants: Spine & Spinal Cord Tumors: Spine & Spinal Cord Tumor Overview

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James E. Bland, MD, FAANS

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SPINE & SPINAL CORD TUMOR OVERVIEW

"Spinal cord tumors, while rare, can leave patients with catastrophic neurological impairment."

Spinal Cord Tumors and Tumors of the Bone of the Spinal Column are an area of specific interest for Dr. Martin L. Lazar and the staff of Neurosurgical Consultants. Significant developments influencing the successful treatment, in most cases, of Intraspinal Tumors (tumors within the Spinal Canal) involve the use of highly advanced Minimally Invasive Microsurgical Techniques.

The majority of these potentially catastrophic patient problems can be successfully managed using a MINIMALLY INVASIVE BILATERAL LAMINECTOMY UNILATERAL (one-sided) APPROACH. This revolutionary concept in Neurosurgery greatly limits the amount of surgical exposure required and therefore reduces the amount of tissue (including the muscles of the Spine) that are touched and retracted during the operation. The BENEFITS OF THIS INCLUDE LESS POST-OPERATIVE PAIN, EARLIER MOBILIZATION, DIMINISHED HOSPITAL STAY, LESS RISK TO COMPLICATIONS, EARLIER RETURN TO ACTIVITIES AS WELL AS LOWER OVER-ALL COSTS.

FOR ADDITIONAL INFORMATION ABOUT MINIMALLY INVASIVE TREATMENTS OF SPINAL CORD TUMORS, PLEASE REVIEW OUR INTRODUCTION TO SPINAL CORD TUMOR CASE STUDIES.

A BRIEF REVIEW OF ANATOMY

Spinal Tumors are usually classified by their relationship to the Spinal Cord and its coverings. The Spine is composed of individual bones (Vertebrae) stacked one on top of the other in a column. There are several parts to each Vertebra. The front (Anterior) part of the Vertebra consists of an oval shaped Vertebral Body (the major weight bearing portion of the Vertebra.) The back (Posterior) portion to the Vertebra consists of an arch of bone (Lamina and Spinous process) to which the large and important paraspinal muscles are attached. The bony arch of each Vertebra is connected to the Vertebral Body by two small columns of bone (Pedicles). The Spinal Canal (the circular center portion of the Vertebra) is formed by the two (2) Lamina (one on either side in the back), the Pedicles on both sides and the Vertebral Body in the front. The Spinal Cord and its Nerve Roots are contained within the Spinal Canal and are covered by a fibrous tubular membrane called "Dura Mater".

Figure1. Cross-sectional diagram of the Spine & Spinal Cord

One convenient way to understand this anatomy is to consider that the Spinal Cord and Spinal Nerves live within a "house made of bone" (the Spinal Canal). The "roof" of the house is formed by the Lamina. The "walls" are formed by the Pedicles and the "basement" by the Vertebral Body. A pair of Spinal Nerves will exit the Spinal Canal at every Vertebral Level through "windows" in the "walls" which are formed by the Pedicles of adjacent Vertebrae.

ANATOMICAL CLASSIFICATION OF SPINAL CORD TUMORS

A. Intraspinal Extradural Tumors

Tumors that are located WITHIN the Spinal Canal and OUTSIDE the Dura Mater are called "Intraspinal Extradural Tumors". Most of these are Metastatic Tumors (cancerous tumors that originate in another organ), which have spread to the Bony Vertebrae and then extend into the Spinal Canal. These Tumors REMAIN OUTSIDE the DURA MATER. Some very rare Benign Fatty Tumors (Lipomas) can be found in the Epidural Space as well, a condition called "Epidural Lipomatosis".

B. Intradural-Extramedullary Tumors

Tumors ARISING INSIDE the Dura Mater, but OUTSIDE the actual substance of the Spinal Cord are termed Intradural-Extramedullary Tumors. The majority of these tumors are Neurofibromas (Nerve Sheath Tumors) or Meningiomas.

C. Intramedullary Tumors

Tumors ARISING within the substance of the Spinal Cord itself are called "Intramedullary Tumors". These are usually Astrocytomas or Ependymomas. Other varieties of Intramedullary Tumors include Hemangioblastomas, Lipomyelomeningocele (Lipoma of the Conus Medullaris) and Lipomas of the Terminal Filum.

It is important to understand that different types of tumors often behave differently and may require treatments that are specific to the characteristics of that tumor. Details of these various types of tumors are explained in more detail in the following material.

SPINE TUMOR FACTS

General:

Spinal Cord Tumors are less common than Brain Tumors. About 10,000 Americans develop Primary Spinal Cord or Metastatic Spine Tumors each year.
Although Spinal Cord Tumors affect people of all ages, they are most common in young and middle-aged adults. (National Institute of Neurological Disorders and Stroke)
Spinal Cord Tumors, while rare, can leave patients severely impaired neurologically. Modern Neuroimaging capabilities (such as MRI and CT Scanning) have allowed these lesions to be diagnosed earlier thus permitting more timely intervention.
Advanced Minimally Invasive Microsurgical Techniques and other specialized treatments can help to minimize the effects of these potentially devastating types of tumors.

PRIMARY SPINAL CORD TUMORS: These are Tumors that derive from cells within the Spine/Spinal Cord

90 percent of Primary Spinal Cord Tumors are BENIGN.
The most common Primary Spinal Cord Tumors are Intradural Extra-medullary (located WITHIN the covering of the Spinal Cord, the Dura Mater, but OUTSIDE the substance of the Spinal Cord itself.) The most common of these are Meningiomas, Neurofibromas and Schwannomas.
The majority of these tumors are slow growing, although some Spinal Cord Tumors can grow rapidly.
Malignant Primary Central Nervous System (Brain & Spinal Cord) Tumors rarely spread out to other body parts although some can "seed" themselves within the Cerebrospinal Fluid (CSF) pathway that surrounds the Brain and Spinal Cord. (National Institute of Neurological Disorders and Stroke)
Men & women are affected equally by benign Spinal Cord Tumors except for Meningiomas which disproportionately affect more women.
The THORACIC region of the Spine is involved more frequently than the CERVICAL region by these tumors. The LUMBO-SACRAL region is the least affected.

INTRAMEDULLARY "PRIMARY" TUMORS (GLIOMA)

The term "GLIOMA" refers to a "family" of tumors, which arise from cells known as "GLIAL CELLS". This series of cells comprises the "glue" cells of the Central Nervous System (CNS), in contradistinction to the "Neurons", which are the "action" cells of the Brain and Spinal Cord. They comprise half the Central Nervous System (CNS) by volume. There are three (3) different cell types in this cell series. The "Astrocyte" was so named, because it resembles the shape of a star, when looked at under a microscope. The next most common cell in this series is the "Ependymal Cell", which lines the cavities of the Brain (called Ventricles) as well as the Central Canal (a small channel within the center) of the Spinal Cord. The Ventricles and Spinal Canal are normal structures within the Brain and Spinal Cord, where Cerebrospinal Fluid (CSF) is manufactured or "flows". The last cell type is the "Oligodendrgogliocyte" (Oligo), which is the cell within the Brain and Spinal Cord responsible for making the insulating material (called Myelin), that surrounds the fibres (axons) which transmit electrical impulses within the Brain and Spinal Cord.

Each of these cell types is capable of forming a tumor. The Neurosurgeons of Neurosurgical Consultants regard ALL OF THESE AS MALIGNANT TUMORS. The degree of malignancy, and therefore, biological aggressiveness can vary from quite indolent to extremely aggressive. These tumors are generally categorized according to their degree of aggressiveness, as judged by a number of factors. Neuropathologists (specialists trained to examine these tumors under powerful microscopes), have tended to "grade" these tumors from 1 to 4, with "4" being the most aggressive and "1" being the least malignant.

Tumors that originate from Astrocytes are termed "ASTROCYTOMA"; those arising from Ependymal Cells are called "EPENDYMOMA" while those originating from Oligodendrogliocytes are called "OLIGODENDROGLIOMA".

All of these tumors have a tendency to "infiltrate" within the Brain and/or Spinal Cord by tracking along the fibre pathways that interconnect every part of the Brain (or Spinal Cord) to every other part of the Brain (or Spinal Cord). Very rarely do these tumors ever spread beyond the Brain or Spinal Cord. However, they do have the capacity to spread (or seed) within the Cerebrospinal Fluid (CSF) pathway.

INTRADURAL EXTRAMEDULLARY TUMORS

The most common of all the Primary Spinal Cord Tumors are Intradural Extra-medullary (located WITHIN the covering of the Spinal Cord, the Dura Mater, but OUTSIDE the substance of the Spinal Cord itself) with most of these being Meningiomas, Neurofibromas and Schwannomas. The vast majority of these tumors are BENIGN and slow growing.

Meningiomas derive from the embryological precursor of the "Meninges" (the covering of the Brain and Spinal Cord) called the "Cap Cell". While these tumors are almost invariably benign and slow growing, they can produce severe Neurological deficits once they reach a size sufficient to severely compress the Spinal Cord and/or Nerve Roots. While they DO NOT usually INVADE the Spinal Cord or Nerve Roots, these tumors can have an intimate relationship with these the surrounding neural structures and their blood supply that makes removal somewhat challenging. Meningiomas CAN INVADE the surrounding Dura Mater, an issue which then requires the surgical removal and replacement of the involved section of Dura (as well as the substance of the intradural portion of the tumor) in order to "cure" the patient.

Neurofibromas and Schwannomas derive from the cells (Schwann cells) that form the Myelin sheath around Nerve fibers. Myelin is the "insulating" material around the Axons of the Nerve and act much like rubber insulating material around electric wires. Myelin's primary function is to facilitate rapid conduction of the electrical impulses that propagate down the Nerve's Axon (from its origin in the Nerve Cell Body) to connect (synapse) with the next Neuron within its particular "functional system". These Tumors usually arise from a SINGLE SENSORY NERVE ROOT and are essentially PART OF THE NERVE ROOT. In order to "cure" this problem surgically, the section of Nerve Root that is involved by the Tumor, must be removed in its entirety. In most cases, removing a single SENSORY NERVE ROOT does not produce a significant Neurological Deficit. Oftentimes, the patient does appreciate any sensory change.

EXAMPLES OF THE SPINAL CORD TUMOR NEUROIMAGING STUDIES TOGETHER WITH INTRA-OPERATIVE PHOTOS ARE PRESENTED IN OUR INTRADURAL EXTRAMEDULLARY TUMORS SECTION AS WELL AS IN OUR SPINAL CORD TUMOR CASE STUDY SECTION.

METASTATIC SPINE TUMORS

Malignant Tumor cells arising elsewhere in the body can easily spread (metastasize) to within the substance of the Brain and the Bone of the Spinal Column; however, they RARELY SPREAD TO THE SUBSTANCE OF THE SPINAL CORD.
Metastatic Spine tumors occur in 10 percent of cancer patients.
One (1) out of every four (4) people who have cancer that has spread somewhere within the body, will also develops metastasis within the Central Nervous System (CNS). The most common metastatic tumors to the Brain and Spine are from LUNG, BREAST and PROSTATE cancers. (Statistic of the National Institute of Neurological Disorders and Stroke)
Ten (10 %) percent of cancer patients with Metastatic Tumors to the Spine have NO PREVIOUS KNOWN CANCER and of these, SPINAL CORD COMPRESSION AND PAIN ARE THE FIRST SIGNS AND SYMPTOMS OF THE DISEASE.

VERTEBRAL COLUMN TUMORS

Spinal Bone Tumors involve the bony Vertebral Column and can be divided into Cancerous Tumors and Benign Tumors. Cancerous Spinal Bone Tumors include Metastatic Cancers and Primary Bone Cancers.

A. Metastatic Spinal Bone Tumors Any type of cancer can spread to Spinal Bones; however, the most common ones are cancers of LUNG, BREAST, PROSTATE and KIDNEY as well as LYMPHOMAS.

B. Primary Cancerous Spinal Bone Tumors

These Tumors are relatively uncommon and include Chordomas, Chondrosarcomas, Osteogenic Sarcomas, Ewing's Sarcomas, Multiple Myelomas, Lymphomas etc. Treatments for these malignant tumors must involve multimodality measures which, includes surgery, chemotherapy and radiation.

C. Benign Spinal Bone Tumors

These Tumors include Osteoid Osteomas, Osteoblastomas, Osteochondromas, Giant Cell Tumors, Aneurysmal Bone Cysts, Plasmacytomas, Hemangiomas, etc. Treatments for these benign tumors must be individualized depending on the type of pathology and their symptoms. BENIGN TUMORS OF THE SPINAL COLUMN CAN OFTEN BE ENTIRELY REMOVED.

SYMPTOMS

Pain and/or Neurological Deficits (Motor and/or Sensory) are the common presenting complaints for these problems. Pain is the MOST COMMON symptom for Primary and Metastatic Bone Tumors. The extent of Pain and Neurological Deficits (as well as the pattern of each symptom) depends on the location, size and type of Tumor as well as the degree to which the Neural elements (Spinal Cord and/or Nerve Roots) are involved and compressed.

DIAGNOSIS

The diagnosis of Tumors of the Spinal Cord, Spinal Column and Nerve Roots is made by a careful Neurological Examination and appropriate Neuroimaging Studies. MRI Scan is highly useful for evaluating the Spinal Cord and the Tumor while CT Scan is most efficient for evaluating the Bone of the Spinal Column. There are occasions when Myelography and Post-myelographic CT Scan can provide vitally important information as well.

PLEASE SEE THE OTHER SECTIONS THAT FOLLOW FOR EXAMPLES OF THESE NEUROIMAGING STUDIES.

TREATMENT

Surgery

Metastatic Cancer is usually impossible to "cure". However, surgical debulking of the tumor (with or without mechanical Spine stabilization) in order to remove any pressure on the Spinal Cord, can improve quality of life. Operative therapy may also require the REMOVAL OF ENTIRE VERTEBRAL BODIES ("ANTERIOR CORPECTOMY") as well as other segments of the involved Vertebrae. In the event that an Anterior Corpectomy has been undertaken, a "reconstruction" of the involved Vertebral Segment(s) will be required. This usually consists of placement of metallic implants together with acrylic material or banked bone in order to preserve the stability of the Spine, following removal of the portion of the Vertebra involved with Tumor (See Figure 2 below.)

There are circumstances that require extraordinarily aggressive surgical procedures that involve complicated resections of sections of the Spinal Column from different simultaneous (or sequential) surgical approaches. In these cases, the operations are conducted from the Anterior and Posterior in an effort to preserve the integrity of the Spinal Cord and Nerve Roots to the extent possible.

Figure 2A (Left): Operative Photo. After a C6 Anterior Corpectomy (with partial removal of the lower part of C5 and the upper part of C7) has been completed, a reconstruction and stabilization of the Spine is required. In this case, a "reconstruction" was accomplished by inserting a Titanium "Pyramesh Cage" that is filled with bone.
Figure 2B (Center): Operative Photo (Same Patient). A Titanium Anterior Internal Fixation Plate supplements the underlying Titanium Cage to provide the structural integrity required of this Cervical Spine.
Figure 2C (Right): Post-operative CT Scan (Same case-Sagittal View). The C6 vertebral body was removed and replaced with the Titanium Cage. The Anterior Plate is held in position with Titanium screws in the C4 & C7 Vertebral Bodies.

Radiation Therapy

For Metastatic Tumors which do not compress the Spinal Cord or destabilize the Spinal Column, Radiation Therapy often significantly reduces Spinal pain. The technical advances in STEREOTACTIC RADIOSURGERY have particular relevance for Radiation of the Spine by diminishing the risk of damage to the Spinal Cord.

Chemotherapy

The Medical management of Metastatic Tumors almost universally requires the use of chemotherapeutic agents (usually in conjunction with Radiation Therapy.) Some tumors are selectively responsive to certain of these medications. Medical Oncologists are generally involved in this level of Medical care.

DISCLAIMER: Every effort has been made by the author(s) to provide accurate and up-to-date information. However, the medical knowledge base is dynamic and errors can occur. By using the information contained herein, the viewer willingly assumes all risks in connection with such use. Neither the author nor Neurosurgical Consultants, p.a. shall be held responsible for errors, omissions in information herein nor liable for any special, consequential, or exemplary damages resulting, in whole or in part, from any viewer(s)' use of or reliance upon, this material.
CLINICAL DISCLAIMER: Clinical information is provided for educational purposes and not as a medical or professional service. Person(s) who are not medical professionals should have clinical information reviewed and interpreted or applied only by the appropriate health professional(s).

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This page last edited on 2/19