Neurosurgical Consultants: Spine & Spinal Cord Tumors: Intradural-Extramedullary Tumors

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INTRADURAL-EXTRAMEDULLARY TUMORS

Intradural-Extramedullary Tumors lie INSIDE the DURAL covering of the Spinal Canal but OUTSIDE the SUBSTANCE of the SPINAL CORD. Patients usually experience PAIN as a PRIMARY SYMPTOM. They often develop WEAKNESS IN ONE OR MORE EXTREMITIES (most often starting in their legs) once the pressure on the Spinal Cord and/or Spinal Nerve Roots is great enough.

Most of the INTRADURAL-EXTRAMEDULLARY TUMORS are BENIGN although some are MALIGNANT. Both varieties are reviewed in the material that follows in this section. We also invite your interest in a more detailed review of some illustrated cases in our SPINAL CORD TUMOR CASE STUDY SECTION.

BENIGN TUMORS

Meningiomas and Schwannomas and Neurofibromas (Nerve Sheath Tumors) comprise the overwhelming majority of this subset of Spinal Tumors. Meningiomas arise from the Arachnoid (a thin covering layer of the Spinal Cord which is located inside the Dura Mater) and are MOST COMMON IN MIDDLE AGED and ELDERLY WOMEN. The Thoracic portion of the Vertebral Column is the most commonly affected part of the Spine. Schwannomas and Neurofibromas arise from the Nerve Roots which come off the Spinal Cord. Neurofibromas can occur as a sporadic condition or as a genetic disorder such as Neurofibromatosis.

Meningiomas, Neurofibromas and Schwannomas are almost always entirely histologically benign. There are some additional, although exceptionally rare, tumors that are included in this group of benign tumors such as Hemangioblastomas, Epidermoids and Dermoids. The latter two (2) are more common in children.

Figure 1: MRI SCAN (Sagittal) View
Intradural Spinal Neurofibroma (Curved Arrow) intermingled within the Lumbar Nerve Roots at the L1 Vertebral Level. The Tumor appears to arise from a SINGLE NERVE ROOT (Horizontal Arrows.)
This 62 year old Male's primary complaint was unrelenting mid-Thoracic back pain with pain radiating into his legs that was worse in certain body positions. He underwent a Minimally Invasive Microsurgical Inferior T12, complete L1 & Superior L2 Bilateral Laminectomy using a Unilateral Approach with complete removal of the Tumor. He has returned to his full time occupation as a CT Scan technician.
(See Figure 2 as well.)

Figure 2: MRI SCAN (Axial View - Same Patient as Figure 1)
The Neurofibroma (Horizontal Arrow) lies within the Spinal Canal at the L1 Vertebral Level and compresses the Spinal Nerve Roots which are displaced Anteriorly (Curved Arrow.)
This case, including the surgical photos, is presented in a more detailed fashion in our SPINAL CORD TUMOR CASE STUDY SECTION.

Figure 3: MRI SCAN (Sagittal View-Gadolinium Enhanced- Same Patient as Figures 4-8)
T9-T10 Intradural Meningioma (Arrow) in a 65 year old Male with 2 year history of progressive difficulty walking and recent onset of severe back and leg pain with lower extremity weakness. At the time that he presented for Neurosurgical consultation, he was no longer capable of walking without assistance.

Figure 4: MRI Scan (Axial View-Same Patient as Figure 3)
The T9-T10 Intradural Meningioma (Arrow) occupies the majority of the Spinal Canal.
The patient underwent a Minimally Invasive Microsurgical complete resection of the tumor (See Figures 5, 6, 7 & 8) and has been restored to full neurological function.

TREATMENT

ALL OF THESE TUMORS ARE CONSIDERED TO BE BENIGN. MOST CAN BE REMOVED SURGICALLY USING ADVANCED Minimally Invasive Microsurgical Techniques

Figure 5A (Left): Intraoperative X-ray for accurate placement of Minimally Invasive "expanding" Retractor used for Multi-level Laminectomy (Same Patient as Figures 3, 4, 6 & 7)
Figure 5B (Right): Operative Photo of Minimally Invasive "expanding" "METRx X-Tube Retractor" in position (Same as Figure 5A)
(Note: Retractor manufactured by the Medtronic Sofamor-Danek Company, Memphis, Tennessee)

Figure 6: Operative Photograph demonstrating the Intradural Meningioma (Up-curved Arrow). The compressed Spinal Cord (Left-curved Arrow) is visible to right of tumor. The "Circular Image" (Horizontal Arrow) on Left is the Minimally Invasive Retractor Tube. (Same Patient as figures 3, 4, 5, 7 & 8).
This Minimally Invasive Operation was accomplished using a Bilateral Multilevel (T9, T10 and Upper T11) Laminectomy through a Unilateral Approach.

Figure 7: Operative Photo through Minimally Invasive Retractor tube.
The Meningioma has been completely resected resulting in the successful "decompression" of the Spinal Cord. In this view the Dura Mater (Vertical Arrows) is kept open by temporary sutures (Black strings).

Figure 8: Operative Photo of same case. The Dura Mater has been sutured closed.

Figure 9A (Left): MRI Scan (Sagittal View) of a T7-T8 Calcified Intradural Tumor (Curved Arrow)
Figure 9B (Center): MRI Scan (Gadolinium Enhanced-Axial View) of a Large Calcified Intradural Meningioma at the T7-T8 level (Straight Arrows.) Note the displacement and compression of the Spinal Cord (Curved Arrow) to the patient's Left. COMPARE THIS TO THE OPERTIVE PHOTOS IN FIGURES 10-12.
Figure 9C (Right): CT Scan (Axial View) to illustrate the ANTERIOR & MEDIAL POSITION of the Calcification (Curved Arrow) in the Meningioma. See Figure 11 for a Photo of the Calcification.

Figure 10: Operative Photo (Same Patient as Figures A-C)
Minimally Invasive T7-T8 Laminectomy (Unilateral Approach) with Complete Resection of a Calcified Intradural Meningioma
The Dura has been opened to expose the Tumor (Down-curved Arrow). Several Nerve Roots are seen as they course over the Tumor (Horizontal Arrows) after having left the Spinal Cord. ALL Nerve Roots remained INTACT. The Spinal Cord is barely visible near the top of this photo on the Right (Vertical Arrow.)
NOTE: The ROUND EDGE of the "Minimally Invasive X-tube Retractor" is visible in the top Left corner of this photo. The Minimally Invasive surgical field for a complete resection of this tumor was quite sufficient.

Figure 11: Operative Photo (Same Patient) The majority of the Meningioma has been resected. The Spinal Cord (Down-curved Arrow) is now in direct view as is the Calcified "Rock" (Horizontal Arrow) that was part of the Anterior Medial Portion of the Tumor.
The "Rock" is still indenting and compressing the Spinal Cord (Vertical Arrow.)

Figure 12: Operative Photo (Same Patient). The entire Tumor has been removed. The "decompressed" Spinal Cord has regained some of its more normal position.
This patient's severe pre-operative spastic paraparesis improved considerably permitting her to regain her ability to walk.

Please see ILLUSTRATED "SPINAL CORD TUMOR CASE STUDIES" on this website for additional information.

MALIGNANT TUMORS

THERE ARE SOME RARE CASES OF INTRADURAL-EXTRAMEDULLARY TUMORS THAT ARE MALIGNANT. THEY ARE ALMOST UNIVERSALLY RELATED TO "METASTATIC" DISEASE OR LYMPHOMA.

TREATMENT

SURGERY

The role of surgery is somewhat limited since complete removal is unlikely. However, "de-bulking" (decreasing the over-all size) of the Tumor can be very effective in controlling the severe pain that is commonly associated with these conditions along with improving the neurological condition that had been associated with compression of the Neural elements by the Tumor. An additional benefit is achieving biopsy confirmation of the Tumor type. There is also the possibility of submitting samples of the Tumor for tissue culture and subsequently testing various chemotherapeutic agents against this Tumor before initiating treatment of the patient. (See next paragraph for further comment)

CHEMOTHERAPY & RADIATION THERAPY

The treatment of these unusual Malignant Tumors must be designed specifically for the Tumor type which commonly requires both Radiation Therapy and Chemotherapy.

Some medical centers are involved in "Clinical Trials" of various chemotherapeutic agents for these difficult to treat tumors. Among the techniques that they may choose to utilize is submitting a sample of the tumor for tissue culture. In this way they are able to "grow" the tumor outside the body and subject it to separate methods of analysis including the particular tumor cell's susceptibility to various chemotherapeutic agents. While there is some controversy related to this, patients affected by these conditions might do well to learn more about it.

The case illustrated here is that of a "CHLOROMA" in a 14 year old male with Acute Myelogenous Leukemia. A Minimally Invasive Microsurgical Resection of the majority of this Intradural-Extramedullary Tumor was accomplished followed by Radiation Therapy and Chemotherapy.

Figure 13: MRI Scan (Sagittal View)
This 14 year old male had a history of Acute Myelogenous Leukemia. He developed severe hip and leg pain followed by considerable weakness in his leg with muscle atrophy.
The tumor (Arrow) proved to be an Intradural Malignant Tumor (Chloroma) at the L4-L5 level.

Figure 14: MRI SCAN. Transaxial View (Same Patient as Figure 3)
This Intradural (Arrow) Malignant Tumor (Chloroma) occupies most of the Spinal Canal at this L4 Level.

Figure 15: MRI SCAN (Same Patient as Figures 13 & 14)
Malignant Intradural Tumor (Chloroma) extended within the Dura and then tracks along the Nerve Root (Curved Arrow) as it exits the Spinal Canal through the Neural Foramen. The Tumor followed beyond the Dural Nerve Root sleeve into the retro-peritoneal space.
A Minimally Invasive Microsurgical Resection of the majority of this Intradural-Extramedullary Tumor was accomplished followed by Radiation Therapy and Chemotherapy.

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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