Spinal tumor

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Spinal tumors are neoplasms located in either the vertebral column or the spinal cord.[1] There are three main types of spinal tumors that are classified based on their location. Extradural tumors are located outside the dura mater lining and are most commonly metastatic.[2] Intradural tumors are located inside the dura mater lining and are further subdivided into intramedullary and extramedullary tumors. Intradural-intramedullary tumors are located within the dura and spinal cord parenchyma, while intradural-extramedullary tumors are located within the dura but outside the spinal cord parenchyma. The most common presenting symptom is nocturnal back pain.[1] Other common symptoms include muscle weakness, sensory loss, and difficulty walking.[1] Loss of bowel and bladder control may occur during the later stages of the disease.[3]

The cause of spinal tumors is unknown. Most extradural tumors are metastatic commonly from breast, prostate, lung, and kidney cancer.[4] There are many genetic factors associated with intradural tumors. The most common clinical syndromes associated with these types of tumors are neurofibromatosis 1 (NF1), neurofibromatosis 2 (NF2), and Von-Hippel Lindau (VHL) syndrome.[1] The most common type of intradural-extramedullary tumors are meningiomas and nerve-sheath tumors.[5] The most common type of intradural-intramedullary tumors are ependymomas and astrocytomas.[6] Diagnosis involves a complete medical evaluation followed by imaging with a CT or MRI. A biopsy may be obtained in certain cases to categorize the lesion if the diagnosis is uncertain.[1][4][5]

Treatment often involves some combination of surgery, radiation, and chemotherapy.[1][4][5] Observation with follow-up imaging may be an option for small, benign lesions.[4] Steroids may also be given before surgery in cases of significant cord compression.[1] Outcomes depend on a number of factors including whether the tumor is benign or malignant, primary or metastatic, and location of the tumor. Treatment is often palliative for the vast majority of metastatic tumors.[5]

Signs and Symptoms[edit]

The symptoms of spinal tumors are often non-specific resulting in a delay in diagnosis. The symptoms seen are due to spinal nerve compression and weakening of the vertebral structure. Pain is the most common symptom at presentation.[1][3][7] Other common symptoms of spinal cord compression include muscle weakness, sensory loss, numbness in hands and legs, and rapid onset paralysis. Bowel or bladder incontinence often occur in the later stages of the disease.[3] Children may present with spinal deformities such as scoliosis.[1][2] The diagnosis is challenging, primarily due to its signs and symptoms being attributed to more common and benign degenerative spinal diseases.[8][9]

Spinal cord compression is commonly found in patients with metastatic malignancy.[10] Back pain is a primary symptom of spinal cord compression in patients with known malignancy.[11] It may prompt a bone scan to confirm or exclude spinal metastasis. Rapid identification and intervention of metastatic spinal cord compression is necessary to preserve neurologic function.[12]

Causes[edit]

The cause of the majority of spinal tumors is currently not known. Primary spinal tumors are associated with a few genetic syndromes.[1][5] Neurofibromas are associated with neurofibromatosis 1 (NF1).[1] Meningiomas and schwannomas are associated with neurofibromatosis 2 (NF2).[1] Intramedullary hemangioblastomas can be seen in patients with von Hippel-Lindau disease.[5] Spinal cord lymphomas are commonly seen in patients with suppressed immune systems.[5] The majority of extradural tumors are due to metastasis, most commonly from breast, prostate, lung, and kidney cancer. [4]

Pathology[edit]

Extradural tumors are mostly metastases from primary cancers elsewhere (commonly breast, prostate and lung cancer).[8] Intradural tumours can be classified as intramedullary (within the spinal parenchyma) or extramedullary (within the dura, but outside the spinal parenchyma). Extramedullary tumours are more common than intramedullary tumours. Common extramedullary tumours include meningiomas, schwannomas, extramedullary ependymomas, haemangioblastomas, while intramedullary tumours include astrocytomas and intramedullary ependymomas.[7]

Diagnosis[edit]

The diagnosis of primary spinal cord tumors is difficult, mainly due to their symptoms, which in early stages mimic more common and benign degenerative spinal diseases. MRI and bone scanning are used for diagnostic purposes. This assesses not only the location of the tumor(s) but also their relationship with the spinal cord and the risk of cord compression.[13]

Spinal tumors are rare in pediatric patients with majority of diagnoses being made around 11 years of age.[14]

Treatment[edit]

  • Steroids (e.g. corticosteroids)[9] may be administered if there is evidence of spinal cord compression. These do not affect the tumoral mass itself, but tend to reduce the inflammatory reaction around it, and thus decrease the overall volume of the mass impinging on the spinal cord.
  • Radiotherapy may be administered to patients with malignant tumors. Radiation is usually delivered to the involved segment in the spinal cord as well as to the uninvolved segment above and below the involved segment.[9]
  • Surgery is sometimes possible. The goals of surgical treatment for spinal tumors can include histologic diagnosis, tumor local control or oncological cure, pain relief, spinal cord decompression and restoration of neurological function, restoration of spine stability, and deformity rectification.[9] Extramedullary tumours are more amenable to resection than intramedullary tumours.[7]
  • The combination of minimally invasive surgery and radiation or chemotherapy is a new technique for treating spinal tumors.[15] This treatment can be tailored to the particular tumor of the spine, either metastatic or primary.[16]
  • Some suggest that direct decompressive surgery combined with postoperative radiotherapy, provide better outcomes than treatment with radiotherapy alone for patients with spinal cord compression due to metastatic cancer.[17][18] It is also important to take into consideration the prognosis of the patients and their ambulation status at diagnosis, and treat accordingly.[10]

References[edit]

  1. ^ a b c d e f g h i j k l Spinal cord tumors. Arnautović, Kenan I.,, Gokaslan, Ziya L.,. Cham, Switzerland. ISBN 978-3-319-99438-3. OCLC 1084270205.CS1 maint: extra punctuation (link) CS1 maint: others (link)
  2. ^ a b Gossman, William; Hoang, Stanley; Mesfin, Fassil B. (2019), "Cancer, Intramedullary Spinal Cord Tumors", StatPearls, StatPearls Publishing, PMID 28723060, retrieved 2019-12-03
  3. ^ a b c Balériaux, D. L. F. (1999-08-01). "Spinal cord tumors". European Radiology. 9 (7): 1252–1258. doi:10.1007/s003300050831. ISSN 1432-1084.
  4. ^ a b c d e Burton, Matthew R.; Mesfin, Fassil B. (2019), "Cancer, Conus And Cauda Equina Tumors", StatPearls, StatPearls Publishing, PMID 28722908, retrieved 2019-12-03
  5. ^ a b c d e f g "Spinal Tumors – Types, Symptoms, Diagnosis and Treatment". www.aans.org. Retrieved 2019-12-03.
  6. ^ Mechtler, Laszlo L.; Nandigam, Kaveer (2013-02-01). "Spinal Cord Tumors: New Views and Future Directions". Neurologic Clinics. Spinal Cord Diseases. 31 (1): 241–268. doi:10.1016/j.ncl.2012.09.011. ISSN 0733-8619.
  7. ^ a b c Nambiar, Mithun; Kavar, B (2012). "Clinical presentation and outcome of patients with intradural spinal cord tumours". Journal of Clinical Neuroscience. 19 (2): 262–6. doi:10.1016/j.jocn.2011.05.021. PMID 22099075.
  8. ^ a b Hamamoto, Yasushi; Kataoka, M.; Senba, T.; Uwatsu, K.; Sugawara, Y.; Inoue, T.; Sakai, S.; Aono, S.; Takahashi, T.; Oda, S. (9 May 2009). "Vertebral Metastases with High Risk of Symptomatic Malignant Spinal Cord Compression". Japanese Journal of Clinical Oncology. 39 (7): 431–434. CiteSeerX 10.1.1.624.6511. doi:10.1093/jjco/hyp039. PMID 19429929.
  9. ^ a b c d Ribas, Eduardo S. C.; Schiff, David (1 May 2012). "Spinal Cord Compression". Current Treatment Options in Neurology. 14 (4): 391–401. CiteSeerX 10.1.1.613.5814. doi:10.1007/s11940-012-0176-7. PMID 22547256.
  10. ^ a b Holt, T.; Hoskin, P.; Maranzano, E.; Sahgal, A.; Schild, S.E.; Ryu, S.; Loblaw, A. (6 March 2012). "Malignant epidural spinal cord compression: the role of external beam radiotherapy". Current Opinion in Supportive and Palliative Care. 6 (1): 103–8. doi:10.1097/spc.0b013e32834de701. PMID 22156794.
  11. ^ Reith, W.; Yilmaz, U. (December 2011). "[Extradural tumors]". Der Radiologe. 51 (12): 1018–1024. doi:10.1007/s00117-011-2152-8. PMID 22198141.
  12. ^ Jennelle, Richard L. S.; Vijayakumar, Vani; Vijayakumar, Srinivasan (2 August 2011). "A Systemic and Evidence-Based Approach to the Management of Vertebral Metastasis". ISRN Surgery. 2011: 719715. doi:10.5402/2011/719715. PMC 3200210. PMID 22084772.
  13. ^ Segal D, Constantini S. C.; Korn, Lidar (14 May 2012). "Delay In Disgnosis of Primary Intra Dural Spinal Cord Tumors". Surg Neurol Int. 3: 52. doi:10.4103/2152-7806.96075. PMC 3356987. PMID 22629489.
  14. ^ Shweikeh F, Quinsey C, Murayi R, Randle R, Nuño M, Krieger MD, Patrick Johnson J (August 2017). "Treatment patterns of children with spine and spinal cord tumors: national outcomes and review of the literature". Childs Nerv Syst. 33 (8): 1357–1365. doi:10.1007/s00381-017-3433-y. PMID 28484868.
  15. ^ "When cancer spreads to the spine, a new operation can cut both hospital and recovery time - NY Daily News".
  16. ^ "Spinal Tumors | Mount Sinai - New York".
  17. ^ Patchell, Dr. Roy A.; Tibbs, Phillip A.; Regine, William F.; Payne, Richard; Saris, Stephen; Kryscio, Richard J.; Mohiuddin, Mohammed; Young, Byron (20 August 2005). "Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial". The Lancet. 366 (9486): 643–648. doi:10.1016/S0140-6736(05)66954-1. PMID 16112300.
  18. ^ Furlan, J.C.; Chan, K.K.; Sandoval, G.A.; Lam, K.C.; Klinger, C.A.; Patchell, R.A.; Laporte, A.; Fehlings, M.G. (May 2012). "The combined use of surgery and radiotherapy to treat patients with epidural cord compression due to metastatic disease: a cost-utility analysis". Neuro-Oncology. 14 (5): 631–640. doi:10.1093/neuonc/nos062. PMC 3337309. PMID 22505658.

External links[edit]

Classification
External resources