Spinal and Spinal Cord tumours

Spinal tumours account for approximately 20% of CNS tumours. They are classified as intradural or extradural. 84% of intradural tumours are outside the spinal parenchyma (extramedullary) and 16% of them are within the spinal parenchyma (within the spinal parenchyma). Intradural tumours are almost always primer CNS tumours.  However, the majority of extradural tumours are metastatic or primary bone tumours.  Majority of the intradural vertebral neoplasms are benign/non-malignant and usually surgically removed.  Tumours in the spinal cord (intradural, intramedullary) tend to cause weakness, spasticity and sensory loss. Extramedullary lesions also show up with radicular pain caused by the compression of the nerve roots (lower motor neurons) and the long tract (upper motor neuron) signs causing cord compression. Early loss of bladder and bowel functions are seen in patients with lesions involving Conus medullaris region. Firstly leg pain and in the late term, sphincter of oddi dysfunction are seen in patients with cauda equine lesion.

MRI is determinative analysis for the definitive diagnosis of spinal tumours.

Neurilemmoma and Neurofibroma

They are typically benign. These are the most common spinal cord tumours and account for approximately 30% of all spinal tumours.  They are usually intradural and extramedullary.  By extending from their neighbouring neural foramen extradurally, they gain the classic "dumbell" tumour shape. ... are completely extradural. Their extradural components tend to expand the relevant foramen.  The treatment is the surgical removal of the tumour.  Multiple neurofibromas are seen with von Recklinghausen neurofibromatosis.  In such cases, only symptomatic tumours should be removed.

Meningioma

Meningiomas account for 26% of spinal cord tumours, they are benign and usually intradural and extramedullary. ... are seen as extradural. 2/3 of them occur in the thoracic region and 80% of the cases are women in the age group of 40-60 years.  Surgical removal is the preferred treatment.

Ependymoma

They originate from the ependymal cells of the central canal of the spinal cord and these intramedullary tumours account for 13% of all spinal cord tumours.  It is more common in men.  Approximately 60% of them are localized in the conus medullaris region.  Ependymomas should be removed surgically.  Being well demarcated usually allows total removal.  When total removal is not possible, usually, radiation therapy is administered.

Astrocytoma

These glial tumours originate from astrocytes and they are usually intramedullary.  Their incidence is almost as same as spinal ependymomas.  Due to their infiltrative structures, total removal is rarely possible.  If low-grade astrocytomas recur, they are usually re-operated.  Radiation therapy is administered for malignant astrocytomas, however it is usually only for palliative purpose.  Although spinal cord astrocytomas grow slowly, their prognosis is often poor.

Lipoma

Lipomas account for ... of spinal tumours and are usually seen with spina bifida and a subcutaneous lipoma.  Although they are benign, they tend to adhere to the spinal cord, therefore they are usually removed partially.  These tumours do not require radiotherapy and the mortality rate is low.

Dermoid

Dermoids are congenital lesions and usually localized in the lumbosacral region.  They are usually seen with a sinus tract extending to the skin surface and may show up with infection.  Their treatment is the surgical removal with the sinus tract.  Their components extending into the spine usually cannot be removed.  Their prognosis is good in the long term.

Metastatic Tumour

Up to 25% of spinal neoplasms are of metastatic origin and the majority of them are extradural.  Often their primers are breast, lung, prostate and kidney.  If the primary focus is unknown or the neurological deterioration is rapid, the treatment is the surgery and biopsy.  Otherwise, local radiotherapy should be preferred.  Other extradural malign tumours include lymphoma, myeloma, plasmacytoma, chordoma and osteogenic sarcoma.  As a result of significant bone destruction or surgical decompression, spinal stabilization may be deteriorated and in such cases, surgical anterior or posterior stabilization is often required.

Peripheral Nerve Tumours

Peripheral nervous system is composed of peripheral and cranial nerves, spinal roots and autonomic nervous system.  Tumours may originate from any of these.  The most common tumours are discussed below.  Less common tumours are gangliogliomas, neuroblastomas, pargangliomas, chemodectomas and pheochromocytomas.

Schwannoma

This tumour is composed of Schwann cells of the peripheral nerves which produce the myelin sheath of the axons.  Schwannoms tend to push the nerves they originate and therefore, they often show up as painless masses.  If they continue to grow, they may cause pain in the regions compatible with the nerve distribution.  As they grow, they damage nervous functions.  They usually occur in the sensory nerves, however they may also occur in the motor nerves. The treatment is surgery.  The nerve they originate from is usually protected.  In some cases, nevertheless, if the tumour is completely removed, it may require a significant loss of the main nerve. If the nerve has a very important function, it is preferred to leave some part of the tumour to protect the nerve.  This is an acceptable method because malignant transformation of these tumours is rare.

Neurofibroma

Unlike schwannomas, neurofibromas surround and compress the nerve since they originate from the nerves.  Often it is difficult to detect the nerve they originate from, since they are seen in the skin.  When they are seen with Von Rechinghausen, they are usually more than one.  If there is only one lesion, the treatment is the surgical removal.  If more than one tumours are present, only the symptomatic ones should be removed.  If the nervous function is critical, a portion of the tumour attached to the nerve should be left. Unlike schwannoma cases, patients with neurofibromas should be followed up closely since these tumours show a high rate of malignant transformation.

Malignant Nerve Sheath Tumour

These tumours are typically seen over the age of 30 years.  The treatment to be preferred is a radical and large surgical excision.  Amputation of the limb is recommended if a finding that suggests muscle or soft tissue spread is present.  These tumours are usually resistant to radiation therapy.

IMPORTANT NOTE

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