Spinal tumors are

neoplasm A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...

s located in either the

vertebral column The spinal column, also known as the vertebral column, spine or backbone, is the core part of the axial skeleton in vertebrates. The vertebral column is the defining and eponymous characteristic of the vertebrate. The spinal column is a segmente ...

or the

spinal cord The spinal cord is a long, thin, tubular structure made up of nervous tissue that extends from the medulla oblongata in the lower brainstem to the lumbar region of the vertebral column (backbone) of vertebrate animals. The center of the spinal c ...

. There are three main types of spinal tumors classified based on their location: extradural and intradural (intradural-intramedullary and intradural-extramedullary). Extradural tumors are located outside the dura mater lining and are most commonly metastatic. 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 of spinal tumors is nocturnal back pain. Other common symptoms include

muscle Muscle is a soft tissue, one of the four basic types of animal tissue. There are three types of muscle tissue in vertebrates: skeletal muscle, cardiac muscle, and smooth muscle. Muscle tissue gives skeletal muscles the ability to muscle contra ...

weakness, sensory loss, and difficulty walking. Loss of bowel and

bladder The bladder () is a hollow organ in humans and other vertebrates that stores urine from the kidneys. In placental mammals, urine enters the bladder via the ureters and exits via the urethra during urination. In humans, the bladder is a distens ...

control may occur during the later stages of the disease. The cause of spinal tumors is unknown. Most extradural tumors are metastatic commonly from breast, prostate, lung, and kidney cancer. There are many genetic factors associated with intradural tumors, most commonly neurofibromatosis 1 (NF1), neurofibromatosis 2 (NF2), and

Von Hippel–Lindau The term () is used in German surnames either as a nobiliary particle indicating a noble patrilineality, or as a simple preposition used by commoners that means or . Nobility directories like the often abbreviate the noble term to ''v.'' ...

(VHL) syndrome. The most common type of intradural-extramedullary tumors are meningiomas and nerve-sheath tumors. The most common type of intradural-intramedullary tumors are ependymomas and

astrocytoma Astrocytoma is a type of brain tumor. Astrocytomas (also astrocytomata) originate from a specific kind of star-shaped glial cell in the cerebrum called an astrocyte. This type of tumor does not usually spread outside the brain and spinal cord, an ...

s. 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. Treatment often involves some combination of surgery, radiation, and chemotherapy. Observation with follow-up imaging may be an option for small, benign lesions. Steroids may also be given before surgery in cases of significant cord compression. 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.

Signs and symptoms

The symptoms of spinal tumors are often non-specific, resulting in a delay in diagnosis. Spinal nerve compression and weakening of the vertebral structure cause the symptoms. Pain is the most common symptom at presentation. Other common symptoms of spinal cord compression include muscle weakness, sensory loss, numbness in hands and legs, and rapid onset

paralysis Paralysis (: paralyses; also known as plegia) is a loss of Motor skill, motor function in one or more Skeletal muscle, muscles. Paralysis can also be accompanied by a loss of feeling (sensory loss) in the affected area if there is sensory d ...

Bowel The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The tract is the largest of the body's systems, after the cardiovascular system. T ...

or bladder incontinence often occur in the later stages of the disease. Children may present with spinal deformities such as

scoliosis Scoliosis (: scolioses) is a condition in which a person's Vertebral column, spine has an irregular curve in the coronal plane. The curve is usually S- or C-shaped over three dimensions. In some, the degree of curve is stable, while in others ...

. The diagnosis is challenging, primarily because symptoms often mimic more common and benign degenerative spinal diseases. Spinal cord compression is commonly found in patients with metastatic malignancy.

Back pain Back pain (Latin: ''dorsalgia'') is pain felt in the back. It may be classified as neck pain (cervical), middle back pain (thoracic), lower back pain (lumbar) or coccydynia (tailbone or sacral pain) based on the segment affected. The lumbar area ...

is a primary symptom of spinal cord compression in patients with known malignancy. Back pain may prompt a

bone scan A bone scan or bone scintigraphy is a nuclear medicine imaging technique used to help diagnose and assess different bone diseases. These include cancer of the bone or metastasis, location of bone inflammation and fractures (that may not be vis ...

to confirm or exclude spinal metastasis. Rapid identification and intervention of metastatic spinal cord compression is necessary to preserve neurologic function.

Causes

The cause of the majority of spinal tumors is currently not known. Primary spinal tumors are associated with a few genetic syndromes. Neurofibromas are associated with neurofibromatosis 1 (NF1). Meningiomas and schwannomas are associated with neurofibromatosis 2 (NF2). Intramedullary

hemangioblastoma Hemangioblastomas, or haemangioblastomas, are vascular tumors of the central nervous system that originate from the vascular system, usually during middle age. Sometimes, these tumors occur in other sites such as the spinal cord and retina. They m ...

s can be seen in patients with von Hippel-Lindau disease. Spinal cord

lymphoma Lymphoma is a group of blood and lymph tumors that develop from lymphocytes (a type of white blood cell). The name typically refers to just the cancerous versions rather than all such tumours. Signs and symptoms may include enlarged lymph node ...

s are commonly seen in patients with suppressed immune systems. The majority of extradural tumors are due to metastasis, most commonly from breast, prostate, lung, and kidney cancer.

Pathophysiology

The

is a long, cylindrical anatomical structure that is located within the vertebral cavity. It runs from the foramen magnum of the skull to the conus medullaris at the lumbar spine. Most symptoms from spinal tumors occur due to compression of the spinal cord as it plays a primary role in motor and sensory function. The spinal cord is surrounded by three layers known as the spinal

meninges In anatomy, the meninges (; meninx ; ) are the three membranes that envelop the brain and spinal cord. In mammals, the meninges are the dura mater, the arachnoid mater, and the pia mater. Cerebrospinal fluid is located in the subarachnoid spac ...

. These are the dura mater, arachnoid mater, and

pia mater Pia mater ( or ),Entry "pia mater"
in
These are further broken down into intramedullary and extramedullary tumors. Intradural-intramedullary tumors are located within the spinal cord itself, with the most common being ependymomas,

s, and

s. Intradural-extramedullary tumors are located within the dura but outside of the spinal cord parenchyma, with the most common being meningiomas and nerve sheath tumors (e.g. schwannomas, neurofibromas). Extradural tumors are located outside the dura mater most commonly in the vertebral bodies from metastatic disease. Common primary cancers in metastatic spinal tumors includes breast, prostate, lung, and kidney cancer. It is important to diagnose and promptly treat metastatic tumors as they can lead to long-term neurologic deficit from epidural spinal cord compression. Primary extradural tumors are rare and most arise from surrounding bony and soft tissue structures, including Ewing's sarcoma,

osteosarcoma An osteosarcoma (OS) or osteogenic sarcoma (OGS) is a cancerous tumor in a bone. Specifically, it is an aggressive malignant neoplasm that arises from primitive transformed cells of mesenchyme, mesenchymal origin (and thus a sarcoma) and that exhi ...

, and vertebral

Diagnosis

Medical examination

The diagnosis of spinal tumors is challenging, as the symptoms can be non-specific and often mimic more common and benign degenerative spinal diseases. A comprehensive medical examination is necessary to look for signs or symptoms that may point towards a more serious condition. This includes a complete neurological exam focusing on any motor or sensory deficits. Patients with either benign degenerative spinal disease or spinal tumors often present with back pain. A patient with

radiculopathy Radiculopathy (; ), also commonly referred to as pinched nerve, refers to a set of conditions in which one or more nerves are affected and do not work properly (a neuropathy). Radiculopathy can result in pain (radicular pain), weakness, altered se ...

myelopathy Myelopathy describes any neurologic deficit related to the spinal cord. When due to trauma, myelopathy is known as (acute) spinal cord injury. When inflammatory, it is known as myelitis. Disease that is vascular in nature is known as vascular ...

raises suspicion for a more serious condition.

Imaging

Imaging is often the next step when the diagnosis is unclear or there is greater suspicion for a serious condition that may need immediate intervention. Common types of medical imaging include

X-ray An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...

s, computer tomography scan (CT),

Magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and ...

(MRI), myelography, and bone scans. MRI is the imaging of choice for spinal tumors. The MRI protocol that is most frequently used includes T1-weighted and T2-weighted sequences, including contrast enhanced T1-weighted sequences. Short-TI Inversion Recovery (STIR) is also commonly added to the MRI protocol for detecting spinal cord tumors. Myelography may be used as a substitute when the patient cannot undergo an MRI or it is unavailable. X-rays and CT are more commonly used to view the bony structures. They are less frequently used for spinal cord tumors, however, since they cannot reliably detect them.

Bone scan A bone scan or bone scintigraphy is a nuclear medicine imaging technique used to help diagnose and assess different bone diseases. These include cancer of the bone or metastasis, location of bone inflammation and fractures (that may not be vis ...

ning may be used as a supplementary imaging modality for tumors involving bony structures of the spine.

Treatment

Treatment greatly varies depending on the type of spinal cord tumors, goals of care, and prognosis. The primary forms of treatment include surgical resection, radiotherapy, and chemotherapy.

Steroids A steroid is an organic compound with four fused rings (designated A, B, C, and D) arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter mem ...

(e.g.

corticosteroids Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are invol ...

) may be administered if there is evidence of spinal cord compression. These do not affect the tumor mass itself, but tend to reduce the inflammatory reaction around it and decrease the overall volume of the mass impinging on the spinal cord.

Surgery

Surgery has several indications depending on the type of tumor, which includes complete resection, decompression of the nerves, and stabilization. An attempt at total gross resection for a possible cure is an option for patients with primary spinal cord tumors. Extramedullary tumours are more amenable to resection than intramedullary tumours, and even possible to be operated through microendoscopic or pure endoscopic approaches. In patients with metastatic tumors, treatment is palliative with the goal of improving the patient's quality of life. In these cases, indications for surgery include pain, stabilization, and spinal cord decompression.

Non-surgical treatment

Observation,

chemotherapy Chemotherapy (often abbreviated chemo, sometimes CTX and CTx) is the type of cancer treatment that uses one or more anti-cancer drugs (list of chemotherapeutic agents, chemotherapeutic agents or alkylating agents) in a standard chemotherapy re ...

, and

radiotherapy Radiation therapy or radiotherapy (RT, RTx, or XRT) is a treatment using ionizing radiation, generally provided as part of cancer therapy to either kill or control the growth of malignant cells. It is normally delivered by a linear particle ...

are possible options as an adjunct to surgery or for tumors not amenable to surgery. Intradural-extramedullary tumors are often benign, so observation with follow-up imaging is an option in cases where the lesions are small and the patient is asymptomatic. Radiotherapy and chemotherapy may be administered alone or in conjunction with surgery. The choice of chemotherapy or radiotherapy is a multidisciplinary process and depends on the histological grade, type of tumor, and amount of surgical resection achieved. In cases where radiotherapy is chosen, radiation is usually delivered to the involved segment in the spinal cord and the uninvolved segment above and below the involved segment. The combination of minimally invasive surgery and

radiation In physics, radiation is the emission or transmission of energy in the form of waves or particles through space or a material medium. This includes: * ''electromagnetic radiation'' consisting of photons, such as radio waves, microwaves, infr ...

is a new technique for treating spinal tumors. This treatment can be tailored to the particular tumor of the spine, either metastatic or primary. 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.

References

{{DEFAULTSORT:Spinal Tumor Nervous system neoplasia