tumours of the spine

Tumours of the SpineTumours of the Spine

Brad HoffmannMBBCh FRCS(Eng) FRCS(SN)

FCS(SA) Neurosurg

Brad HoffmannMBBCh FRCS(Eng) FRCS(SN)

FCS(SA) Neurosurg

Spinal TumoursSpinal Tumours

15% of primary CNS tumours are in the spine

Most are benign Mostly present with compression rather than invasion

15% of primary CNS tumours are in the spine

Most are benign Mostly present with compression rather than invasion

Spinal tumours-typesSpinal tumours-types Extradural-55% (probably higher) Arise in bone or extradural tissues.

Intradural extramedullary-40%.

Intramedullary-5%. Affect white matter tracts and grey matter

Extradural-55% (probably higher) Arise in bone or extradural tissues.

Intradural extramedullary-40%.

Intramedullary-5%. Affect white matter tracts and grey matter

Differential diagnosisDifferential diagnosis

• ExtraduralMetastatic-lymphoma, lung, breast, prostate

Primary spinal tumours- chordomas, osteoid osteoma, osteoblastoma, aneurysmal bone cyst, vertebral haemangioma

Occasionally extradural- meningiomas, neurofibromas, chloromas, angiolipoma

• ExtraduralMetastatic-lymphoma, lung, breast, prostate

Primary spinal tumours- chordomas, osteoid osteoma, osteoblastoma, aneurysmal bone cyst, vertebral haemangioma

Occasionally extradural- meningiomas, neurofibromas, chloromas, angiolipoma

Differential diagnosisDifferential diagnosis Intradural extramedullary

MeningiomasNeurofibromasLipomas (also intramedullary)Metastatic (only 4%)

Intradural extramedullaryMeningiomasNeurofibromasLipomas (also intramedullary)Metastatic (only 4%)

Differential diagnosisDifferential diagnosis Intramedullary

Astrocytoma-30%Ependymoma-30%Miscellaneous

Malignant glioblastomaDermoidEpidermoidTeratomaLipomaHaemangioblastoma

IntramedullaryAstrocytoma-30%Ependymoma-30%Miscellaneous

Malignant glioblastomaDermoidEpidermoidTeratomaLipomaHaemangioblastoma

Intramedullary tumours-Presentation

Intramedullary tumours-Presentation

Pain- radicular/ non radicular. Local pain/stiffness.NB- pain with recumbency. Often bilateral

Motor disturbance Other sensory disturbance Sphincter disturbance Other-scoliosis, cutaneous stigmata, visible mass

Usually insidious, progressive

Pain- radicular/ non radicular. Local pain/stiffness.NB- pain with recumbency. Often bilateral

Motor disturbance Other sensory disturbance Sphincter disturbance Other-scoliosis, cutaneous stigmata, visible mass

Usually insidious, progressive

Intramedullary tumours-TreatmentIntramedullary

tumours-Treatment

Surgery Radiotherapy (rare-glioma group)

Observation (“masterly inactivity”)

Surgery Radiotherapy (rare-glioma group)

Observation (“masterly inactivity”)

Intramedullary tumoursIntramedullary tumours

Intramedullary tumoursIntramedullary tumours

Intramedullary tumoursIntramedullary tumours

Spinal tumours-miscellaneous

Spinal tumours-miscellaneous

Spinal tumours-miscellaneous

Spinal tumours-miscellaneous

Spinal tumours-miscellaneous

Spinal tumours-miscellaneous

Spinal tumours-miscellaneous

Spinal tumours-miscellaneous

Spinal tumours-miscellaneous

Spinal tumours-miscellaneous

Spinal tumours-miscellaneous

Spinal tumours-miscellaneous

Thoracic meningiomaThoracic meningioma

Thoracic meningiomaThoracic meningioma

Spinal lipomaSpinal lipoma

Spinal lipomaSpinal lipoma

Intradural, extramedullary…Intradural,

extramedullary…

Spinal epidural metastases

Spinal epidural metastases

Suspect if history of cancer NB-pain at rest/ recumbency Occurs in 10% of cancer patients 80%-lung, breast, GI, prostate, melanoma, lymphoma

Routes-haematogenous Thoracic>cervical>lumbar Pain is first symptom in 95%, followed by neurological symptoms/ signs

Suspect if history of cancer NB-pain at rest/ recumbency Occurs in 10% of cancer patients 80%-lung, breast, GI, prostate, melanoma, lymphoma

Routes-haematogenous Thoracic>cervical>lumbar Pain is first symptom in 95%, followed by neurological symptoms/ signs

Spinal metastasesSpinal metastases

Primary site can be unknown/asymptomatic

15% present with paraplegia, but up to 75% have weakness at diagnosis

Symptoms to diagnosis-2 months Patients “triaged” according to severity of symptoms/signs

Primary site can be unknown/asymptomatic

15% present with paraplegia, but up to 75% have weakness at diagnosis

Symptoms to diagnosis-2 months Patients “triaged” according to severity of symptoms/signs

Spinal metastasesSpinal metastases

Most severe group- about 75% have abnormal Xrays:Pedicle erosionPedicle wideningCompression fractureScalloping of vertebral bodySclerosis, osteoblastic changes

Most severe group- about 75% have abnormal Xrays:Pedicle erosionPedicle wideningCompression fractureScalloping of vertebral bodySclerosis, osteoblastic changes

Spinal metastasesSpinal metastases

Further Ix:MRI +/- contrastRarely myelogramIsotope bone scan +ve in 66%Metastatic work-up

Further Ix:MRI +/- contrastRarely myelogramIsotope bone scan +ve in 66%Metastatic work-up

Spinal metastasesSpinal metastases

TreatmentIndividualisedUsually palliativeRadiotherapy most commonSurgeryDexamethasonePain control

TreatmentIndividualisedUsually palliativeRadiotherapy most commonSurgeryDexamethasonePain control

Other conditions to consider..

Other conditions to consider..

Osteoporotic fractures Disc lesions Infection-intra-osseous, epidural.. Haematomas-AVM, anticoagulation.. Facet joint cysts Demyelination, transverse myelitis Abdominal, renal, vascular pathology Paget’s disease Psychological factors

Osteoporotic fractures Disc lesions Infection-intra-osseous, epidural.. Haematomas-AVM, anticoagulation.. Facet joint cysts Demyelination, transverse myelitis Abdominal, renal, vascular pathology Paget’s disease Psychological factors

“Red flags”“Red flags”

Cancer or infection• Age >50 or <20• Hx of cancer• Unexplained weight loss• Immunosuppression• Drug abuse• UTI-fever, chills• Pain not relieved by rest

Cancer or infection• Age >50 or <20• Hx of cancer• Unexplained weight loss• Immunosuppression• Drug abuse• UTI-fever, chills• Pain not relieved by rest

“Red flags”“Red flags”Fracture

• Significant trauma• Prolonged use of steroids• Age >70

Cauda Equina Syndrome• Acute urinary incontinence, saddle anaesthesia

• Faecal incontinence, decreased anal tone

• Global / progressive weakness and numbness in legs (+ pain)

Fracture• Significant trauma• Prolonged use of steroids• Age >70

Cauda Equina Syndrome• Acute urinary incontinence, saddle anaesthesia

• Faecal incontinence, decreased anal tone

• Global / progressive weakness and numbness in legs (+ pain)