Spinal cord tumor are neoplasms of a primary and metastatic nature, localized in the near—spinal space, membranes or substance of the spinal cord. The clinical picture of spinal tumors is variable and may include radicular syndrome, segmental and conductive sensory disorders, single- or bilateral paresis below the lesion level, pelvic disorders. In diagnostics, it is possible to use radiography of the spine, contrast myelography, cerebrospinal fluid tests and cerebrospinal fluid studies, but the leading method is MRI of the spine. Treatment is carried out only surgically, chemotherapy and radiation exposure are of auxiliary importance. The operation may consist in radical or partial removal of the spinal neoplasm, emptying its cyst, decompression of the spinal cord.
General information
The most common spinal cord tumor is diagnosed in people aged 30 to 50 years, in children it occurs in rare cases. In the structure of CNS tumors in adults, spinal cord neoplasms account for about 12%, in children — about 5%. Unlike brain tumors, spinal tumors have a predominantly extra-cerebral location. Only 15% of them originate directly in the substance of the spinal cord, the remaining 85% arise in various structures of the spinal canal (fatty tissue, spinal cord membranes, vessels, spinal roots). Vertebrogenic, vol. E. growing from the vertebrae, neoplasms belong to bone tumors.
Classification
Modern clinical neurosurgery and neurology use several basic classifications of spinal neoplasms in their practice. In relation to the spinal cord, tumors are divided into extramedullary (80%) and intramedullary (20%). An extramedullary spinal cord tumor develops from the tissues surrounding the spinal cord. It can have subdural and epidural localization. In the first case, the neoplasm is initially located under the dura mater, in the second — above it. Subdural tumors in most cases are benign in nature. 75% of them are neurinomas and meningiomas. Neurinomas arise as a result of metaplasia of Schwann cells of the posterior roots of the spinal cord and clinically debut with radicular pain syndrome. Meningiomas originate in the dura mater and fuse tightly with it. Extradural tumors have a very variable morphology. Neurofibromas, neurinomas, lymphomas, cholesteatomas, lipoma, neuroblastoma, osteosarcomas, chondrosarcomas, myeloma can act as such neoplasms.
An intramedullary spinal cord tumor grows from its substance and therefore manifests segmental disorders. Most of these tumors are represented by gliomas. It should be noted that spinal gliomas have a more benign course than brain gliomas. Among them, ependymoma is more common, which accounts for 20% of all spinal neoplasms. It is usually located in the area of the cervical or lumbar thickening, less often in the area of the ponytail. Astrocytoma, prone to cystic transformation, and malignant glioblastoma, characterized by intensive infiltrative growth, are less common.
Based on the localization, a spinal cord tumor can be craniospinal, cervical, thoracic, lumbosacral and a ponytail tumor. Approximately 65% of spinal formations are related to the thoracic region.
By its origin, a spinal cord tumor can be primary or metastatic. Spinal metastases can give: esophageal cancer, malignant tumors of the stomach, breast cancer, lung cancer, prostate cancer, renal cell carcinoma, granular cell carcinoma of the kidney, thyroid cancer.
Symptoms of a spinal cord tumor
In the clinic of spinal neoplasms, there are 3 syndromes: radicular, brownsecar (the diameter of the spinal cord is affected by half) and a complete transverse lesion. Over time, any spinal cord tumor, regardless of its location, leads to damage to its diameter. However, the development of symptoms with the growth of intra- and extramedullary tumors is markedly different. The growth of extramedullary formations is accompanied by a gradual change in the stages of radicular syndrome, Brownsecar syndrome and total lesion of the diameter. At the same time, the spinal cord lesion at the initial stages is caused by the development of compression myelopathy, and only then by the germination of the tumor. Intramedullary tumors begin with the appearance of dissociated sensory disorders of segmental type at the level of formation. Then gradually there is a complete defeat of the spinal diameter. The radicular symptom complex occurs in the late stages when the tumor spreads beyond the spinal cord.
Radiculopathy is characterized by intense pain of the radicular type, which increases with coughing, sneezing, tilting the head, physical work, straining. Usually there is an increase in pain in a horizontal position and its weakening when sitting. Therefore, patients often have to sleep half-sitting. Over time, the pain syndrome is joined by segmental loss of all types of sensory perception and reflex disorder in the innervation zone of the root. When percussion of spinous processes occurs at the level of a spinal tumor, pain radiates to the lower parts of the body. The onset of the disease with radicular syndrome is most typical for an extramedullary spinal cord tumor, especially for a neurinoma. Such a manifestation of the disease often leads to errors in the primary diagnosis, since the radicular syndrome of tumor genesis is clinically not always possible to differentiate from radiculitis caused by inflammatory changes of the root in infectious diseases and pathology of the spinal column (osteochondrosis, intervertebral hernia, spindyloarthrosis, scoliosis, etc.).
Brown-Sekara syndrome is a combination of homolateral central paresis below the site of spinal cord injury and dissociated sensory disorders of the conductor type. The latter include the loss of deep types of vibration, muscle—joint sensitivity on the side of the tumor and a decrease in pain and temperature perception on the opposite side. At the same time, in addition to conductive sensory disturbances on the affected side, segmental disorders of surface perception are noted.
The total lesion of the spinal diameter is clinically manifested by bilateral conductive prolapses of both deep and superficial sensitivity and bilateral paresis below the level at which the spinal cord tumor is located. There is a disorder of pelvic functions that threatens the development of urosepsis. Vegetative-trophic disorders lead to the appearance of bedsores.
Symptoms depending on the localization
Craniospinal tumors of extramedullary location manifest with radicular pains of the occipital region. The symptoms of damage to the brain substance are very variable. Neurological deficit in the motor sphere can be represented by central tetra- or triparesis, upper or lower paraparesis, cross hemiparesis, in the sensitive sphere — it varies from complete sensory preservation to total anesthesia. There may be symptoms associated with impaired cerebral cerebrospinal fluid circulation and hydrocephalus. In some cases, trigeminal neuralgia, neuralgia of the facial, pharyngeal and vagus nerves are noted. Craniospinal tumors can grow into the cranial cavity and cerebral structures.
Neoplasms of the cervical region located at the C1-C4 level lead to conduction disorders of sensitivity below this level and spastic tetraparesis. A feature of the C4 level lesion is the presence of symptoms caused by paresis of the diaphragm (shortness of breath, hiccups, difficulty sneezing and coughing). The formations of the cervical thickening area are characterized by central lower and atrophic upper paraparesis. Spinal cord tumor in segments C6-C7 is manifested by myosis, ptosis and enophthalmos (Horner’s triad).
Tumors of the thoracic region give a clinic of shingling root pains. At the initial stage, due to the neuroreflective spread of pain, patients are often diagnosed with acute cholecystitis, appendicitis, pancreatitis, pleurisy. Then conductive sensory and motor disorders join, abdominal reflexes fall out. The upper limbs remain intact.
Neoplasms of the lumbosacral region located in the L1-L4 segments are manifested by radicular syndrome, atrophy of the anterior thigh muscle group, loss of tendon knee reflexes. Epiconus tumors (segments L4-S2) — peripheral paresis and hypesthesia in the buttocks, posterior femoral surface, lower leg and foot; urinary and fecal incontinence. Cone tumors (segments S3-S5) do not lead to paresis. Their clinic consists of pelvic disorders, sensory disorders of the anogenital zone and anal reflex prolapse.
Ponytail tumors are characterized by slow growth and, due to the displacement of the roots, can reach large sizes, having a subclinical course. They make their debut with a sharp pain syndrome in the buttock and leg, simulating sciatic nerve neuropathy. Asymmetric sensory disturbances, distal flaccid paresis of the legs, loss of Achilles reflexes, urinary retention are typical.
Diagnostics
The disorders revealed during the neurological examination allow the neurologist only to suspect an organic lesion of spinal structures. Further diagnosis is carried out using additional examination methods. Spine x-ray is informative only in the advanced stage of the disease, when the tumor process leads to displacement or destruction of the bone structures of the spinal column.
The sampling and examination of cerebrospinal fluid has a certain diagnostic role. Carrying out a number of cerebrospinal fluid dynamic tests during lumbar puncture makes it possible to identify a block of subarachnoid space. When the spinal canal is filled with a tumor in the puncture area, during the examination, the cerebrospinal fluid does not flow out (the so-called “dry puncture”), but root pain occurs due to the needle entering the tumor tissue. The analysis of the cerebrospinal fluid indicates protein-cellular dissociation, and hyperalbuminosis is often so pronounced that it leads to the coagulation of the cerebrospinal fluid in the test tube. The detection of tumor cells in the cerebrospinal fluid is a rather rare finding.
In recent years, most specialists have abandoned the previously used isotope myelography and pneumomyelography due to their low information content and significant danger. Contrast myelography allows to indicate the level of spinal lesion, as well as to assume an extra- or intramedullary type of tumor. However, its results are far from ambiguous, and its implementation is associated with certain risks. Therefore, myelography is now used only if it is impossible to use modern neuroimaging studies.
The safest and most effective way to diagnose a spinal cord tumor is an MRI of the spine. The method makes it possible to visualize soft tissue formations located in the spinal column in layers, analyze the volume and prevalence of the tumor, its localization in relation to the substance, membranes and roots of the spinal cord, make a preliminary assessment of the histostructure of the neoplasm.
Complete verification of the diagnosis with the establishment of the histological type of tumor is possible only after morphological examination of its tissue samples. The collection of material for histology is usually performed during surgery. During the diagnostic search, it is necessary to differentiate the spinal cord tumor from discogenic myelopathy, syringomyelia, myelitis, arteriovenous aneurysm, funicular myelosis, amyotrophic lateral sclerosis, hematomyelia, cerebrospinal circulation disorders, tuberculoma, cysticercosis, echinococcosis, gumma of tertiary syphilis.
Treatment
The main effective method of treatment is surgical. Radical removal is possible with benign extramedullary spinal tumors. Root neurinoma removal and meningioma removal are performed after a preliminary laminectomy. Examination of the spinal cord at the microscopic level indicates that its damage due to compression by extramedullary formation is completely reversible at the stage of Brown-Secar syndrome. Partial restoration of spinal functions can also occur when the tumor is removed at the stage of complete transverse lesion.
Removal of intramedullary tumors is very difficult and often entails injury to the cerebrospinal substance. Therefore, as a rule, it is carried out with pronounced spinal disorders. With the relative preservation of spinal functions, decompression of the spinal cord, emptying of the tumor cyst is carried out. It is hoped that the microneurosurgical method being introduced into practical medicine will eventually open up new opportunities for surgical treatment of intramedullary tumors. To date, radical removal from intramedullary tumors is advisable only for ponytail ependymoma, however, during the removal of the epedymoma, there is a risk of damage to the cone. Radiation therapy in relation to intramedullary tumors is considered ineffective today, it practically has no effect on low-grade astrocytomas and ependymomas.
Due to their infiltrative growth, malignant spinal cord tumors are not available for surgical removal. In relation to them, radiation and chemotherapy are possible. An inoperable spinal cord tumor, proceeding with an intense pain syndrome, is an indication for an analgesic neurosurgical operation, consisting in cutting the spinal root or spinal-thalamic pathway.
Forecast
The immediate and long-term prognosis of a spinal tumor is determined by its type, location, structure, and duration of spinal cord compression. Removal of extramedullary tumors of a benign nature in 70% leads to the complete disappearance of the existing neurological deficit. At the same time, the recovery period varies from 2 months to 2 years. If spinal compression lasted more than 1 year, it is not possible to achieve full recovery, patients receive disability. Mortality of persons who underwent removal of extramedullary arachnoendotheliomas does not exceed 1-2%. Intramedullary and malignant spinal tumors have an unfavorable prospect, since their treatment is only palliative.