Spinal Cord

tumors
Mahmoud Wahdan
Benha university
 ‫الر ِح ِميم‬
‫الر ْح َم ِن ه‬ ‫ِب ْس ِم ه ِ‬
‫َّللا ه‬

‫(وقل الحمد هلل سميرميكم آمياته‬

‫فتعرفونها و ما ربك بغافل عما‬
‫تعملون)‬
‫سورة النمل‬
‫االمية‪93‬‬
ANATOMY
The spinal cord develops from the caudal part of the neural tube.
The wall of the neural tube consists of neuroepithelial cells.
The neuroepithelial cells begin to give rise to neuroblasts. They form the
mantle layer.
The mantle (intermediate) layer later forms the gray matter of the
spinal cord.
The outermost layer of the spinal cord, the marginal layer, contains
nerve fibers emerging from neuroblasts in the mantle layer.
As a result of myelination of nerve fibers, this layer takes on a white
appearance and therefore is called the white matter of the spinal cord.
Neural Tube Components
2. Basal Plate
It is the ventrolateral thickening of the
intermediate zone (mantle layer) of the
neural tube.
It gives rise to motor neuroblasts of the
ventral and lateral horns (somatic efferent
{SE} and general visceral efferent {GVE} cell
regions).
 Axons from motor neuroblasts exit the spinal
cord and form the ventral roots.
It becomes the ventral horn of the spinal
cord.
 In addition to the ventral
motor horn and the dorsal
sensory horn, a group of
neurons accumulates
between the two areas and
forms a small intermediate
horn. This horn, containing
neurons of the
sympathetic portion of
the autonomic nervous
system, is present only at
thoracic (T1–T12) and
upper lumbar levels (L2 or
L3) of the spinal cord.
3. Sulcus limitans
- It is a longitudinal groove in the lateral wall of the neural
tube that appears during the 4th week of development.
- It separates the alar (sensory) and basal (motor) plates.
-It disappears in the adult spinal cord, but is retained in the
rhomboid fossa of the brain stem as the superior and inferior
fovea.
- It extends from the spinal cord to the rostral midbrain.
4. Roof plate
- It is the nonneural roof of the central canal, which connects
the two alar plates.
5. Floor plate
- It is the nonneural floor of the central canal, which connects
the two basal plates.
- It contains the ventral white commissure.
Positional Changes Of Spinal Cord
 At the 8th week of development, the spinal cord extends
through the whole length of the vertebral canal.
 At birth, the conus medullaris extends to the level of the
3rd lumbar vertebra (L3).
 In adults, the conus medullaris terminates at
intervertebral disc between L1-2.
 Unequal growth between the vertebral column and the
spinal cord results in the formation of the cauda equina
which consists of dorsal and ventral roots, that descends
below the level of the conus medullaris.
 Unequal growth results also in the formation of the
nonneural filum terminale, which anchors the spinal cord
to the coccyx.
 Bony Anatomy
Osseous spinal column surrounding the spinal cord is formed
of :

Vertebrae
There are 33 vertebrae that make up the bony structure of the
spinal column

Discs
Each 2 vertebrae are separated by a soft cartilaginous
substance, called a disc

Ligamentous structures
The stability and mobility of the spinal column is maintained by
a network of strong ligamentous structures.
This figure shows spine and related structures
Spinal cord and meninges.T.S
Arterial supply :
 descending branches of the vertebral arteries (i.e.,
anterior and posterior spinal arteries) and
 multiple radicular arteries derived from segmental vessels.

VENOUS DRAINAGE :
 Veins have a distribution similar to that of the arteries.
 Anterior longitudinal trunks consist of anteromedian and
anterolateral veins.
 Sulcal veins drain the anteromedian portions
 Anterolateral regions drain into anterolateral veins.
Diagrammatic representation showing the origin and general
location of principal arteries supplying the spinal cord.
 Internally the spinal cord is divided into gray and white matter.

section of the spinal cord Intra-dural anatomy

The spinal cord contains ascending and descending
tracts that carry information and orders from the
brain to the end organs
Pathology and
epidemiology
 a prevalence of 3–10 per 100,000 per year.

 They predominantly occur in the middle age .

 About 15 % of CNS neoplasms.

 Metastatic involvement of the intradural compartment is

rare.

 About two thirds of spinal cord tumors in adults are

extra-medullary in location.

 One third are intramedullary. More than 80 % are 1ry

glial tumors. Most of these are histologically benign.
 Clinical
presentation
 Almost all patients with extramedullary tumors have
pain, which most commonly has a radicular pattern

 Intramedullary spinal cord tumors present with

complaints of back or radicular pain or paraethesias.

 Children present with scoliosis or neurologic complaints

 torticollis : persistence or its association with other

objective findings should lead to a search for an etiology
basis.
 Weakness is the second most common complaint.
Children present most frequently with gait problems

 Dysesthesias and paraesthesias are more common

than numbness

 Sphincteric disturbances usually urogenital and less

commonly anal occur in the form of difficult
evacuation, retention, incontinence, and impotence.
 neurological status assessed with Mckormic scale
Investigations
 The imaging modality of choice for evaluation
of intradural spinal tumors is MRI.

 But plain x ray films and CT are still performed.

 Contrast-enhanced images are important to

1-define the extent of the lesion
2-useful in distinguishing cysts or syrinx from
neoplastic involvement .
3- are important in postoperative follow-up.
 Meningiomas are often solid, well-circumscribed
The dura tail and calcification may be seen

 Meningiomas appear isointense on T1 and slightly

hyperintense on T2

 In general, meningiomas gives homogeneous

enhancement, except for calcified areas.

 Meningiomas compress and displace the spinal

cord.
Sagittal T1-weighted image demonstrates a mass
just behind the odontoid which is isointense with
the spinal cord.

b A T2-weighted image shows the mass to give

minimally lower signal than the spinal cord.

c, d A contrast-enhanced sagittal and axial T1-

weighted
images show the extent of the tumor, which
enhances homogeneously indicating meningioma
 Schwannomas typically seen in the dorsal sensory
roots.

 They displace the spinal cord to the contralateral side .

 commonly isointense on T1 and markedly hyperintense

on T2.

 When large they extend into the neural foramina and

prevertebral space in a “dumbbell” fashion.
patient with a dumbbell schwannoma of the left C7
nerve root expanding the left foramen at C6/7.
 Neurofibromas encase rather than displace the
nerve roots.

 They are typically rounded or fusiform tumors ,

isointense on T1 and markedly hyperintense on
T2. with intense and uniform enhancement.

 Multiple and plexiform neurofibromas are often

seen in patients with (NF-I).
 Ependymomas usually shows uniform
enhancement and are symmetrically located within
the cord.

 T2 images are more sensitive for tumor detection

because most tumors are hyperintense to the spinal
cord on T2

 Polar cysts are identified in the majority of cases ,

particularly in cervical and cervicothoracic tumors.

 Heterogeneous enhancement from intra-tumoral

cysts or necrosis can be seen with ependymomas.
 Cervical cord ependymoma
At both ends, associated cysts are visible
 Appearance of Astrocytomas on MRI variable.

 less well defined than ependymomas because of

their irregular tumor margins.

 Contrast uptake may be minimal, uniform, or

patchy.

 Heterogeneous uptake because of intratumoral

cysts or necrosis.
cervical low-grade Astrocytoma
 Surgical
Treatment
 Surgical resection remains the treatment of
choice for spinal tumors.

 With small lateral tumors, a hemilaminectomy

may be adequate.

 The dura is then opened in the midline.

 Identification of the midline raphe

 Leaving the arachnoid membrane intact is advised

during dura opening.
Basically, three options exist for myelotomy :

 In most instances, the myelotomy is done in the

midline.

 If the tumor is located laterally, the dorsal root

entry zone may be used.

 With tumors reaching the surface or those

with exophytic growth, the spinal cord can be
entered in that area
 The dissection plane between the tumor mass
and normal cord tissue is relatively easy to
preserve in most cases of spinal ependymoma.

 Expansive growth of spinal cord ependymomas

enables complete removal of tumors.
medial posterior arachnoid septum was sutured to the opposite dura
to mobilize the cord slightly to the opposite side.

Anterior root carrying the tumor is isolated with a small hook,

coagulated and transected
situation after radical removal of this schwannoma. With cutting of the
arachnoid retention sutures the cord regains its normal position.
Intra operative NeuroMonitoring :

 Kurokawa’s group invented a technology in 1972 to utilize

the spinal cord evoked potential (SCEP) after direct
stimulation of the spinal cord.

 UK employed spinal somatosensory evoked potential in

1983.

 Somatosensory evoked potential (SEP) recording is of use

to assess the functional integrity of the sensory system.
 A limitation of SEPs monitoring is that the evoked
responses may be absent or weak preoperatively

 Dorsal column injury is detected during the

operation.

 However the motor functions may be damaged

without changes in the SEPs intra-operative
recording
Illustrative cases
Ependymoma
M
39
Post operative:--

18 months Post op. :-

62
F
Microcystic meningioma
Post operative:--
Conclusions
 The spinal cord tumors are lesions that can be
treated safely and effectively by surgery only .

 Total resection must be the essential aim before

surgery and must be tried whenever possible

 The surgery must be carried out at the time of

the diagnosis

 Preoperative neurological state, pathological type,

pathological grade and degree of resection are
the most important factors that affected the final
outcome of our patients
 Intraoperative neurophysiology of the spinal cord
has become an important tool of Neurosurgery

 Complications are encountered mainly with high

grade and infiltrative masses

 Recurrence is an important issue and is directly

correlated with the degree of tumor resection
and pathological grade and infiltrative nature of
the tumor.