Primary Spine Tumors
Primary spinal tumors may be benign or malignant. Benign causes include vertebral hemangioma, osteoid osteoma, osteoblastoma, aneurysmal bone cyst, osteochondroma, and giant cell tumors of the bone. Malignant tumors include chondrosarcoma, chordoma, and osteogenic sarcoma. Osteoid osteomas and osteoblastomas should be completely excised for cure. Surgical resection may also be attempted for malignant lesions, although prognosis is generally poor and recurrence rate is high. Aneurysmal bone cysts and giant cell tumors can be treated via intralesional curettage.
Metastatic Spine Tumors
Metastatic tumors are the most common malignancy of the spine. The spine has a rich vascular supply that is prone to hematogenous spread from a primary tumor site, including lung, breast, and prostate. Metastatic disease may be found in all spinal compartments but is most often in the extradural space. Prostate and breast cancer may be osteolytic (bone destructive) or osteoblastic (growth stimulating). Lymphoma and lung metastases are osteolytic. Metastatic tumors can cause pathologic vertebral fractures. Decision to operate depends on primary disease progression and spinal stability. In a patient with low disease burden and high quality of life, surgical resection and spinal fusion may be undergone to reverse or limit neurologic deficit and ensure spinal integrity. In a patient with high disease burden and poor prognosis, surgical intervention will be limited, with the goal of providing palliative treatment.
The extradural space, outside the spinousdura, is the most common location for spinal tumors, where they may arise in the vertebral bodies or epidural tissues. These comprise 50% of all spinal tumors. They typically arise from the osseous spine, intervertebral discs, and adjacent soft tissues. On imaging, the hallmark is focal displacement of the thecal sac away from the mass. The most common extradural tumors are metastatic, as discussed above. Benign tumors include hemangioma, osteoid osteoma, and osteochondroma. Cysts and other benign tumor-like masses include eosinophilic granuloma, epidural lipomatosis, synovial cysts, and arachnoid cysts. Malignant tumors include chordoma, lymphoma, osteosarcoma, chondrosarcoma, plasmacytoma (as in multiple myeloma), and metastatic disease. The most common presenting symptom for all extramedullary tumors is local pain. Depending on extension, compression of the spinal cord or nerve roots may cause radiculopathy or neurologic deficit. Extradural tumors are amenable to surgical resection, which is recommended to provide symptomatic relief. Adjuvant radiation therapy and/or chemotherapy is recommended for malignant lesions.
Intradural Extramedullary Spinal Cord tumors
This is the second most common location for spinal tumors, where lesions may arise in the leptomeninges or nerve roots. Although these masses are located within the dural sheath, they are outside the spinal cord.Intraduralextramedullary spinal cord tumors make up 40% of all spinal masses. The most common tumor types are meningiomas and neurofibromas, both of which are benign. Symptoms include local or radicular pain, motor deficits, or sensory symptoms. Sphincter disturbance is rare. Spinal schwannomas, sporadic or associated with neurofibromatosis, are benign, slow-growing, and typically intradural. Patients present with local pain and do not develop neurologic deficits until late. In general, tumors producing neurologic symptoms should be surgically resected. For schwannomas specifically, depending on degree of nerve root involvement, the entire nerve root may have to be sacrificed. For benign tumors, recurrence is rare following gross total excision.
Intradural Intramedullary Spinal Cord Tumors
Tumors arising in the spinal cord substance are rare, comprising only 5% of spinal tumors. They can produce devastating sympoms due to white matter tract and grey matter destruction. Lesion types most commonly include astrocytoma and ependymoma. Others may be malignant glioblastoma, dermomid, epidermoid, teratoma, lipoma, or hemangioblastoma.
Ependymomas are the most common glioma of the lower spinal cord, conus, and filum and typically present in adults. They are benign and slow-growing. MRI with contrast should be used to evaluate the entire spinal cord due to CSF seeding. Gold-standard treatment is surgical excision.
For all of the aforementioned tumor types, pain — local or radicular — is the most common presenting complaint. Other symptoms include weakness or sensory loss. Asymptomatic lesions should be monitored with imaging. MRI is recommended. Total excision should be attempted for symptomatic lesions at symptom onset. Gross total resection may be attempted for low-grade astrocytomas with a plane of separation from the spinal cord. For high-grade astrocytomas and/or those without a plane of separation, biopsy alone or limited excision only is recommended. Radiation therapy, with or without chemotherapy, is suggested for high-grade astroctyomas.