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Spinal Neoplasms

Spinal neoplasms are similar to intracranial tumors but involve the spinal cord or its roots. Untreated spinal neoplasms can eventually cause paralysis. As primary tumors, they originate in the meningeal coverings, the parenchyma of the cord or its roots, the intraspinal vasculature, or the vertebrae. They can also occur as metastatic foci from primary tumors, but death usually results from the primary condition.

Primary tumors of the spinal cord may be extramedullary (occurring outside the spinal cord) or intramedullary (occurring within the cord). Extramedullary tumors may be intradural (meningiomas and schwannomas) and account for about 60% of all primary spinal cord neoplasms. Extramedullary tumors may also be extradural (metastatic tumors from breasts, lungs, prostate, leukemia, or lymphomas) and account for about 25% of these neoplasms.

Intramedullary tumors, or gliomas (astrocytomas or ependymomas), are comparatively rare and account for only about 10% of spinal neoplasms. In children, these lesions are low-grade astrocytomas.

Spinal cord tumors are rare compared with intracranial tumors (ratio of 1 :4). They occur with equal frequency in men and women, except for meningiomas, which occur more often in women. Spinal cord tumors can grow anywhere along the cord or its roots.

Causes

Little is known about the cause of spinal cord tumors. They have been associated with central von Reck­linghausen's disease.

Diagnostic tests 

Lumbar puncture reveals clear yellow cerebrospinal fluid (CSF), resulting from increased protein levels if the flow is completely blocked. If the flow is partially blocked, protein levels rise, but the fluid appears only slightly yellow in proportion to the CSF protein level. A Papanicolaou test of the CSF may show malignant cells of metastatic carcinoma.

X-rays show distortions of the intervertebral foramina; changes in the vertebrae or collapsed areas in the vertebral body; and localized enlargement of the spinal canal, indicating an adjacent blockage.

Myelography identifies the lesion's level by outlining the tumor if it causes a partial obstruction. The myelogram shows the anatomic relation to the cord and the dura. If the tumor causes a complete obstruction, the injected contrast agent can't flow past the tumor. This study is dangerous in instances of nearly complete cord compression because withdrawn or escaping CSF will allow the tumor to exert greater pressure against the cord.

Treatment

Spinal cord tumors are treated with decompression or radiation therapy. Not usually indicated for metastatic tumors, laminectomy may be done for primary tumors that produce spinal cord or cauda equina compression. If the tumor progresses slowly or if it's treated before the cord degenerates from compression, signs and symptoms are likely to subside, and function may be restored.

In a patient with metastatic carcinoma or lymphoma who suddenly experiences complete transverse myelitis with spinal shock, functional improvement is unlikely, even with treatment. This patient's prognosis is poor.

If the patient has incomplete paraplegia of rapid onset, emergency surgical decompression may save cord function. Steroid therapy may minimize cord edema until the patient undergoes surgery.

Partial removal of intramedullary gliomas, followed by radiation therapy, may temporarily ease signs and symptoms. Metastatic extradural tumors can be controlled with radiation therapy, analgesics, and, in hormone-mediated tumors (breast and prostate), appropriate hormone therapy.

Transcutaneous electrical nerve stimulation (TENS) may relieve radicular pain from spinal cord tumors and is a useful alternative to opioid analgesics. TENS works by applying an electrical charge to the skin, thereby stimulating large-diameter nerve fibers and inhibiting the transmission of pain impulses along nerve fibers.

The risk of infection is increased by treatment in many cases, but the risk also increases as the patient's condition deteriorates.



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