Spinal tumors

Spinal tumors (spinal cord tumors), with severe morbidity and mortality rates (disease and death); It has been the focus of attention in neurosurgery because of the positive results when early diagnosis and appropriate treatment methods are applied. Parallel to the technological progress, the increase in diagnostic possibilities and the development of surgical techniques, especially microsurgery, have increased the rates of treatment success.

Approximately 10% to 25% of central nervous system tumors are located in the spinal cord. The incidence of spinal tumors in the population varies between 2-10/100,000. Separating spinal tumors according to their localization provides convenience in diagnosis and treatment. For this reason, the dura mater (outer layer of the spinal cord membrane) relationship is taken into account in the classification. Spinal tumors are grouped accordingly as extradural, intradural extramedullary and extramdullary. The ratio of intradurals to extradurals is 2/3. Of all spinal tumors, 55% are extradural, 40% are intradural extramedullary, and 5% are intradural intramedullary localized tumors.

While extradural tumors constitute the majority of tumors, metastatic tumors constitute the rest of primary spinal tumors; Neurofibroma and meningioma constitute the majority of extramedullary spinal tumors. Ependymoma, astrocytoma and hemangioblastoma constitute 90% of intramedullary spinal tumors.

Spinal tumors mostly consist of benign tumors. In parallel with the development of early diagnosis and treatment possibilities, it has been observed that better results have been obtained.

In recent years, a great development has been observed in radiosurgery. CyberKnife radiosurgery has been beneficial in pain control and improvement of quality of life. Shortness of treatment period, rapid recovery and positive response to treatment can be considered as the main benefits of CyberKnife radiosurgery. While this technique can be used primarily in spinal lesions; It can also be used in inoperable cases, in cases that have received radiotherapy before, or as a support for the surgical technique.

While stereotactic radiosurgery and radiotherapy allow high doses in spinal lesions; spinal cord dose should be limited to the tolerance level. In the majority of postoperative patients who underwent radiosurgery and initially had neurodeficiency, the picture either remained stable or improved.

II Intradural – Extramedullary Spinal Tumors

Intradural extramedullary tumors constitute 40% of spinal tumors and approximately 70% are formed by meningioma and schwannoma; It is stated that 90% of them are benign in character (benign), can be completely removed, and a worsening of neurological status is observed at a rate of 0-10%. With microsurgery, safe and successful results are obtained in tumors in this region. However, alternative techniques should not be ignored in cases with neurofibromatosis, recurrent tumors, multiple lesions and cases with high surgical risk. CyberKnife Radiosurgery in Bening Intradural extramedullary tumors is a safe and low morbidity technique.

IIA Menengiomas:

Spinal meningiomas are less common than intracranial ones; It constitutes approximately 7.5-12.7% of all meningiomas. It constitutes approximately 25-46% of all intradural-extramedullary tumors. It is a benign tumor. It is common in the 50s and 60s. The female male ratio is 4-5/1.

It is located in 67-84% thoracic (back), 14-27% cervical (neck), 2-14% lumbar (waist) region. The importance of gender in localization was emphasized. Density was found especially in the thoracic region in women.

It is usually located intradural extramedullary (83-94%); however, it can also be seen as 3-9% extradural and 5-14% intradural/extradural masses. The risk of malignant transformation is high in those who are completely extradural.

Pain is the most common and early symptom. With the introduction of Magnetic Resonance Imaging (MRI) into routine use, the time to diagnosis has been shortened and surgery has been possible without severe neurological deficits.

82-99% can be completely removed. After the surgery, there is a continuous improvement in a few months. It has good prognosis. Although recurrent (recurrent) meningiomas are rare, they were seen between 1.3-6.4% in different series. If it is benign, usually radiotherapy and chemotherapy are not required. Radiotherapy (radiation) after subtotal resection (partial removal) is controversial. Radiotherapy can be applied in recurrent meningiomas. Mortality and morbidity rates are low (0-3%).

IIBSchwannoma / Neurofibroma:

Nerve sheath tumors (neurinoma, neurofibroma, neurolemmamo and schwannoma) are tumors that originate from schwan cells and are common in the general population (0.3-0.5/100,000). It is common in the 30-50s; although gender dominance is not observed, in different series; It has been reported to occur slightly more in women than in men.

It is located in the cervical and lumbar regions, mostly in the thoracic region, respectively. More than 90% of them are benign. They are slow growing tumors. 80% have pain, 10% have weakness, sphincter problems and sensory disturbances.

The aim is to completely remove the tumor. In this case, the prognosis is extremely good. Since they originate from the nerve root, they should be dissected and cut if necessary, it almost never causes serious functional problems. Recurrences usually occur after subtotal resection. There is no indication for post-surgical radiotherapy.

In a study in which post-operative (post-operative) long-term results were examined; 76.59% of the cases recovered, 17.02% showed partial recovery, 4.25% remained unchanged, worsened in 0.7% and died in 1.41%.

I.II. Intradural Intramedullary Spinal Tumors

Of these, 45% are astrocytomas and 35% are ependymomas. Intramedullary spinal tumors constitute approximately 20-30% of all intradural spinal tumors in adults, while this rate varies between 40% and 50% in children. Hemangioblastoma is the third most common intramedullary tumor. Other tumors in this group are; embryogenic tumors (dermoid, epidermoid, teratoma), neuronal tumors (oligodendrioglioma, ganglioglioma) and lipomas.

While emphasizing the importance of preoperative (preoperative) neurological status in terms of outcome; stated that tumors in the thoracic (back) region also increase the risk of postoperative (post-operative) morbidity.

I.II.A. Astrocytomas:

More common in children and adolescents. It is more common in men than women. In terms of location, the thoracic region and the cervical region constitute the majority. In general, there is multi-regional involvement. About half contain cystic areas.

The most common initial symptom is pain; The pain generally fits the location of the tumor, tends to increase with movement and at night. Benign malignant (good bad) rate is 3/1.

Complete removal of the tumor is intended, but is not usually possible. It is recommended to drain with an ultrasonic aspirator without damaging the normal neural tissue. Radiotherapy is recommended after surgery for high grade and recurrent tumors .

I.II.B. Ependymomas:

Ependymomas are the most common intramedullary tumors in adults; It is the second most common in children. They are common in the 30s and 40s. The male to female ratio is 2/1. 90% of them are located in the lumbosacral region, followed by the cervical region.

The most common complaints are pain and loss of strength in one extremity. It often presents as neck and back pain. Neurological deficits usually occur in the last stages of the disease and in the case of delayed diagnosis.

The results are good in total resections, and there is a possibility of recurrence (recurrence) in subtotal (partial) removals. The prognosis is quite good. Ependymomas are sensitive to radiation therapy, and with such an additional treatment, success has been achieved against local recurrence and metastases. Chemotherapy is limited to recurrent cases where radiotherapy and surgery cannot be applied.

I.II.C. Others

Hemangioblastoma:

60% of this benign tumor is intramedullary; It is more common in the thoracic and cervical regions. The mean age is 35 years and most cases are usually under 40 years of age. There is no gender difference. Well circumscribed allows for surgical removal.

II. Extradural Spinal Tumors

II.I. Metastatic Extradural Tumors

Skeletal system metastases (dissemination) are most common in the spine. The most common primary sources are: lung, breast, prostate, kidney, thyroid, gastrointestinal tract and lymphoma. In men, lung and prostate; Breast and lung are the more common primary sources in women.

60% of these tumors are seen in men and 40% in women, and they peak between the ages of 40-65 (10,40). Metastases are most commonly seen in the lumbar region, less commonly in the thoracic region, and least in the cervical region.

It has been reported that the average duration of the complaints is 2 months, it is often located in the thoracic and lumbar regions, the most common first complaint is pain, paraplegia (paralysis) can develop at a rate of 10-15%, and generally the most common primary focus is the lung.

Spinal metastases; 95% is extradural, the remainder is mostly intradural extramedullary (4%) and rarely intramedullary metastases (1%).

More than half of the cases have motor loss (weakness), and about half of them have sphincter problems and sensory disturbances.

In 90% of cases with symptomatic spinal metastases, findings are found on direct radiographs. Bone scintigraphy is used to identify multiple lesions and distant metastases. Computed tomography and MRI are very important in detecting metastasis, in differential diagnosis, and in planning surgery.

When radiotherapy and surgical resection are applied together, positive results increase up to 44%-68%. The success of the surgery varies according to the localization of the tumor. In cases of rapidly progressing paraplegia, emergency surgery should be performed, otherwise it should be known that irreversible and complete spinal cord injuries may occur. Surgical decompression followed by stabilization and radiotherapy is the most selective treatment for metastatic spinal tumors.

II.II. Primary Spinal Tumors:

Primary spinal tumors are not as common as metastatic extradural tumors. Approximately 11% of all primary skeletal tumors are in the spinal region. Primary spinal tumors show activity by invasion of adjacent tissues and compression on the spinal cord. There is a relationship between age and whether it is benign or malignant; Those under the age of 21 are usually benign.

In radiological diagnosis, direct radiographs are used first. MRI provides great convenience in the classification and characterization of the tumor. CT is important in the evaluation of bone structure .

Surgery, chemotherapy and radiotherapy are among the treatment options. The aim of surgery is complete removal of the tumor without disturbing the stabilization.