Upload
ahmed-debes
View
641
Download
3
Tags:
Embed Size (px)
DESCRIPTION
Spinal cord tumors [extra-medullary , intra-medullary]
Citation preview
SPINAL CORD TUMORSBY : DR / AHMED MOHAMMED DEBES
NEUROSURGERY RESIDENT AT AHMED MAHER TEACHING HOSPITAL
CAIRO, EGYPT.
TUESDAY 09/10/2014
Spinal Cord Tumors
Intra-dural
Intra-medullary Extra-medullary
Extra-dural
Extra-medullary
Nerve Sheath Tumors
schwannomas neurofibromas
Meningiomas
Filum Terminale Ependymomas
• Gross
• Micro
• Asso.
Neurofibromas
• Fusiform
• Fibrous tissue + nerve fibers
• Neurofibromatosis type I
Schwannomas
• globoid masses, suspended eccentrically
• Antoni-A(elongated cells) Antoni-B(stellate-shaped
• schwannomatosis
• 4th – 6th decade , male = female
•Mostly affect dorsal root
most common
30%
(cervical)
10%
1%
arachnoid cap
cells
decade ,
•Mainly , upper
cervical spine and
foramen magnum
•ventral or ventrolateral,
may
•10%
•Do not penetrate the
pia
decade ,
•Myxopapillary
ependymomas
•Cuboidal cells surrounding a
vascularized core of
hyalinized connective tissue
•Benign
neural crest, benign,
neurosecretory granules
dumbbell tumors in
pediatric
thoracic spine
rarely
cause mass effect
CSF drop metastases,
direct penetration of the
dural root sleeve
•Depend on location
•Local back pain & radicular
pain
•Worsening pain on
recumbency
Signal abnormalities
CSF capping
cord/cauda displacement
•T1 iso/ slightly hypointense
•T2 hyperintense
•Contrast enhancement
benign,
excision, Recurrences are rare
-Posterior laminectomy
-unilateral facetectomy
-open dura
-Dorsal (visualized), Ventral
(dissect dentate ligament
-Cauterize tumor
-Neurostimulation
-Dumbbell shaped (resection of
both nerve roots)
-Surgical removal easy due to
- absence of bony involvement
- well-defined spinal epidural
space
- lack of venous sinus
involvement
-Recurrence 10 %
- Posterior laminectomy
- Anterior approaches for purely
ventral tumors
-Management of the dural base
• excision of the dural then graft
• extensive in situ coagulation
-Role of surgery depends on
size of the tumor and its
relationship
-Gross total en bloc resection
- Small, well circumscribed within
the fibrous coverings & easily
separable from the nerve roots
-Subtotal
-Radiation therapy
Intra-medullary
Astrocytomas Ependymomas
Hemangioblastoma
80% 8%
-First 3 decades of life
-Most common pediatric
intramedullary cord tumor
-60% of occur in the
cervical
-20% associated syringes
-Most are grade I or II
-Associated NF1
-Most common
intramedullary tumors in
adults
-Male = Female, middle
age
-65% have associated
cysts
-Associated NF2
-Cellular ependymoma
the most common
-Benign, unencapsulated,
circumscribed and do not
-Associated with von
Hippel-Lindau syndrome
(AD)
-At any age
-Associated syringes
-Benign tumors of
vascular origin
-Circumscribed, not
encapsulated
-located dorsally or
dorsolaterally
most
common dysembryogenic
lesion, increased fat
deposition in metabolically
normal fat cells, subpial
location.
The lung
and breast are the most
common primary tumor
sites
history of radiation
•Nonspecific
neurological deficit
can cause abrupt
deterioration
(ependymomas)
and
dysfunction occur early
Cord enlargement
Enhancement
•T1 iso/ slightly hypointense
•T2 hyperintense
-uniform contrast enhancement
-Polar cysts
-Heterogeneous contrast
enhancement
-Irregular margins
•Microsurgical removal is the
most effective treatment of
ependymomas &
hemangioblastomas.
•For astrocytomas are more
controversial.
•Resection should be limited to
tumor tissue
•Preservation of neurological
function rather than complete
tumor resection is paramount
• Preoperative steroids
and antibiotics
• General anesthesia,
intubated & prone
• Sensory and motor
evoked potentials
monitoring
• Midline skin,
subperiosteal bony
dissection
• Laminectomy extend
one segment above
and below the tumor
•The facets are
preserved.
• Strict hemeostasis before the
dura is opened
• The dura is opened in the
midline and tented laterally
with sutures
• Operating microscope
• The arachnoid is opened
• Cord inspected for surface
abnormalities ,U/S localize
tumor
• midline myelotomy through
the posterior median septum
• dorsal midline -- midpoint
between the dorsal nerve root
entry zones bilaterally
• Midline crossing vessels in
• Pia incised sharply with a
micro knife or scissors
• myelotomy extend over the
entire rostrocaudal extent of
the tumor
• Spreading the posterior
columns gently with micro
forceps
• Pial traction sutures are
placed
• Technique of tumor removal
is determined by the surgical
Objective (biopsy , removal)
• Internal decompression with
an ultrasonic aspirator or
laser
• The myelotomy is not closed
Q) WHAT TYPES OF NERVES DO NEUROFIBROMAS GENERALLY ARISE FROM?
•Dorsal root
•Ventral root
•Both of them
INTRADURAL SPINAL NERVE SHEATH TUMORS ARE TOTALLY MALIGNANT ( T ) OR ( F )
•False only 2.5 % are malignant
MENINGIOMAS USUALLY ARISE FROM WHICH TYPE OF CELLS ?
•Arachnoid cap cells
………. ARE BENIGN TUMORS OF VASCULAR ORIGIN ?
•Hemangioblastomas
Q) IN RESECTING AN INTRAMEDULLARY SPINAL CORD TUMOR, WHAT IS A SURE WAY TO RECOGNIZE THE MIDLINE IF THE TUMOR IS DEFORMING THE NORMAL SPINAL CORD ANATOMY?
•Midpoint between the dorsal nerve root entry zones
bilaterally
Q) WHAT IS THE MOST COMMON INTRAMEDULLARY SPINAL CORD TUMOR IN ADULTS?
•Ependymoma
•Meningiomas
•Astrocytoma
•Hemangioblastoma
Q) WHAT IS THE MOST COMMON INTRAMEDULLARY SPINAL CORD TUMOR IN PEDIATRIC ?
•Ependymoma
•Meningiomas
•Astrocytoma
•Hemangioblastoma
THE ENDTHANK YOU