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Spinal Neoplasms

A spinal neoplasm is anyone of many tumor types that are similar to intracranial tumors and involve the spinal cord or its roots. If untreated, they can eventually cause paralysis.

Primary spinal neoplasms 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.

Causes

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

Intramedullary tumors, or gliomas (astrocytomas or ependymomas), are comparatively rare, accounting for only about 10% of tumors. In children, they're 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, with the exception of meningiomas, which occur most often in women. Spinal cord tumors can occur anywhere along the length of the cord or its roots.

Signs and symptoms

Extramedullary tumors produce symptoms by pressing on nerve roots, the spinal cord, and spinal vessels; intramedullary tumors, by destroying the parenchyma and compressing adjacent areas. Because intramedullary tumors may extend over several spinal cord segments, their symptoms are more variable than those of extramedullary tumors.

The following clinical effects are likely with all spinal cord neoplasms:

• Pain is most severe directly over the tumor, radiates around the trunk or down the limb on the affected side, and is unrelieved by bed rest.
• Motor symptoms include asymmetrical spastic muscle weakness, decreased muscle tone, exaggerated reflexes, and a positive Babinski's sign. If the tumor is at the level of the cauda equina, muscle flaccidity, muscle wasting, weakness, and progressive diminution in tendon reflexes are characteristic.
• Sensory deficits include contralateral loss of pain, temperature, and touch sensation (Brown-Sequard syndrome). These losses are less obvious to the patient than functional motor changes. Caudal lesions invariably produce paresthesias in the nerve distribution pathway of the involved roots.
• Bladder symptoms vary according to the stage of the tumor. Early signs include incomplete emptying or difficulty with the urinary stream, which is usually unnoticed or ignored. Urine retention is an inevitable late sign with cord compression. Cauda equina tumors cause bladder and bowel incontinence from flaccid paralysis.
• Constipation can also occur.

Diagnosis

Several tests aid in diagnosis:

• Spinal tap
• X-rays
• Myelography

Treatment

Spinal cord tumors usually require decompression or radiation. Laminectomy is indicated for primary tumors that produce spinal cord or cauda equina compression; it's not usually indicated for metastatic tumors.

If the tumor is slowly progressive, or If it's treated before the cord degenerates from compression, symptoms are likely to disappear, and complete restoration of function is possible. In a patient with metastatic carcinoma or lymphoma who suddenly experiences complete transverse myelitis with spinal shock, functional improvement is unlikely, even with treatment, and his outlook is ominous.

If the patient has incomplete paraplegia of rapid onset, emergency surgical decompression may save cord function. Steroid therapy minimizes cord edema until surgery can be performed. Partial removal of intramedullary gliomas, followed by radiation, may alleviate symptoms for a short time.

Metastatic extradural tumors can be controlled with radiation, analgesics and, in the case of hormone-mediated tumors (breast and prostate), appropriate hormone therapy.

Transcutaneous electrical nerve stimulation (TENS) may control radicular pain from spinal cord tumors and is a useful alternative to narcotic analgesics. In TENS, an electrical charge is applied to the skin to stimulate large-diameter nerve fibers and thereby inhibit transmission of pain impulses through small­diameter nerve fibers.