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23 Spinal Tumors 267
Ta b l e 2 3 . 4 Mag n e t ic re s o n a nce im ag in g n d in g s in sp in al in fe ct ion ve rsus t um o r s ve rs u s
compression fractures
Diag nosis T1 T2 Di erentiating fndings
Ve r t e b r a l
osteomyelitis
Osteoporotic
compression
fracture
– Decreased signal
within disk and
end plates
– Loss of end plate
de nition
– Decreased
signal in the
involve d b od y
– Incomplete
– Increased signal
within disk and
end plates
– Loss of end plate
de nition
– Increased signal
in t he b ody
– Incomplete
marrow
– Disk/end plate involvement
> ve r t ebral b ody
– Hyperintense abscesses
on T2
– Tuberculous spondylitis
does not involve
contiguous levels
– Soft tissue mass is poorly
de ned
– Returns to isointensity on
T1 a nd T2
– Marrow preservation in
the posterior third of the
Neo p last ic
disease
marrow
replacem ent
– Decreased
signal
– De ned area
of in ltrative
edema
– Pedicle
involve m ent
replacem ent
– Increased signal
– De ned area
of in ltrative
edema
– Pedicle
involve m ent
body
– No disk or cartilaginous
involve m ent
– Noncontiguous
involve m ent is fre qu e nt
– No restoration of normal
signal intensity as in
fract u re
– Soft tissue masses are
eccentric, large, and well
de ned
7. Magnetic resonance imaging (MRI) di erentiation of infection, fracture, and
tumor (Table 23.4).
D. Pr im ar y t u m or t yp es:
1. See Ta b l e 2 3 . 5 , Ta b l e 2 3 . 6 , Ta b l e 2 3 . 7 , and Table 23.8.
E. St a gin g:
1. Weinstein–Boriani–Biagini system (Fig. 23.2) (Table 23.9).
a. Three-dimensional description of tumor invasion.
F. Tr e a t m e n t :
1. Goals:
a. Establishment of a de nitive diagnosis.
b. Maintenance of neurological function.
c. Restoration of spinal stability.
d. Pain relief.
e. Control of local tumor and prevention of metastases.
272
23 Spinal Tumors
Fi g . 2 3 . 2 Th e Weinstein–Bo riani–Biagini system for spinal tum or staging.
Ta b l e 2 3 . 9 We in st e in –Bo ria n i– Bia gin i st ag in g syst e m
Ty p e N o t e s
An a t o m ic a l zo n e s Tw e lve p ie - like zo n e s s t a r t i n g a t t h e s p in o u s
process and rotating clockwise
In vo lve m e n t o f d i e re n t ve rt e bra l
laye rs
Ext r a o s s e o u s s o f t t i s s u e
In t r a o s se o us (su p e r cia l)
In t r a o s se o us (d e e p )
Ext r a o s s e o u s (e xt r a d u r a l )
Spe ci cat ion o f t he spin al
segment(s) involved
2. Treatment is dictated by diagnosis, location of tumor, and general health of
the patient.
3. Radiation versus surgery:
a. In 2005, Patchell et al reported the results of a multicenter, randomized,
cont rolled trial that compared the outcom es associated w ith surgery plus
radiation versus radiation alone for patients with nerve compression
Ext r a o s s e o u s (in t r a d u r a l )
from m et ast atic can cer to the spin e.
23 Spinal Tumors 273
(1) Advantages of surgery plus postoperative radiation versus radiation
alone.
(a) A greater num ber of patients were able to walk after treatm ent
(84% vs 57%).
(b) Longer m aintenance of con t in ence.
(c) Greater muscle strength, functional ability, and increased
survival.
(d) Decreased requirem ent of corticosteroid and opioid medication
after treatment.
(e) The study was terminated early due to the signi cant advantage
of the surgical treatment over radiation alone.
4. Radiation therapy is recommended for the following patients:
a. Cord compression caused by a soft tissue tumor without compromise of
the surrounding bony architecture.
b. Radioresponsive tumors:
(1) Hem atopoietic.
(2) Prostate.
(3) Breast.
c. Decom pression with concom itant radiation therapy is associated with
superior outcomes w hen compared with radiotherapy alone for patients
with metastatic cancer causing spinal cord compression.
d. Spinal radiation prior to surgical intervention is associated with greater
rates of wound complications (dehiscence, infection, revision) and
adverse surgical outcom es.
5. Surgery:
a. Indications.
(1) Diagnostic evaluation.
(2) Curative excision (benign tum ors and certain malignant tum ors).
(3) Spinal instability or deform ity secondary to neoplastic bone
destruction.
(4) Neurological deterioration.
(5) Failure of previous radiation therapy.
(6) Radiation-resistant tum ors.
(7) Unrem itting pain.
b. Surgical strati cation.
(1) Diagnosis of tum or.
(a) Benign versus malignant (Fig. 23.3 and Fig. 2 3 .4 ).
(b) Prim ary versus m etastat ic.
(2) Stage.
(a) Degree of spinal involvem ent.
(b) Potential m etast atic spread.
(3) Neurological status.
(a) Primary indicator of postsurgical outcom e.
i. Rapid progression of sym ptom s (< 1 week) is a poor
prognostic indicator.
ii. Patient s with severe de cits (inabilit y to walk, loss of bowel/
bladder function) are less likely to recover.
274
23 Spinal Tumors
a
b cd
Fi g . 2 3 . 3 Exa m p l e s o f p r i m a r y b e n i g n t u m o r s o f t h e s p i n e . (a) Co m p ut e d to m og ra p hy (CT) sca n de m o n -
strating an osteoid osteom a with a central nidus and sclerotic rim at the posterior part of the vertebral
body. (b) Lateral radiograph demonstrating an osteoblastoma of C2 with an expansile sclerotic bone. (c)
La t e r a l r a d i o g r a p h s d e m o n s t r a t i n g v e r t e b r a p l a n a a t C 6 d u e t o e o s i n o p h i l i c g r a n u l o m a . (d) La t eral lu m bar
radiograph showing a hem angiom a with osteopenia and vert ical striations of the vertebral body.
(4) Prognosis.
(5) Structural stability (Fig. 23.5).
(6) Pain status.
c. Surgical approach.
(1) Excise the entire lesion if possible.
(a) Total en bloc spondylectom y (Fig. 23.6 and Fig. 23.7).
i. Accom plish ed through a posterior app roach.
ii. Particularly usefu l if excising the lesion is curative.
• Ch on d rosarcom a.
(2) Approach anteriorly or posteriorly or both depending on the location
of the tumor.
(a) A decompressive lam inectom y does not address an te r ior
pathology and predisposes patients to postoperative instability.
23 Spinal Tumors 275
a b
Fi g . 2 3 . 4 In t ra d u ra l n e uro b ro m a . (a) Ant e ro po s t e rio r m ye lo gr a p hy sh owin g a m ye lo gr a p hic b lo ck a t
L1 d u e t o a n e u r o b r o m a . T h e m y e l o g r a p h i c b l o c k i s s m o o t h a n d m e n i s c a l i n s h a p e ( arrows) due to the
int radural adhesio n s, whe re as e xt rad u ral le sions p ro d u ce a ragg e d m arg in. (b) Com p ute d t om og ra p hic
scans showing erosion of the vertebral body and pedicle due to expansion of intradural neuro bromas.
(3) Metastatic tum ors are usually approached anteriorly if the spinal
cord compression is anterior.
(a) Reconstruction can be perform ed with autograft, allograft,
methyl methacrylate cement, or synthetic materials.
i. Autograft/allograft allows potential biologic incorporation.
ii. Methyl m ethacr ylate o ers instan tan eous stability but m ay fail
in patien ts whose expected life span is prolonged (> 1 year).
iii. Pat ients w ho receive postoperative irradiation have decreased
chances of achieving biological fusion.
d. Stereotactic radiosurgery (SRS).
(1) Delivers very high doses of radiation to an ultraspeci ed locus of
tissue in an e ort to minimize damage to the surrounding structures.
(2) Coupled with robotic navigation to guide the trajectory of the
radiation beam in six dimensions.
(3) Advancem ents in SRS, including intensity-m odulated radiotherapy,
have further ampli ed the precision and accuracy of radiotherapy to
lim it dam age to the spinal cord.
(a) This high level of precision allows for multiple treatments, if
necessary.
(4) Can be used in conjunction with surgical decompression.
276
23 Spinal Tumors
a b
c
Fi g . 2 3 . 5 Im a g es of a 1 7 -ye a r-o ld g irl wit h g ia n t ce ll t u m o r in vo lvin g t h e s acru m . (a) Anteroposte-
rior view of the spine and pelvis showing a destructive lesion involving the sacrum and left sacroiliac
joint . (b) Lateral radiograph showing a destructive lesion at S1–S2. Note that the sacrum is not well
demarcated. (c) Computed tomographic scan showing the extent of the tumor with involvement of
the left sacroiliac joint.
23 Spinal Tumors 277
de
f
Fi g . 2 3 . 5 (Continued) Im a g e s o f a 1 7 -ye ar-o ld g irl wit h g ia n t ce ll t um o r in vo lvin g t h e s a cru m .
(d) T2-weighted sagittal magnetic resonance image showing a large tumor extension into the pel-
vis ant e riorly an d int o t he sp inal canal post e riorly. (e,f) A posterior approach was used to perform a
lam ine ct o m y of L5 and t h e sa crum wit h e xcisio n o f t h e t um or. Re co n st ru ct io n was p e rfo rm e d wit h a
transiliac bular graft, lumbar pedicle screws, bilateral iliac screws, and rod xation. The patient was
mobilized immediately, and healing was evident without recurrence at follow-up.
278
23 Spinal Tumors
a
b
Fi g . 2 3 . 6 (a) Axial computed tomographic image of a chondrosarcoma in the sacrum. (b) Micro-
scopic image of chondrosarcom a cells.
23 Spinal Tumors 279
a b
Fi g . 2 3 . 7 ( a , b ) Anteroposterior and lateral radiographs following total spondylectomy for a T11
chordom a with spinal instrumentation and graft in position. (From Dickman CA, Fehlings MG,
Go kas la n ZL. Sp in al Cord a nd Spinal Co lu m n Tum ors . Ne w Yo rk, NY: Thie m e Me d ica l Pu b lish e rs; 2 0 0 6:
Fig . 3 4.1 4 . Re p ro d u ce d w it h p e rm issio n . )
Sugg este d Reading
Cloy d JM, Aco st a FL Jr, Po ll e y M Y, Am e s CP. En b lo c r es e c t io n fo r p r im a r y a n d m e t a-
static tumors of the spine: a systematic review of the literature. Neurosurgery
2010;67(2):4 35–444, d iscu ssion 444–445
Gerszten PC, Men del E, Ya m ada Y. Rad ioth er a p y an d rad iosu rger y for m et ast at ic sp in e
disease: what are the options, indications, and outcomes? Spine 2009;34(22, Suppl):
S78 – S92
Gh o gaw ala Z, Man s eld FL, Borges LF. Sp in a l rad iat io n before su rgical d e co m p ression a d -
versely a ects outcom es of su rgery for sym ptom at ic m etastatic sp in al cord compression . Spine 2001;26(7 ):818–8 24
Kli m o P Jr , Th o m p s o n CJ, Ke st le JR, Sch m id t MH. A m et a - an a lys is of su r g e r y ve rs u s co n -
ven t ional radiotherapy for the t reatm en t of m etastatic sp in al epidu ral disease. Neuro -on col 2005;7(1):64–76
Polly DW Jr, Ch ou D, Sem b rano JN, Ledon io CG, Tom it a K. An an alysis of decision making an d
treatment in thoracolumbar metastases. Spine 2009;34(22, Suppl):S118–S127
24 Spinal Infections
24.1 General Considerations
I. Ve r t eb ral o st e om yelit is.
A. In cid e n ce / r is k fa ct o r s .
1. Approximately 2 to 7% of all osteomyelitis (1–2% in children).
2. Lumbar > thoracic > cervical.
3. Males > females (2:1).
4. More common after the fth decade of life (> 50% of cases).
5. Risk factors include diabetes, malnutrition, perioperative hyperglycemia,
obesity, smoking, immunocompromise (steroids, HIV/AIDS), previous surgery.
B. Et io lo gy.
1. Hematogenous spread is the most common route for vertebral osteomyelitis.
a. Urinary tract is the most common source (e.g., urinary tract infections,
transient bacteremia from genitourinary procedures).
b. Soft tissue infections.
c. Respiratory infections.
2. Unidenti ed source.
3. Direct inoculation (e.g., penetrating trauma, invasive spinal procedure).
4. Causative bacteria (in order of frequency):
a. Gram-positive aerobic cocci (> 80%).
(1) Staphylococcu s aureu s (> 50%).
(a) Methicillin-resistant S. aureu s (7%).
(2) Streptococcu s (10–20%).
(3) Coagulase-negative Sta p h y lococcus (10%).
(4) Prop io n ib a ct eriu m a cn es (d elayed in fect ion).
b. Gram-negative aerobic cocci (15–20%).
(1) Most common origin is from the urinary tract (Esch er ich ia coli,
Pseu do m on as a er u gin osa , Prot eu s).
c. Gastrointestinal tract organism s.
(1) Salm on ella (rare).
(a) More comm on in patients with sickle cell.
d. Granulomatous infections (far less common).
(1) Mycobacterium tuberculosis, fu ngi, sp iroch et es.
280
(2) More common in the thoracic region.
C. Pa t h olo g y.
1. Inoculation.
a. Hematogenous spread to the vertebral metaphysis most likely occurs via
rich arterial anastomosis (nutrient artery) (Fig. 24.1).
(1) Batson’s valveless venous plexus is not considered to play a
signi cant role in bacterial hematogenous seeding.
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