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208 V Miscellaneous
c. Restoration of spinal stability
d. Pain relief
e. Control of local tumor and prevention of metastases
2. Treatment is dictated by diagnosis, location of tumor, and general
health of the patient.
3. Radiation therapy is recommended for the following patients.
a. Cord compression caused by a soft tissue tumor without compro-
mise of the surrounding bony architecture
b. Radioresponsive tumors
(1) Hematopoeitic
(2) Prostate
(3) Breast
4. Surgery
a. Indications
(1) Diagnostic evaluation
(2) Curative excision (benign tumors and certain malignant tumors)
(3) Spinal instability or deformity secondary to neoplastic bone de-
struction
(4) Neurological deterioration
(5) Failure of previous radiation therapy
Table 19–4 MRI Findings in Spinal Infection vs Tumors vs Compression Fractures
Diagnosis T1 T2 Differentiating Findings
Vertebral Decreased signal within Increased signal Disk/end plate involvement
osteomyelitis disk and end plates within disk and vertebral body
Loss of end plate end plates Hyperintense abscesses
definition Loss of end plate on T2
definition Tuberculous spondylitis
does not involve
contiguous levels
Soft tissue mass is poorly
defined
Osteoporotic Decreased signal in the Increased signal Returns to isointensity on
compression involved body. in the body T1 and T2
fracture Incomplete marrow Incomplete marrow Marrow preservation
replacement replacement in the posterior third of
the body
Neoplastic Decreased signal Increased signal No disk or cartilaginous
disease Defined area of Defined area of involvement
infiltrative edema infiltrative Noncontiguous
Pedicle involvement edema involvement is frequent
Pedicle No restoration of normal
involvement signal intensity as in
fracture
Soft tissue masses are
eccentric, large, and
well defined
Table 19–5 Primary Benign Bone Tumors
Tumor Age (y) Sex Vertebral Location Radiographic Findings Symptoms/Signs Treatment
Osteoid osteoma 30 M Posterior elements Isolated radiolucency with Painful scoliosis Marginal excision
surrounding sclerosis Pain is classically Radiofrequency ablation
2 cm in diameter relieved with
salicylates
Osteoblastoma 20 M Posterior elements Radiolucent, expansile Painful scoliosis Marginal excision
lesion sclerosis
2 cm in diameter
Hemangioma Variable M F Body trabeculae Vertical striations Most are Usually incidental findings
Honeycomb appearance asymptomatic that do not require
intervention
If surgical resection is
required, preoperative
embolization may reduce
intraoperative bleeding
Giant cell tumor 30 F Body and sacrum Lytic, expansile lesion with Recurrence is common 10% incidence of malignant
matrix calcification secondary to transformation following
inadequate resection irradiation
Aneurysmal 25 F Posterior elements Lytic, expansile lesion with Pain Excision
bone cyst fluid-fluid levels Preoperative angiography
with embolization
Injection of a sclerosing agent
Eosinophilic 20 M Body Vertebra plana Rarely symptomatic Self-limiting
granuloma Conservative treatment with
an orthosis
Osteochondroma 30 M Posterior elements Difficult to visualize on Symptomatic Excision if symptomatic
plain films Most are found in
the cervical spine
Table 19–6 Primary Malignant Bone Tumors
Ver tebr al
Tumor Age (y) Sex Location Radiographic Findings Signs/Symptoms Treatment
Solitary
plasmacytoma 50 M Body Punched-out lesion Back or lower limb Radiotherapy (highly sensitive)
pain Surgery for stabilization
Treatment correlates with the
level of M light chain
component on Serum
Protein Electrophoresis (SPEP)
Chordoma 50–70 M Sacrum, MRI is the modality Symptoms are Aggressive surgical excision
C1–C2 of choice secondary to with wide margins
High signal intensity mass effect. Attempts should be made to
on T2 • Constipation spare midsacral nerve roots
• Urinary frequency to preserve bowel/bladder
• Cord compression function
Lym pho ma 20 M Body Osteolytic lesions Local pain Isolated lesions are treated with
Ivory vertebra radiotherapy
Diffuse lymphoma is treated
with radiotherapy and
adjuvant chemotherapy
Chondrosarcoma 35 M F Body Extensive bony Pain Surgical excision with wide
destruction Palpable mass margins
Soft tissue mass with Radio- and chemoresistant
matrix calcification malignancy
Osteosarcoma 20 M Body Mixed lytic and sclerotic Pain and neurological Surgical excision with wide
lesion with cortical deficit margins
destruction and soft Combined chemotherapy and
tissue calcification radiotherapy
Ewing’s sarcoma 40 M F Body Sclerotic lesion with Pain and neurological Combined radio- and
spiculated bone growth deficit chemotherapy
Soft tissue mass Surgery reserved for instability
and neurological deficit
Table 19–7 Intraspinal Neoplasms or Cysts
Tumor Age (y) Sex Findings Radiographic Treatment Comments
Schwannoma 20–50 M F Circular filling defect on Excision Most common spinal nerve or cord tumor
myelogram Predilection for flexor surfaces and main
nerve trunks
Characteristic features are shooting pain
and paresthesia induced by palpation
of the nerve
Two thirds of patients with neurofibromatosis
develop schwannomas
Neurofibroma 20–30 Circular defect, dumbbell Excision Most are solitary lesions (90%)
shaped Located primarily on cutaneous nerves
Palpation does not produce pain as in
schwannomas
Neurofibromas unlike schwannomas
involve and entangle multiple nerve
fascicles and travel parallel to the nerve
Meningioma 50–60 F Circular defect with dural Excision 80–90% in thoracic spine
attachment Tumors are Believed to originate from an arachnoid
located cap of meningothelial cells
dorsal to More common intracranially
spinal cord, Pain is the most frequent initial symptom
facilitating
removal
212 V Miscellaneous
(6) Radiation-resistant tumors
(7) Unremitting pain
b. Surgical stratification
(1) Diagnosis of tumor
(a) Benign versus malignant (Figs. 19–1, 19–2)
(b) Primary versus metastatic
(2) Stage
(a) Degree of spinal involvement
(b) Potential metastatic spread
(3) Neurological status
(a) Primary indicator of postsurgical outcome
(i) Rapid progression of symptoms (1 week) is a poor
prognostic indicator.
(ii) Patients with severe deficits (inability to walk, loss of
bowel/bladder function) are less likely to recover.
(4) Prognosis
(5) Structural stability (Fig. 19–3)
(6) Pain status
c. Surgical approach
(1) Excise the entire lesion if possible (Fig. 19–4).
(a) Total spondylectomy
(i) Accomplished through a posterior approach
(ii) Particularly useful if excising the lesion is curative
* Chondrosarcoma
Table 19–8 Intradural Intramedullary Tumors
Radiographic
Tumor Age (y) Sex Findings Treatment Comments
Ependymoma 20–60 F Intraparenchymal Excision Arise from cuboidal
high signal ependymal cells
intensity Most common adult primary
Centrally located spinal parenchymal lesion
circular lesion Pain is the most common
symptom
Typically, weakness of the
limbs distal to the spinal
levels of involvement
Astrocytoma 20–50 M F Infiltrative lesion Excision Originate from
with no distinct transformation of glial
borders unlike cells
ependymomas Most astrocytomas are
low-grade lesions
Similar clinical presentation
to ependymomas
Chapter 19 Spinal Tumors 213
Figure 19–1 Examples of primary benign
tumors of the spine. (A) Computed tomog-
raphy (CT) scan demonstrating an osteoid
osteoma with a central nidus and sclerotic
rim at the posterior part of the vertebral
body. (B) Lateral radiograph demonstrat-
ing an osteoblastoma of C2 with an expan-
sile sclerotic bone. (C) Lateral radiographs
demonstrating vertebra plana at C6 due to
eosinophilic granuloma. (D) Lateral lumbar
radiograph showing a hemangioma with
osteopenia and vertical striations of the
vertebral body.
Figure 19–2 Intradural neurofibroma. (A) Anteroposterior myelography showing a myelo-
graphic block at L1 due to a neurofibroma. The myelographic block is smooth and meniscal in
shape (arrows) due to the intradural adhesions, whereas extradural lesions produce a ragged
margin. (B) CT scans showing erosion of the vertebral body and pedicle due to expansion of in-
tradural neurofibromas.
Figure 19–3 Images of a 17-year-old girl with giant cell tumor involving the sacrum. (A) Antero-
posterior 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)CT scan showing the extent of the tumor with involvement of the left
sacroiliac joint.
214 V Miscellaneous
Chapter 19 Spinal Tumors 215
Figure 19–3 (Continued) Images of a 17-year-old girl with giant cell tumor involving the sacrum.
(D) T2-weighted sagittal magnetic resonance image showing a large tumor extension into the
pelvis anterior and into the spinal canal posteriorly. (E,F) A posterior approach was used to perform
a laminectomy of L5 and the sacrum with excision of the tumor. Reconstruction was performed
with a transiliac fibular graft, lumbar pedicle screws, bilateral iliac screws, and rod fixation. The
patient was mobilized immediately, and healing was evident without recurrence at follow-up.
216 V Miscellaneous
Figure 19–4 (A) CT scan through the sacrum demonstrating a large lytic mass obliterating the
sacrum and canal. (B) Histological analysis demonstrates the presence of physaliphorous cells
indicating the diagnosis of chordoma.
Chapter 19 Spinal Tumors 217
(2) Approach anteriorly or posteriorly or both depending on the lo-
cation of the tumor.
(a) A decompressive laminectomy does not address anterior
pathology and predisposes patients to postoperative insta-
bility.
(3) Metastatic tumors are usually approached anteriorly if the
spinal cord compression is anterior.
(a) Reconstruction can be performed with autograft, allograft,
methyl methacrylate cement, or synthetic materials.
(i) Autograft/allograft allows potential biologic incorporation.
(ii) Methyl methacrylate offers instantaneous stability but
may fail in patients whose expected life span is pro-
longed (1 year).
(iii) Patients who receive postoperative irradiation have
decreased chances of achieving biologic fusion.
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