Spinal Tumor

A spinal tumor is an abnormal mass of tissue within or surrounding the spinal cord and/or spinal column. These cells grow and multiply uncontrollably, seemingly unchecked by the mechanisms that control normal cells. Spinal tumors can be benign (non-cancerous) or malignant (cancerous). Primary tumors originate in the spine or spinal cord, and metastatic or secondary tumors result from cancer spreading from another site to the spine.

Spinal tumors are referred to in two ways.

By the region of the spine in which they occur. These basic areas are the cervical, thoracic, lumbar, and sacrum.
By their location within the spine.

Intradural-extramedullary

The tumor is located inside the thin covering of the spinal cord (the dura), but outside the actual spinal cord. Frequency of occurrence in this location is 40%. The most common of these types of tumors develop in the spinal cord's arachnoid membrane (meningiomas), in the nerve roots that extend out from the spinal cord (schwannomas and neurofibromas), or at the spinal cord base (filum terminale ependymomas). Although meningiomas are often benign, they can be difficult to remove and may recur. Nerve root tumors are also generally benign, although neurofibromas may become malignant over time. Ependymomas at the end of the spinal cord can be large, and the delicate nature of fine neural structures in that area may make removal difficult.

Intramedullary

These tumors grow inside the spinal cord. They typically derive from glial or ependymal cells (a type of glial cell) that are found throughout the interstitium of the spinal cord. Frequency of occurrence in this location is approximately 5%. Astrocytomas and ependymomas are the two most common types. Astrocytomas are more common in the thoracic region followed by the cervical. Ependymomas are most common in the filum (bottom region of the spinal cord), followed by the cervical region. They are often benign (compared to intracranial), but can be difficult to remove. Intramedullary lipomas are rare congenital tumors most commonly located in the cervicothoracic spinal cord.

Extradural

The tumor is located outside the dura, which is the thin covering surrounding the spinal cord. The frequency of occurrence in this location vs the ones above is approximately 55%. These lesions are typically attributed to metastatic cancer or less commonly schwannomas derived from the cells covering the nerve roots. Occasionally, an extradural tumor extends through the intervertebral foramina, lying partially within and partially outside of the spinal canal.

Causes

The cause of most primary spinal tumors is unknown. Some of them may be attributed to exposure to cancer-causing agents. Spinal cord lymphomas, which are cancers that affect lymphocytes (a type of immune cell), are more common in people with compromised immune systems. There appears to be a higher incidence of spinal tumors in particular families, so there is most likely a genetic component.

In a small number of cases, primary tumors may result from the presence of these two genetic diseases:

Neurofibromatosis 2: In this hereditary (genetic) disorder, benign tumors may develop in the arachnoid layer of the spinal cord or in the supporting glial cells. However, the more common tumors associated with this disorder affect the nerves related to hearing and can inevitably lead to loss of hearing in one or both ears.

Von Hippel-Lindau disease: This rare, multi-system disorder is associated with benign blood vessel tumors (hemangioblastomas) in the brain, retina, and spinal cord, and with other types of tumors in the kidneys or adrenal glands.

Symptoms

Non-mechanical back pain, especially in the middle or lower back, is the most frequent symptom of both benign and malignant spinal tumors. This back pain is not specifically attributed to injury, stress or physical activity. However, the pain may increase with activity and can be worse at night when lying down. Pain may spread beyond the back to the hips, legs, feet or arms and may worsen over time — even when treated by conservative, nonsurgical methods that can often help alleviate back pain attributed to mechanical causes. Depending on the location and type of tumor, other signs and symptoms can develop, especially as a tumor grows and compresses on the spinal cord, the nerve roots, blood vessels or bones of the spine.

Additional symptoms can include the following:

Loss of sensation or muscle weakness in the legs, arms or chest
Stiff neck or back
Pain and/or neurologic symptoms (such as tingling) increase with Valsalva maneuver
Difficulty walking, which may cause falls
Decreased sensitivity to pain, heat and cold
Loss of bowel or bladder function
Paralysis that may occur in varying degrees and in different parts of the body, depending on which nerves are compressed
Scoliosis or other spinal deformity resulting from a large and/or destructive tumor

Treatment

Treatment decision-making is often multidisciplinary, incorporating the expertise of spinal surgeons, medical oncologists, radiation oncologists, and other medical specialists. The selection of treatments including both surgical and non-surgical is therefore made keeping in mind the various aspects of the patient’s overall health and goals of care.

Non-Surgical Treatments

Nonsurgical treatment options include observation, chemotherapy, and radiation therapy. Tumors that are asymptomatic or mildly symptomatic and do not appear to be changing or progressing may be observed and monitored with regular MRIs. Some tumors respond well to chemotherapy and others to radiation therapy. However, there are specific types of metastatic tumors that are inherently radioresistant (i.e. gastrointestinal tract and kidney): in those cases, surgery may be the only viable treatment option.

Surgery

Indications for surgery vary depending on the type of tumor. Primary (non-metastatic) spinal tumors may be removed through complete en-bloc resection for a possible cure. In patients with metastatic tumors, treatment is primarily palliative, with the goal of restoring or preserving neurological function, stabilizing the spine, and alleviating pain. Generally, surgery is only considered an option for patients with metastases when they are expected to live 3 – 4 months or longer, and the tumor is resistant to radiation or chemotherapy. Indications for surgery include intractable pain, spinal cord compression, and the need for stabilization of pathological fractures.

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