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Spinal Cord Tumors

by Roy A. Patchell, MD

Spinal cord tumors may develop within the spinal cord parenchyma, directly destroying tissue, or outside the cord parenchyma, often compressing the cord or nerve roots. Symptoms include progressive back pain and neurologic deficits referable to the spinal cord or spinal nerve roots. Diagnosis is by MRI. Treatment may include corticosteroids, surgical excision, and radiation therapy.

Spinal cord tumors may be intramedullary (within the cord parenchyma) or extramedullary (outside the parenchyma).

Intramedullary tumors

The most common are gliomas (eg, ependymomas, low-grade astrocytomas). Intramedullary tumors infiltrate and destroy cord parenchyma; they may extend over multiple spinal cord segments or result in a syrinx (see Syrinx of the Spinal Cord or Brain Stem).

Extramedullary tumors

These tumors may be intradural or extradural. Most intradural tumors are benign, usually meningiomas and neurofibromas, which are the most common primary spinal tumors. Most extradural tumors are metastatic, usually from carcinomas of the lungs, breasts, prostate, kidneys, or thyroid or from lymphoma (eg, Hodgkin lymphoma, lymphosarcoma, reticulum cell sarcoma).

Intradural and extradural tumors cause neurologic damage by compressing the spinal cord or nerve roots. Most extradural tumors invade and destroy bone before compressing the cord.

Symptoms and Signs

Pain is an early symptom, especially for extradural tumors. It is progressive, unrelated to activity, and worsened by recumbency. Pain may occur in the back, radiate along the sensory distribution of a particular dermatome (radicular pain), or both. Usually, neurologic deficits referable to the spinal cord eventually develop. Common examples are spastic weakness, incontinence, and dysfunction of some or all of the sensory tracts at a particular segment of the spinal cord and below. Deficits are usually bilateral.

Many patients with extramedullary tumors present with pain, but some present with sensory deficits of the distal lower extremities, segmental neurologic deficits, symptoms of spinal cord compression, or a combination. Symptoms of spinal cord compression can worsen rapidly and result in paraplegia and loss of bowel and bladder control. Symptoms of nerve root compression are also common; they include pain and paresthesias followed by sensory loss, muscular weakness, and, if compression is chronic, muscle wasting, which occurs along the distribution of the affected roots.

Diagnosis

  • MRI

Patients with segmental neurologic deficits or suspected spinal cord compression require emergency diagnosis and treatment.

The following suggest spinal tumors:

  • Progressive, unexplained, or nocturnal back or radicular pain

  • Segmental neurologic deficits

  • Unexplained neurologic deficits referable to the spinal cord or nerve roots

  • Unexplained back pain in patients with primary tumors of the lungs, breasts, prostate, kidneys, or thyroid or with lymphoma

Diagnosis is by MRI of the affected area of the spinal cord. CT with myelography is an alternative but is less accurate.

If MRI does not show a spinal cord tumor, clinicians consider other spinal masses (eg, abscesses, arteriovenous malformations—see Spinal Cord Arteriovenous Malformations) and paravertebral tumors. Spinal x-rays, taken for other reasons, may show bone destruction, widening of the vertebral pedicles, or distortion of paraspinal tissues, especially if the tumor is metastatic.

Treatment

  • Corticosteroids

  • Excision, radiation therapy, or both

For patients with neurologic deficits, corticosteroids (eg, dexamethasone 100 mg IV, then 10 mg po qid) are begun immediately to reduce spinal cord edema and preserve function. Tumors compressing the spinal cord are treated as soon as possible.

Some well-localized primary spinal cord tumors can be excised surgically. Deficits resolve in about half of these patients. If tumors cannot be surgically excised, radiation therapy is used, with or without surgical decompression. Compressive metastatic extradural tumors are usually surgically excised from the vertebral body, then treated with radiation therapy. Noncompressive metastatic extradural tumors may be treated with radiation therapy alone but may require excision if radiation therapy is ineffective.

Key Points

  • Spinal cord tumors may be intramedullary (within the cord parenchyma) or extramedullary (outside the parenchyma).

  • Extramedullary tumors may be intradural or extradural.

  • Most intradural tumors are benign meningiomas and neurofibromas, which are the most common primary spinal tumors; most extradural tumors are metastatic.

  • Give corticosteroids to patients with neurologic deficits.

  • Surgically excise spinal cord tumors and/or use radiation therapy.

Drugs Mentioned In This Article

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