THE SPECTRUM OF INTRADURAL SPINAL TUMORS

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1 ORIGINAL ARTICLE THE SPECTRUM OF INTRADURAL SPINAL TUMORS Mumtaz Ali, Zahid Khan, Seema Sharafat, Khalid Mehmood, Alamgir, Parvaiz Khan, Mohammad Usman Department of Neurosurgery, Lady Reading Hospital, Peshawar- Pakistan ABSTRACT Objective: To assess the spectrum of clinical, radiological and histological features of patients with intradural spinal tumors. Materials and methods: This descriptive study was carried out in Department of Neurosurgery Lady Reading Hospital Peshawar, from April 00 to March 009. Medical records of patients with spinal tumors were revieqwed and patients operated for intradural spinal tumors were identified. A total of patients, out of 55 cases of spinal tumors, with different intradural spinal tumors were considered in this study. Their clinical features, radiological reports, peroperative findings and histological reports were analyzed in different aspects. Results: There were total of patients with age range from years to 74 years, with median age of 8 years. Out of these 87 were males and 5 were female, overall male to female ratio of.5:. Backache, leg weakness, parasthesia and poor sphincters were the main clinical features. MRI spine (74 cases) was the main diagnostic tool along with plain X-rays and X-ray myelography in limited cases (5 cases). CT myelogram was done only in cases. The common site of involvement was dorsal spine followed by lumber and cervical spines respectively in 85, 80 and 47 cases. Histological report was suggestive of in 66, in 96, in 0, Dermoid in, in 7, Hemangioblastom and Tuberculoma in cases each and Hydatid cyst in one case. Conclusion: and meningioma constituted majority of cases belonging to intradural extramedulary group, while ependymoma and astrocytoma were common intramedullary tumors. Third and 5th decade of life was the common age group for both Intramedulary and extramedulary tumors. Intramedulary lesions were common in rd decade of life. Key words: Spinal tumors, spinal neurofibroma, intradural meningioma, spine dermoid. INTRODUCTION neuropathy, intercostal neuralgia and referred pain Spinal canal is a confined space and like angina, cholycystitis and renal pain. expanding spinal tumors within this space may Sciatica is a common symptom in tumors have a devastating effect upon the function of at or below conus medularis. Cord compression is spinal cord and nerves. The tumors commonly leading to long tract signs as quadriplegia. arising within the space are intradural and majority Paraplegia is late neurological dysfunction of cases respond satisfactory to surgical excision. resulting in significant morbidity, bed sores and sphincteric problems. Back pain including Spinal tumors are 5 % of all primary nocturnal pain is another important feature of CNS tumors out of which 65 to 8 % are spinal tumors. intradural. Intradural extramedulary tumors are mainly, neurofibroma and meningioma making There are limited local studies on about 80-90% of these tumors. Lipoma, dermoid, intraspinal tumors. In assessing the different epedermoid and drop metastasis are less common. aspects of these lesions, this study will help the Only 7-% are intramedullary either astrocytoma clinicians to identify these lesions early, in time or ependymoma. The clinical features mimic for treatment and thus decrease morbidity and different neurological disorders like entrapment improve prognosis of the patients. 7

2 MATERIAL AND METHODS The record of all patients with spinal tumors was seen and patients with intradural tumors were analyzed in detail. Out of 55 patients admitted as diagnosed cases of spinal tumors, only were having intradural tumors and operated in the neurosurgery department, PGMI, lady reading hospital Peshawar between April 00 to March 009. Patients of both genders irrespective of their age who had intradural extramedulary and intramedullary lesions were included in the study and those who had recurrence of the tumors or those who had extradural lesions were excluded. These patients belonged to different areas of the province. The demographic data and clinical, radiological, and histological features of the patients were analyzed. All the patients were operated after establishing a neuroradiological diagnosis. X- rays were done in all the cases. Neuroradiological investigations included myelography, CT myelography, CT scan and MRI Figure of the concerned area. Preoperative work up was done. For proper localization loop guided localization was done in the cervical, thoracic and thoracolumber area. All the patients under went Laminectomy and microscopic decompression was done. Gross total resection was done in intradural extramedulary tumors. Median myelotomy was performed for Intramedulary lesions and far lateral and transspinal approach in cases of dumbbell tumors. For tissue diagnosis, biopsy was taken and preserved in 0% formaline and sent to laboratory on same day. All cases were reported by one senior pathologist. In cases of doubtful diagnosis re-opinion was taken. RESULTS We studied 55 patients with spinal tumors out of which patients had intradural spinal lesions. Patient characteristics are shown in Table. Figure - shows the radiological, per operative and histopathological features. : A: MRI of Cervical intradural extramedulary spinal tumor () B: Histopathology of with Antoni A and B cells A B Figure A & B: Dorsal intradural extramedulary spinal tumor () A B Figure : A: removed surgically B:Histopathology of meningioma with Psamoma bodies A B 8

3 Table : Patient Characteristics (n = ) Description Sex No. of patients %age Male % Female 5 40.% Feature Backache % Leg weakness % Parasthesia/poor sphincters 04.% Radicular pain 94 0.% Spine tenderness 7.08% Nocturnal pain % MRC grading %.8% 54.59% 57.85% % % Age incidence: Their ages ranged from and half to 74 years, with mean age of years (Figure 4). Figure 4: Age distribution of the sample Neuroimmaging: MRI spine was the main diagnostic tool and was done in 74 (87.8%) cases. plain x-ray and myelography was done in 5 (.%) patients. CT myelographs was done in cases only.(table ). Histathology: The histopathology of the sample showed predominance of neurofibroma cases ( n = 6 6 ), f o l l o w e d b y M e n i n g i o m a a n d ( n= 96 and 0) respectively. (Table ) Cervical spine DISCUSSION Table : Location of tumor Thoracic spine Lumbar spine No. of patients %age % 59.% 5.6% Table : Histopathology of lesions Dermoid Astrcytoma Tuberculoma Hemangioblatoma Arachnoid cyst Lipoma Hydatid cyst No. of patients %age 5.% 0.77% 6.4%.85%.4% 0.96% 0.96% 0.64% 0.64% 0.% Intraspinal tumors are 5 % of all primary CNS tumors and constitute a large group of patients presenting to neurosurgeons in clinical practice. Studies reveal that although no age limit is spared but intradural spinal tumors are more 4, 5 common in peoples in th to 6th decade of life. We almost have the same results operating upon the patients whose age ranged between to 74 years and most of them were in rd and 5th decade of life. In our study intradural spinal tumors commonly occurred in males, but Nittner have reported that meningiomas are more common in females while incidence of neurofibroma is 5 equal in men and women. The exact cause for this commonalty of intradural spinal tumors in males is not clear. 9

4 Extramedulary tumors are more common The tumors damage the spinal cord and (50-60%) than intramedullary tumors (7-%) of nerve roots by compression, ischemia and a l l i n t r a s p i n a l t u m o r s. M e n i n g i o m a a n d infiltration of neoplastic cells. The symptoms and neurofibroma are the most common, making 80- signs are pain, weakness, sensory loss, autonomic 90% of intradural extramedulary tumors. dysfunction, gait disturbance and spinal deformity. are lipoma, dermoid and epidermoid. Of the The patient can present with any combination of intramedullary tumors astrocytoma are 0% and the above symptoms and signs. In children there is ependymoma are 9%. We have comparable loss of developmental milestone, scoliosis, results in our study and meningioma and kyphosis, foot deformity, gait disturbance and neurofibroma comprised more than 84% of total enuresis. i n t r a d u r a l e x t r a m e d u l a r y t u m o r s, w h i l e ependymoma and astrcytomas were the commonest Pain is the most common presenting intramedullary tumors. symptom. Motor deficit occurs in 80-90%, which is patchy and asymmetrical. Sphincter disturbance 4 accounts for the 5% of reported in 5 % cases. In our study backache and intraspinal neoplasm. s are slow motor deficit was noted in 78.% and 76.6% th growing benign lesions. Peak incidence is in 5 patients respectively, which is comparable to the th and 6 decades. Spinal meningiomas are most literature. Sphincteric dysfunction was more commonly seen in thoracic spine region although common (. %) in our study; this may be 4 that can occur in cervical and lumber regions. because of late presentation of the patients for Incidence in thoracic region is 80%, cervical treatment. region 5% and lumber region %. Eighty percent 5 meningiomas occur in females. In our study Magnetic resonant imaging (MRI) provides almost % of patients had meningioma. They crucial information regarding the extent, location were common in female and in dorsal spine. and internal structure of mass, thus critically narrowing the differential diagnosis and guiding 6, 4-6 According to levy W et al, with a series surgery. Because of this reason MRI was the o f 6 6 s p i n a l n e r v e s h e a t h t u m o r s, 8 % investigation most commonly done in our study neurofibromas were intradural, 0% extradural and (74 cases/ 87.8%). 7% both intradural and extradural. Peak age is years. It's Incidence in thoracic spine was 9%, Surgical indications of intraspinal tumors lumber % and cervical %. In our study 66 are: neurological deficit, intractable pain, tissue patients had neurofibroma making it 5.%. diagnosis and spinal deformity. The goals of surgery are; decompression of spinal canal, tumor I n t r a m e d u l l a r y s p i n a l c o r d t u m o r s resection or debulking, tissue diagnosis, correction comprise 4-0% of all CNS tumors. They account of spinal deformity and stabilization of the spine. for about 5% of adult intradural spinal tumors but Minimally invasive approaches to spinal tumors in children they account for 50% of intradural have evolved rapidly over the past 5-0 years as spinal tumors. s are slightly more clinicians seek to avoid the morbidity and longcommon than astrocytoma in adults, but term dysfunction associated with traditional open astrcytomas are more prevalent in children and surgical procedures. Cyber knife radio surgical adolescents. In our study s were ablation of such tumors is technically feasible and more common than astrcytoma. associated with low morbidity. The outcome of Hemangioblatoma accounts for -4% of surgery depends upon preoperative neurological intramedullary spinal cord tumors. Dermoids are status of the patient. Patients with severe congenital lesions. More common in childerns and neurological dysfunction usually do not recover, usually occur in lumbar spine. Epedermoids w h e r e a s p a t i e n t s w i t h m i l d t o m o d e r a t e usually occur in conus or Cauda equine region. We dysfunction can often recover in part or had patients with Hemangioblatoma in our study, completely. two of them were in the st decade of life and rd one was years old. CONCLUSION Multiple cavernous angiomas of the Cauda and meningioma constituted equine manifests as acute onset of severe low back majority of cases belonging to extramedulary pain radiating into the bilateral legs. Primary i n t r a d u r a l g r o u p w h i l e e p e n d y m o m a a n d intraspinal peripheral primitive neuroectodermal astrocytoma were common intramedullary tumors. tumors are extremely rare tumors with only seven Overall males are affected more than females. reported cases in the literature. Primary Third and 5th decades of life were the common intraspinal hemangiopericytoma is a rare malignant a g e g r o u p s f o r b o t h i n t r a m e d u l l a r y a n d mesenchymal tumor with high rate of recurrence extramedulary tumors. Intramedulary tumors were and metastasis. We had no patient with multiple common in rd decade of life. is cavernous angiomas or hemangiopericytoma in our study. more common in cervical spine while ependymoma in lumbar spine. 0

5 REFERENCES. Barami K, Dagnew E. Endoscope assisted posterior approach for the resection of ventral intradural spinal cord tumors: report of two cases. Minim Invasive Neurosurg 007;50:70-.. Rossi A, Gordolfio C, Morana G, Tortori donati P. Tumors of the spine in children. Neuroimaging Clin N Am 007;7-8.. Rubinstein LJ. Tumors of the central nervous system. In: Delellis RA, editor. Atlas of tumor pathology. Washington DC: Armed Forces Institute of Pathology;97. astrocytomas in children. Neurosurgery 990;7: Houten JK, Cooper PR. Spinal cord astrocytomas: presentation, management and outcome. J Neurooncol 000;47:9-4.. Miyake S, Uchithesi Y, Takaishi Y, Sakagami Y, Kohmura E. Multiple cavernous angiomas of the cauda equine: case report. Neurol Med Chir (Tokyo) 007;47: Perry R, Gpngales I, Finlay J, Zacharaulis S. Primary peripheral primitive neuroectodermal tumors of the spinal cord: report of two cases and review of the literature. J Neurooncol 007;8: Ilyas M. Spinal intradural tumors: experience w i t h 5 c a s e s o f s c h w a n o m a s a n d. Zhao Y, Zhao JZ. Clinical and pathological meningiomas. Pak J Neurol Surg 00;7:5-6. c h a r a c t e r i s t i c s o f p r i m a r y i n t r a s p i n a l hemangiopericytoma and choice of treatment. 5. Nittner K. Spinal meningiomas, neuromas and Chin Med J 007;0:5-9. neurofibromas and hangloss tumors. In:Vinken PJ, Bruyan GW, editors. Handbook of clinical 4 Sze G. Neuplastic disease of the spinal cord. n e u r o l o g y. A m s t e r d a m : N o r t h - H o l l a n d In: Atlas SW, editor. Magnetic resonance Publishing Co;976. p imaging of the brain and spine. Philadelphia: Lippincott williams and wilkins; 00. p. 6. Levy WJ, Latchaw J, Hahn JF, Sawhny B, Bay J, Dohn DF. Spinal neurofibroma: a report of 66 cases and comparison with meningioma. 5. Parizel PM, Balériaux D, Rodesch G, Neurosurgery 986;8:-4. Segebarth C, Lalmand B, Christophe C, et al. Gd-DTPA-enhanced MR imaging of spinal 7. McCormick PC, Torres R, Stein BM. tumors. AJR Am J Roentgenol 989;5:087- Intramedullary ependymoma of the spinal 96. cord. J Neurosurg 990;7: Dillon WP, Normal D, Newton TH, Bolla K, 8. Schwartz TH, McCormick PC. Intramedullary Mar A. Intradural spinal cord lesions: Gdependymoma: clinival presentation, surgical DTPA-enhanced MR imaging. Radiology treatment, stratigies and prognosis. J 989;70:9-7. Neurooncol 000;47: Otoole JE, Eichholz KM, Fessler RG. 9. Rossitch E, Zeidman SM, Burger PC, Curnes Minimally invasive approaches to vertebral JT, Harsh C, Anscher M, et al. Clinical and p a t h o l o g i c a l a n a l y s i s o f s p i n a l c o r d column and spinal cord tumors. Neurosurg Clin N Am 006;7: Address for Correspondence: Dr. Mumtaz Ali Associate Professor and Incharge, Department of Neurosurgery, Lady Reading Hospital, Peshawar - Pakistan Neurosurgeon_ali@yahoo.com