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INTRAMEDULLARY SPINAL CORD TUMORS K. Liaropoulos, P. Spyropoulou, N. Papadakis 3rd Neurosurgery clinic, Athens Euroclinic

INTRAMEDULLARY SPINAL CORD TUMORS

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INTRAMEDULLARY SPINAL CORD TUMORS. K. Liaropoulos, P. Spyropoulou, N. Papadakis 3rd Neurosurgery clinic, Athens Euroclinic. EPIDEMIOLOGY. 2-4% of tumors in the CNS in adults and children Exception: the first year of life (Around 12%). ORIGIN. Most tumors are of glial origin - PowerPoint PPT Presentation

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Page 1: INTRAMEDULLARY SPINAL CORD TUMORS

INTRAMEDULLARY SPINAL CORD TUMORS

K. Liaropoulos, P. Spyropoulou, N. Papadakis3rd Neurosurgery clinic, Athens Euroclinic

Page 2: INTRAMEDULLARY SPINAL CORD TUMORS

EPIDEMIOLOGY

2-4% of tumors in the CNS inadults and children

Exception: the first year of life(Around 12%)

Page 3: INTRAMEDULLARY SPINAL CORD TUMORS

ORIGIN

Most tumors are of glial origin

Ependymoma (52%)Ependymoma (52%)Astrocytoma (46%)Astrocytoma (46%)

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LOCALIZATION IN THE SPINAL CORD

cervicobulbar 11% cervical 24% cervicothoracic 25% thoracic 22% thoracolumbar 13% total 5%

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SYMPTOMS

a) Pain (back or radicular)b) Paresthesiac) Scoliosis (in children)

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CLINICAL PROFILE

TorticollisMotor deficitSphincter disorders

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Neurological examination

HypoaesthesiaMotor deficitPyramidal syndrome

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HISTOLOGICAL EXAMINATION

A) EPENDYMOMAAccording to the World Health Organization (WHO)

• of 2nd grade (90%)of 2nd grade (90%)

• rarely of 3rd graderarely of 3rd grade

B) ASTROCYTOMA

•most of 2nd grade most of 2nd grade • rarely of 3rd graderarely of 3rd grade

• glioblastomas very rareglioblastomas very rare

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NEURORADIOLOGY

A) Radiography• Very limited contributionVery limited contribution

B) Myelography• Indirect diagnosis due to swelling ofIndirect diagnosis due to swelling of

the spinal cord• Does not indicate the characteristics of theDoes not indicate the characteristics of the

lesion• Invasive examinationInvasive examination

C) Computed tomography• Limited contributionLimited contribution

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The MRI plays a dominant role in imaging

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Advantages of MRI

In most cases it contributes to:

A) LocalizationB) SizeC) Solid - cystic componentsD) Composition some times(Lipoma, cavernous hemangioma)

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MRI of grade II ependymoma

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MRI of grade II conus astrocytoma

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MRI in multiple sclerosis

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MRI of grade II ependymoma

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MRI of metastases

Page 17: INTRAMEDULLARY SPINAL CORD TUMORS

MRI of melanoma

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MRI in lipoma

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ATTENTION!

MRI can not distinguish between astrocytoma and

ependymoma with any degree of accuracy.

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TREATMENT

The main treatment issurgery

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SURGICAL TECHNIQUE

•Position: prone

• laminectomy / laminotomy

•Exposure of dura mater

•Exposure of arachnoid mater(With microscissors)

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•Overview of the spinal cord(swelling - change in the color)

•Localization of posterior medianfissure (sometimes difficult)

Page 23: INTRAMEDULLARY SPINAL CORD TUMORS

•Overview of the spinal cord(swelling - change in the color)

•Localization of posterior medianfissure (sometimes difficult)

Page 24: INTRAMEDULLARY SPINAL CORD TUMORS

•Exposure of spinal cord•Biopsy•Ultrasound-guided resection•Detailed haemostasis•Suture

Page 25: INTRAMEDULLARY SPINAL CORD TUMORS

Surgical resection of grade II ependymoma

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COMPLICATIONS

A) Sensory:Change little after the thirdmonth

B) Motor:Typically improve by1 ½ years

Page 27: INTRAMEDULLARY SPINAL CORD TUMORS

IMPORTANT

In the best case scenariothe long-term neurological condition will be

the same as the condition that first drove the patient to the doctor

Page 28: INTRAMEDULLARY SPINAL CORD TUMORS

RADIOTHERAPY

• We mention it last in order toemphasize that we do not believe there is any reason for this method,unless for treatment of malignanttumors, especially in children.•Even in these casesits value and safety have yetto be proved.

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SUMMARY AND CONCLUSIONS

There is no pathognomonic profileof intramedullary tumors.However, pain in the back orneck or radicular pain or diffusedysesthesia, are always the firstsigns of an intramedullary tumor

Page 30: INTRAMEDULLARY SPINAL CORD TUMORS

The MRI is the preferredscreening test and shouldinclude full sections and the injection of contrast medium.Only the following cases presenta characteristic picture:Hemangioblastoma, dermoidcysts, epidermoid cysts andlipomas

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2/3 of intramedullary tumorsare of glial origin. Sometimes thehistological verification isdifficult and requires additionalstaining and immunohistochemical

techniques

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The operation of intramedullarytumors is guided by the anatomyand relies on the accessthrough the posterior median fissure.The main risk is lesion(Temporary or permanent) of the

posteriorcolumn in 70% of cases

Page 33: INTRAMEDULLARY SPINAL CORD TUMORS

The resection of intramedullarytumors is currently performed with

CUSA.Laser is not indicated becauseit blackens the surgical field and characteristics of the intramedullary tumor are lost

Page 34: INTRAMEDULLARY SPINAL CORD TUMORS

The main goal of the surgeryof intramedullary tumors is totalresection. This is possible only whenthere is a separating regionbetween the intramedullary tumor and the

spinal cord.In absence thereof, total resection is impossible andsuch attempt is dangerous and unnecessary.

Page 35: INTRAMEDULLARY SPINAL CORD TUMORS

If the tumor is astrocytoma,the prognosis is not necessarilyhopeless.Approximately 50% are totallyresectable

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When the MRI indicatesthe presence of an intramedullary

tumor, surgeryis necessary since evencompletely benign tumors havebeen resected in patients wherethe MRI is referred to as invasive type of diagnostics

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Radiotherapy is contraindicatedin dealing withintramedullary tumors

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The low mortality,morbidity and recurrence ofintramedullary tumors constitutesurgery the onlyeffective treatment forintramedullary tumors.