Tumors of the spinal cord

Tumors of the spinal cord constitute 10-15% of all tumors of the central nervous system and are equally common in men and women aged 20 to 60 years.

Symptoms of the tumors of the spinal cord

Symptoms of tumors of the spinal cord are manifested by syndromes.

Radicular-shell pain syndrome

The most typical for extramedullary (extra-cerebral) tumors. Depending on which of the roots is affected (anterior or posterior), pain occurs along the root, sensitivity is impaired. With extramedullary tumors, the radicular pain increases in the horizontal position (Razdolsky's symptom), especially if the tumor is located in the region of the horse's tail, and decreases - in the vertical. This has an important differential diagnostic value, because in some diseases, for example, in tuberculous spondylitis, the pain is weakened and the patient's horizontal position. Important is also a symptom of the spinous process: soreness with percussion of spinous processes and paravertebral at the level of the pathological process. The bow symptom is characterized by increased local pain syndrome when the head is tilted forward.

For neurin is a symptom of liquor thrust - the emergence or strengthening of radicular pain in the compression of the jugular veins. At the same time, the outflow of venous blood from the brain worsens, intracranial pressure rapidly builds up, and the wave of cerebrospinal fluid spreads through the subarachnoid spaces of the spinal cord, acting on the tumor as a push with a root tension, resulting in pain pain.

Reflexes, arcs of which pass through the affected spine or become closed at the level of the affected segment, decrease or disappear with an objective examination of the patient. Therefore, the level of the location of the tumor can sometimes be suspected on the basis of prolapse of reflex arches - those or other tendon reflexes (peripheral paresis or paralysis).

Disturbance of sensitivity by the root type is manifested in the form of numbness, crawling, chills, sensation of cold or heat in the innervation zone of the spine. For radicular syndrome, the phase of irritation and the phase of loss of functions are characteristic. Initially, paresthesias are temporary (phase of irritation)), then - permanent. Gradually, the patient decreases sensitivity (hypoesthesia) in the innervation zone of the spine (the phase of prolapse), which in the case of continuing lesions of several roots leads to the development of anesthesia (lack of sensitivity) in the corresponding dermatomes.

Syndrome of a lesion of a diameter of a spinal cord

It is associated with the appearance of a conductive segmental symptomatology according to the level of compression of the spinal cord. With progressive growth of the tumor and compression of the spinal cord, there are symptoms of compression of the spinal cord according to the conductor type below the level of lesion with a gradual increase in neurologic symptoms. There is a so-called syndrome of damage to the diameter of the spinal cord in the form of a disturbance of motor, sensitive and autonomic functions according to the central type below the level of the lesion.

Patients have paresis or paralysis of the central type (spastic). The main signs of the central paresis are: increased muscle tone, increased tendon and periosteal reflexes, the appearance of pathological pyramidal reflexes (as a consequence of the disturbance of the inhibitory effect of the cerebral cortex and the strengthening of the reflex activity of the segmental apparatus of the spinal cord). Skin, abdominal, cremasterous and other reflexes, on the contrary, disappear, which has an important topico-diagnostic significance.

Disturbances of sensitivity are manifested in the form of hyperpathy, hypesthesia, anesthesia below the level of lesion. Progressive sensory disturbances along the conductor type. With extramedullary tumors, there is a characteristic upward type of sensitivity disturbance - from the distal parts of the body (stop, perineum) with a gradual spread of sensitive disorders up to the level of the lesion, which is explained by the gradual compression of the conducting pathways of the spinal cord from the outside, where the longest fibers innervating the distal parts of the body . With intramedullary tumors - on the contrary, a descending type of sensitivity disorder develops, which is explained by the law of eccentric arrangement of conductors (Flatau law).

Vegetative function disorder syndrome

The syndrome of disturbance of vegetative functions first of all is shown by disturbances of functions of pelvic organs (perineoanal syndrome). In tumors located above the sympathetic (LI-LII) and parasympathetic (SIII-SV) centers for the regulation of pelvic organs, there is an initial urge to urinate, then the patient develops a retention of urine. There is a so-called paradoxical ishuria (discharge of urine drop by drop).

With intramedullary tumors of the spinal cord, the clinical symptoms of certain segments of the spinal cord (segmental type) appear in the early stages of development, which is manifested by hyperpathy and sympathy in the area of affected segments. There are fibrillar muscle twitches, disturbances of sensitivity by dissociated type (loss of surface while maintaining deep types of sensitivity). In the future, symptoms of spinal cord injury by peripheral type (muscle hypotrophy, hypotension).

With the growth of the tumor, the destruction of the spinal cord from the inside and its spindle-shaped thickening, the symptoms of the spinal cord injury along the conductor type are joined as a result of compression of the conducting pathways of the spinal cord to the walls of the spinal canal. During this period, the spinal cord lesion clinic is of a mixed nature. Symptoms of the defeat of the segmental apparatus are joined by the symptoms of pyramidal spinal cord insufficiency, symptoms of spinal cord involvement are of central type below the level of the diameter (tendon and periosteal reflexes appear, pathological pyramidal signs appear, ). At the same time, atrophy of certain muscle groups is preserved in the zone of segmental disorders.

Often there are tumors of the spinal cord, the symptoms of which depend on its localization.

With tumors of the cervical spinal cord at the level of CI-CIV segments, there is radicular pain in the occipital region. With the limitation of the volume of movements in the cervical spine. The central tetraparesis (or tetraplegia) grows, the sensitive disorders in the upper and lower extremities progress. When the tumor is localized at the level of the CIV segment, a violation of breathing is added due to the lesion of the diaphragmatic nerve (paralysis of the diaphragm). With craniospinal tumors, clinical symptomatology of intracranial hypertension with congestion on the fundus can occur, with oblong brain damage - tabloid abnormalities.

To defeat segments CV-DI is characterized by the development of flaccid peripheral paresis of the upper limbs and the central lower paraparesis, which eventually changes into lower paraplegia. When compressing the tumor of the ciliospinal center (CVIII-DI), Bernard-Horner syndrome (ptosis, miosis, enophthalmus) or its elements develops. The V and IX pairs of cranial nerves may be impaired.

In tumors of the thoracic spinal cord, in addition to the syndrome of damage to the diameter of the spinal cord in the form of violations of motor, sensitive and autonomic functions of the central type below the level of damage, there may be radicular pain along the intercostal nerves. Disturbance of cardiac activity can be observed when the tumor is localized at the level of D-DVI segments. With lesion of the lower-thoracic segments, there is pain in the abdominal region, which can lead to an erroneous opinion about the patient's cholecystitis, pancreatitis or appendicitis. For tumors in the region of DVII-DVIII, the absence of upper abdominal reflexes is characteristic, in tumors in DIX-DX - the absence of middle and lower abdominal reflexes, for the defeat of DXI-DXII segments - the absence of only lower abdominal reflexes.

When the tumor is below the level of the lumbar thickening (LI-SI), the patient develops low flaccid paraplegia or paraparesis with no reflexes and atony of the muscles of the lower extremities, the function of the pelvic organs is disrupted. When the tumor is localized at the level of the upper part of the thickening, knee reflexes are not caused or decreased, Achilles are raised. When the tumor is at the level of the lower segments of the lumbar thickening, the knee reflexes are preserved, the stops are reduced or not called.

For the defeat of the epiconus (LIV-SII), the appearance of a flaccid paresis of the flexor and extensor of the feet, the muscles of the peroneal group, the sciatic muscles is characteristic, with the preservation of the knee and the loss of achilles reflexes.

Tumors in the region of the cerebral cone are characterized by pain in the perineal region and in the anogenital zone. When the tumor affects the parasympathetic centers, there are violations of the function of the pelvic organs along the peripheral type (incontinence of urine and stool, sexual weakness).

Tumors in the region of the ponytail are manifested by severe pain in the sacrum, anogenital zone, in the lower extremities, which increase in the horizontal position, especially at night. Progressive motor and sensory disorders in the lower limbs along the radicular type, the function of the pelvic organs by the type of incontinence is disrupted.

Forms

Classify tumors of the spinal cord by histogenesis, localization, and degree of malignancy.

According to the histological structure, tumors that develop from the brain tissue - astrocytomas, ependymomas, glioblastomas, oligodendrogliomas, etc., are isolated from the vessels - angiomas, from the membranes - meningiomas, from the roots of the spinal cord - neurinomas, from connective tissue elements - sarcomas, from adipose tissue - lipomas.

Depending on the location, tumors of the spinal cord are divided into extramedullary (extra-cerebral), developing from the membranes of the brain, its roots and surrounding tissues surrounding the spinal cord and intramedullary (intracerebral) arising from the cellular elements of the spinal cord. In turn, extramedullary tumors are divided into subdural (intradural), which are located under the dura mater, epidural (extradural), formed over the dura mater and epi-subdural.

In relation to the spinal canal, tumors of the spinal cord are divided into intravertebral (within the spinal canal), extravertebral, extra-intravertebral (according to the type of hourglasses - tumors Guleke).

With regard to the length of the spinal cord, tumors of the cervical, thoracic, lumbar regions, tumors of the horse tail are secreted. In more than half of cases, tumors are found in the cervical and lumbar regions. In the cervical spinal cord tumors in children are twice as common as in the elderly, and in the thoracic spine they are detected three times more often in the elderly than in children. Tumors of horse tail are diagnosed in about 1/5 of patients. For children, lipomas, dermoid cysts, sarcoma, epidural ependyma are more common. In middle-aged people more often there are neurinomas, less often - meningiomas. Older people diagnosed with meningiomas, neurinomas, metastases of cancer.

There are also craniospinal tumors - they spread from the cranial cavity to the vertebral canal or vice versa.

To extramedullary tumors of the spinal cord are:

1. Meningioma (arachnoidendothelioma), originating from the meninges;
2. neurinomas, which develop from Schwann cells predominantly of the posterior roots of the spinal cord;
3. Vascular tumors (hemangiendothelioma, hemangioblastoma, angiolipoma, angiosarcoma, angioretikulomy - well vascularized, in some cases, numerous tumors (Gischgel-Lindau disease);
4. lipomas and others, depending on the histocellular structure, neoplasm. Approximately 50% of extramedullary spinal cord tumors are meningiomas (arachnoidendothelioma). In most cases, they are located subduralno. Meningioma refers to tumors of the shell-vascular series, develop from the meninges or their vessels. They are tightly connected to the dura mater. Sometimes meningiomas calcify (psammoma).

Neurinomas occur in 1/3 of the patients. They develop from the Schwann cells of the posterior roots of the spinal cord, so they are also called schwannomas. Neurinomas are tumors of a dense consistency, oval in shape, surrounded by a thin capsule. Numerous neurinomas are characteristic of Recklinghausen's disease. Tumors of heterotopic origin (dermoid cysts, epidermoids, teratomas) are diagnosed primarily in children in the first years of life.

Chondromas, chordomas, chondrosarcomas belong to the rarely occurring neoplasms, which are localized mainly in the sacral region.

A special group in the clinical plan is a horse tail tumor, which is manifested mainly by root syndromes.

Intramedullary tumors of the spinal cord are mainly represented by gliomas (astrocytomas, enendymomas, etc.). Less common are multiform glioblastomas, medulloblastomas, olngodendrogliomas. Intramedullary tumors develop mainly from the gray matter of the spinal cord and belong to malignant tumors with infiltrative growth. Macroscopically in the area of localization of the intramedullary tumor, the spinal cord is spindle-shaped thickened.

Enendimomas are diagnosed mainly in patients 30-40 years old and in school-age children. They are localized most often in the cervical region and in the region of the horse tail, can extend to two, three or more segments. Astrocytomas are relatively benign forms of intramedullary tumors, they are most often found in children 2-5 years of age and are localized mainly in the cervico-thoracic region of the spinal cord.

Metastatic tumors occur in 1% of cases. As a rule, they penetrate through the venous system of the spine. Such metastases spread from the breast, prostate, lungs, digestive tract, kidneys. These tumors grow rapidly, destroy the bone tissue of the spine, ligamentous apparatus and soft tissues, causing spinal cord compression with severe pain syndrome. For all tumors of the spinal cord, a gradual course of the disease is characteristic as a result of progressive compression of the spinal cord and lesion of its roots, and the rate of progression of neurologic symptoms depends on the location of the tumor, the direction of growth, histogenesis.

Diagnostics of the tumors of the spinal cord

In a number of cases, the clinical symptomatology characteristic of tumors of the spinal cord may resemble clinical symptoms in such diseases as osteochondrosis, myelitis, arachnoiditis, tuberculosis, spondylitis, discitis, osteomyelitis, syphilis, multiple sclerosis, ALS, pathology of the spinal cord, etc. Therefore for differential diagnosis and clarification of the nature of the process, it is very important to use the data of anamnesis, the dynamics of the disease and the progression of clinical symptoms, objective examination data ol, the use of auxiliary methods.

Among the auxiliary research methods, MRI and CT are the most informative at present, which allow to establish the nature of the process and localization of the spinal cord tumor definitively. In a number of cases, MRI with intravenous contrast enhancement is used for more accurate and reliable information. Spondylography (roentgenography) of the spine is widely used in two projections. Spondylograms can reveal: calcifications, vertebral fracture, widening of intervertebral openings (with extra-intravertebral tumors), narrowing of the roots of the arches and increasing the distance between them (the Elsberg-Dyke symptom).

Radionuclide scintigraphy is a method of examination with the help of radiopharmaceuticals, inert gases (for example, IXe), introduced into the body with the help of special radiometric equipment. The degree of accumulation of radiopharmaceuticals in the brain can be used to judge the localization and character of the process, the genesis of the disease, especially in cases where differential diagnosis is difficult (for example, with metastases of cancer and inflammatory diseases of the spine - spondylitis, discitis).

The technique of lumbar puncture with carrying out liquorodynamic samples (Quakenstedt and Stukey) for diagnosis of tumors of the spinal cord has recently been used extremely rarely. The revealed liquorodynamic block in the cases of Quakenstedt and Stukey testifies to the compression of the spinal cord and the violation of the patency of the subarachnoid spaces, which, in combination with the biochemical and microscopic studies of the cerebrospinal fluid and the observed protein-cell dissociation, indicates a high probability of the patient having a tumor of the spinal cord.

Myelography is the radiography of the intra-vertebral contents after contrasting the subarachnoid space with contrast medium (majodil, omnipak) or gas (oxygen, helium). The method is used to determine the level of compression of the spinal cord. With the help of descending myelography, the upper level of compression of the spinal cord can be specified, and with the help of the ascending one, the lower one. As a diagnostic method, at present myelography is rarely used due to the appearance of more informative, minimally invasive methods of investigation (MRI).

[1], [2], [3], [4]

Treatment of the tumors of the spinal cord

The only radical treatment for most tumors of the spinal cord is surgical removal. The earlier the surgical removal of the tumor is performed, the more favorable the postoperative result will be. Purpose of the operation:

1. the most radical removal of the tumor;
2. maximum preservation of blood supply to the tissues of the spinal cord;
3. surgical intervention with minimal damage to the structures of the spinal cord and its roots, in connection with which surgical approaches have been developed depending on the location of the tumor).

To remove the tumor of the spinal cord, in a number of cases, a laminectomy is performed in accordance with the level of the tumor location. With neurinomas, the root from which the tumor has grown is coagulated and crossed, after which the tumor is removed. With considerable difficulties, tumors are removed that spread along the root of the spine extradurally and beyond the spinal canal. Such tumors consist of two parts (intra-and extravertebral) and have the form of an hourglass. In such cases, combined accesses from the side of the vertebral canal, or from the thoracic or abdominal cavity, are used to remove neurin.

When removing meningiomas in order to prevent recurrence of the tumor, the dura mater from which the tumor was formed is removed or coagulated. If the tumor is located subduralno, for its removal it is necessary to make an opening of the dura mater.

Intramedullary tumors, more often astrocytomas, do not have clear boundaries with the spinal cord and are significantly spread along it, so the possibilities of their total removal are limited. Removal of intracerebral tumors of the spinal cord should be carried out exclusively with the use of microsurgical techniques. After surgery, it is advisable to conduct radiation and chemotherapy (radiation dose is selected depending on the histogenesis of the tumor), radiosurgery.

In the early postoperative period, rehabilitation therapy is provided: exercise gymnastics, massage of the extremities, etc., the use of biostimulators is absolutely unacceptable.

Forecast

The results of surgical treatment of the spinal cord tumor depend on the size, histogenesis, tumor localization, and radical operative intervention. The more pronounced the symptoms of the spinal cord tumor and the longer the period before the operation, the more slowly the restoration of the impaired functions of the spinal cord will occur after the operation. The results of surgical treatment are better the earlier and more radically the operation is performed, especially in the case of the removal of a benign extra-medullary tumor of small dimensions.