Spinal cord tumors

Spinal cord tumors account for 10-15% of all CNS tumors and occur equally frequently in men and women aged 20 to 60 years.

Symptoms spinal cord tumors

Symptoms of spinal cord tumors manifest as syndromes.

Radicular-meningeal pain syndrome

Most typical for extramedullary (extracerebral) tumors. Depending on which of the roots is affected (anterior or posterior), pain occurs along the root, sensitivity is impaired. In extramedullary tumors, radicular pain increases in the horizontal position (Razdolsky's symptom), especially if the tumor is located in the area of the equine tail, and decreases in the vertical position. This is of great differential diagnostic importance, because in some diseases, for example, in tuberculous spondylitis, the pain weakens in the horizontal position of the patient. The spinous process symptom is also important: pain during percussion of the spinous processes and paravertebrally at the level of the pathological process. The bow symptom is characterized by an increase in local pain syndrome when bending the head forward.

Neurinomas are characterized by the symptom of cerebrospinal fluid impulse - the occurrence or intensification of radicular pain with compression of the jugular veins. In this case, the outflow of venous blood from the brain worsens, intracranial pressure rapidly increases, and a wave of cerebrospinal fluid spreads through the subarachnoid spaces of the spinal cord, acting on the tumor as an impulse with tension of the root, as a result of which pain syndrome occurs or intensifies.

Reflexes whose arcs pass through the affected root or close at the level of the affected segment are reduced or disappear during objective examination of the patient. Therefore, the level of the tumor location can sometimes be suspected based on the loss of reflex arcs - certain tendon reflexes (peripheral paresis or paralysis).

Radicular sensitivity disorder manifests itself as numbness, crawling, cold or warm sensations in the root innervation zone. Radicular syndrome is characterized by an irritation phase and a function loss phase. At first, paresthesias are temporary (irritation phase), then permanent. Gradually, the patient's sensitivity decreases (hypesthesia) in the root innervation zone (loss phase), which, in the case of ongoing damage to several roots, leads to the development of anesthesia (lack of sensitivity) in the corresponding dermatomes.

Transverse cord lesion syndrome

Associated with the appearance of conductive segmental symptoms corresponding to the level of spinal cord compression. With progressive tumor growth and spinal cord compression, symptoms of spinal cord compression by conductive type occur below the level of damage with a gradual increase in neurological symptoms. The so-called syndrome of damage of the transverse spinal cord occurs in the form of a disorder of motor, sensory and vegetative functions along the central line below the level of damage.

Patients develop paresis or paralysis of the central type (spastic). The main signs of central paresis are: increased muscle tone, increased tendon and periosteal reflexes, the appearance of pathological pyramidal reflexes (as a result of a violation of the inhibitory effect of the cerebral cortex and increased reflex activity of the segmental apparatus of the spinal cord). Cutaneous, abdominal, cremasteric and other reflexes, on the contrary, disappear, which has an important topical diagnostic value.

Sensitivity disorders manifest themselves as hyperpathy, hypoesthesia, anesthesia below the level of the lesion. Sensitivity disorders progress according to the conductive type. With extramedullary tumors, a characteristic ascending type of sensitivity disorder is observed - from the distal parts of the body (foot, perineum) with a gradual spread of sensory disorders up to the level of the lesion, which is explained by the gradual compression of the spinal cord conduction pathways from the outside, where the longest fibers innervating the distal parts of the body are located. With intramedullary tumors - on the contrary, a descending type of sensitivity disorder develops, which is explained by the law of the eccentric arrangement of conductors (Flatau's law).

Syndrome of impaired vegetative functions

The syndrome of vegetative function disorders is primarily manifested by disorders of the pelvic organs (perineoanal syndrome). In tumors located above the sympathetic (LI-LII) and parasympathetic (SIII-SV) centers of pelvic organ regulation, imperative urges to urinate initially occur, then the patient develops urinary retention. The so-called paradoxical ischuria (urine excretion drop by drop) occurs.

In intramedullary spinal cord tumors, clinical symptoms of damage to certain segments of the spinal cord (segmental type) occur at early stages of development, which is manifested by hyperpathies, sympathalgias in the area of the affected segments. Fibrillary twitching of muscles, sensitivity disorders of a dissociated type (loss of superficial sensitivity while maintaining deep types of sensitivity) occur. Later, symptoms of damage to the spinal cord of a peripheral type appear (muscle hypotrophy, hypotonia).

As the tumor grows, the spinal cord is destroyed from within and its fusiform thickening is accompanied by symptoms of spinal cord damage of the conductive type as a result of compression of the spinal cord conductive pathways to the walls of the spinal canal. During this period, the clinical picture of spinal cord damage is mixed - symptoms of pyramidal insufficiency of the spinal cord are added to the symptoms of damage to the segmental apparatus, symptoms of spinal cord damage of the central type appear below the level of the transverse cord (tendon and periosteal reflexes increase, pathological pyramidal signs appear, conductive sensitivity disorders progress). At the same time, atrophy of certain muscle groups in the zone of segmental disorders persists.

Spinal cord tumors are common, the symptoms of which depend on their location.

In case of tumors of the cervical spinal cord at the level of segments CI-CIV, radicular pain in the occipital region occurs with a limitation of the range of motion in the cervical spine. Central tetraparesis (or tetraplegia) increases, sensory disturbances in the upper and lower extremities progress. When the tumor is localized at the level of segment CIV, respiratory failure due to damage to the phrenic nerve (diaphragmatic paralysis) is added. In case of craniospinal tumors, clinical symptoms of intracranial hypertension with congestion in the fundus may occur, and in case of damage to the medulla oblongata - boulevard disturbances.

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

In case of tumors of the thoracic spinal cord, in addition to the syndrome of damage to the transverse spinal cord in the form of disorders of motor, sensory and vegetative functions of the central type below the level of damage, radicular pain along the intercostal nerves may occur. Cardiac dysfunction may be observed when the tumor is localized at the level of segments D-DVI. When the lower thoracic segments are damaged, pain occurs in the abdominal region, which may lead to the erroneous opinion that the patient has cholecystitis, pancreatitis or appendicitis. Tumors in the DVII-DVIII region are characterized by the absence of upper abdominal reflexes, tumors in DIX-DX - the absence of middle and lower abdominal reflexes, for damage to segments DXI-DXII - the absence of only lower abdominal reflexes.

If the tumor is below the level of the lumbar thickening (LI-SI), the patient develops lower flaccid paraplegia or paraparesis with the absence of reflexes and atony of the muscles of the lower extremities, the function of the pelvic organs is impaired. If the tumor is localized at the level of the upper part of the thickening, knee reflexes are not evoked or are reduced, Achilles reflexes are increased. If the tumor is at the level of the lower segments of the lumbar thickening, knee reflexes are preserved, foot reflexes are reduced or not evoked.

For damage to the epiconus (LIV-SII), the development of flaccid paresis of the flexors and extensors of the feet, muscles of the peroneal group, sciatic muscles with preservation of the knee and loss of Achilles reflexes is characteristic.

Tumors in the area of the medullary cone are characterized by pain in the perineum and anogenital area. When the parasympathetic centers are affected by the tumor, pelvic organ dysfunction of a peripheral type occurs (urinary and stool incontinence, sexual weakness).

Tumors in the area of the equine tail are manifested by severe pain in the sacrum, anogenital area, in the lower extremities, which intensify in a horizontal position, especially at night. Motor and sensory disorders in the lower extremities progress according to the radicular type, the function of the pelvic organs is impaired according to the incontinence type.

Forms

Spinal cord tumors are classified according to histogenesis, localization, and degree of malignancy.

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

Depending on the localization, spinal cord tumors are divided into extramedullary (outside the brain), developing from the membranes of the brain, its roots and nearby tissues surrounding the spinal cord, and intramedullary (inside the brain), 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 above the dura mater and epi-subdural.

Based on their relationship to the spinal canal, spinal cord tumors are divided into intravertebral (within the spinal canal), extravertebral, and extra-introvertebral (hourglass type - Guleke tumors).

Depending on the length of the spinal cord, there are tumors of the cervical, thoracic, lumbar regions, and tumors of the equine tail. In more than half of the cases, tumors are found in the cervical and lumbar regions. In the cervical region, spinal cord tumors in children are twice as common as in the elderly, and in the thoracic region, they are detected three times more often in the elderly than in children. Tumors of the equine tail are diagnosed in approximately 1/5 of patients. Children are more likely to develop lipomas, dermoid cysts, sarcomas, and epidural ependymomas. In middle-aged people, neurinomas are more common, and meningiomas are less common. In the elderly, meningiomas, neurinomas, and cancer metastases are diagnosed.

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

Extramedullary spinal cord tumors include:

1. meningiomas (arachnoid endotheliomas) originating from the meninges;
2. neuromas, which develop from Schwann cells, primarily in the posterior roots of the spinal cord;
3. vascular tumors (hemangioendotheliomas, hemangioblastomas, angiolipomas, angiosarcomas, angioreticulomas - well vascularized, in some cases numerous neoplasms (Heinrich-Lindau disease);
4. lipomas and other neoplasms, depending on the histostructure. Approximately 50% of extramedullary spinal cord tumors are meningiomas (arachnoid endotheliomas). In most cases, they are located subdurally. Meningiomas are tumors of the meningeal-vascular series, developing from the meninges or their vessels. They are tightly connected to the dura mater. Sometimes meningiomas calcify (psammomas).

Neurinomas occur in 1/3 of patients. They develop from 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 mainly in children in the first years of life.

Chondromas, chordomas, and chondrosarcomas are rare neoplasms that are localized mainly in the sacral region.

A special group in clinical terms is made up of tumors of the equine tail, which manifest themselves primarily as radicular syndromes.

Intramedullary tumors of the spinal cord are mainly represented by gliomas (astrocytomas, enendymomas, etc.). Less common are multiform glioblastomas, medulloblastomas, and olgodendrogliomas. 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.

Enendymomas are diagnosed mainly in patients aged 30-40 years and in school-age children. They are localized most often in the cervical region and in the area of the equine tail, and can spread to two, three or more segments. Astrocytomas are relatively benign forms of intramedullary tumors, most often found in children aged 2-5 years and localized mainly in the cervicothoracic 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 mammary gland, prostate, lungs, gastrointestinal tract, kidneys. These tumors grow quickly, destroy the bone tissue of the spine, ligaments and soft tissues, causing compression of the spinal cord with severe pain syndrome. All spinal cord tumors are characterized by a progradient course of the disease as a result of progressive compression of the spinal cord and damage to its roots, and the rate of progression of neurological symptoms depends on the localization of the tumor, the direction of growth, and histogenesis.

Diagnostics spinal cord tumors

In some cases, the clinical symptoms characteristic of spinal cord tumors may resemble the clinical symptoms of such diseases as osteochondrosis, myelitis, arachnoiditis, tuberculosis, spondylitis, discitis, osteomyelitis, syphilis, multiple sclerosis, ALS, spinal cord vascular pathology, etc. Therefore, to conduct differential diagnostics and clarify the nature of the process, it is very important to use anamnesis data, the dynamics of disease development and progression of clinical symptoms, data from an objective examination of the patient, and the use of auxiliary research methods.

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

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

The technique of lumbar puncture with cerebrospinal fluid flow tests (Queckenstedt and Stukey) for the diagnosis of spinal cord tumors has been used extremely rarely lately. The cerebrospinal fluid flow block revealed by the Quekenstedt and Stukey tests indicates spinal cord compression and obstruction of the subarachnoid spaces, which, in combination with the biochemical and microscopic studies of the cerebrospinal fluid and the detected protein-cell dissociation, indicates a high probability of the presence of a spinal cord tumor in the patient.

Myelography is an X-ray of the intravertebral contents after contrasting the subarachnoid space with a contrast agent (majodil, omnipaque) or gas (oxygen, helium). The method is used to determine the level of spinal cord compression. Descending myelography can clarify the upper level of spinal cord compression, and ascending myelography can clarify the lower level. Myelography is rarely used as a diagnostic method due to the advent of more informative, minimally invasive research methods (MRI).

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Treatment spinal cord tumors

The only radical method of treating most spinal cord tumors is their surgical removal. The earlier the surgical removal of the tumor is performed, the more favorable the postoperative outcome will be. The purpose of the operation:

1. maximally radical removal of the tumor;
2. maximum preservation of blood supply to the spinal cord tissues;
3. performing 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 a spinal cord tumor, in some cases a laminectomy is performed according to the level of the tumor. In the case of neurinomas, the root from which the tumor grew is coagulated and transected, after which the tumor is removed. Tumors that spread along the root extradurally and beyond the spinal canal are removed with considerable difficulty. Such tumors consist of two parts (intra- and extravertebral) and have an hourglass shape. In such cases, combined approaches are used to remove neurinomas from both the spinal canal and the thoracic or abdominal cavities.

When removing meningiomas to prevent tumor recurrence, the dura mater from which the tumor originated is removed or coagulated. If the tumor is located subdurally, it is necessary to open the dura mater to remove it.

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

In the early postoperative period, rehabilitation therapy is carried out: therapeutic exercises, massage of the limbs, etc. The use of biostimulants is absolutely unacceptable.

Forecast

The results of surgical treatment of spinal cord tumors depend on the size, histogenesis, localization of the tumor, and the radicality of the surgical intervention. The more pronounced the symptoms of the spinal cord tumor and the longer the period before the operation, the slower the restoration of the impaired functions of the spinal cord after the operation. The results of surgical treatment are better the earlier and more radical the operation is performed, especially in the case of removal of a benign extramedullary tumor of small size.