Tumors of the spine and back pain

The last decade is characterized by an increase in the total number of oncological diseases, an increased level of their diagnosis and treatment. The possibilities of magnetic resonance imaging and radioisotope scanning make it possible to establish the localization and prevalence of tumor lesion early enough, including the appearance of clinical symptoms of the disease. This fully applies to the problem of tumor lesions of the spine, so it is quite natural to see the appearance in recent years of classifications of tumors of the spine, built not only on a detailed histomorphological analysis of pathology. The increased technical capabilities of surgical treatment led to the appearance of anatomical and surgical classifications, which are also the basis of tactical schemes of surgical treatment. In most modern schemes of combined treatment of malignant tumors of the spine, the role of surgical intervention is leading, and the appearance of neurological complications in the patient raises the question of the need for urgent surgery.

Morphological classifications of tumors of the spine are based on data from the histological examination of the affected department.

Anatomical classifications of tumors of the spine are based on the definition of the affected area, its prevalence within the vertebra and on the tissues that contact the spine. Anatomical classifications, on the one hand, are based on common oncological principles of disease staging (McLain and Enneking classifications). On the other hand, these classifications take into account the peculiarities of intra-organ microcirculation and the pathways of the spread of the tumor process. This allows us to consider them tactical-surgical, and in accordance with them determine the scope and nature of surgical intervention (classification of WBB and Tomita et al).

RF McLain identified several anatomical zones of the vertebrae and stages of its tumor lesion, while the principle of "zonal" division was determined by the ratio of tumor localization to the vertebral canal. In turn, stages A, B and C of tumor growth were defined as intraosseous, parasomal and extraossal spread of the tumor, and to stage C, the author also attributed its extraorganic metastasis.

Morphological classification of tumors of the spine

Classification Galli RL, Spait DW Simon RR, (1989)
I. Tumors of the bone system
Tumors of chondroid (cartilaginous) origin	a) osteochondroma, b) chondroma, c) chondroblastoma, d) chondrosarcoma, e) chondromixoid fibroid
Osteogenic tumors	a) osteoma, b) osteoid-osteoma, c) osteoblastoma, d) osteogenic sarcoma, e) periosteal ossifying fibroids
Resorptive processes	a) bone cyst, b) diffuse fibrocystic osteitis, c) fibrous dysplasia, d) giant cell tumor
II. Tumors of different origin
Outgoing from the bone marrow	a) Ewing's tumor, b) multiple myeloma, c) chlorine or chloroleukemia, d) histiopitoma, e) eosinophilic granuloma, e) reticulosarcoma.
Metastatic	With lymphosarcoma, neuroblastoma, sarcoma, thyroid, milk, prostate and kidney cancer
Invasive	a) chordoma, b) angioma and angiosarcoma, c) fibroma, fibrosarcoma of fascia or nerve membranes, d) myosarcoma, e) synovium
Classification of Boriani S., WeinsteinJ.N., 1997
I. Primary benign tumors of the spine	a) osteochondroma (exostosis), b) osteoblastoma and osteoidosteoma, c) aneurysmal bone cyst, d) hemangioma, e) giant cell tumor, e) eosinophilic granuloma
II. Primary malignant tumors of the spine	a) malignant multiple myeloma and solitary plasmacytoma, b) primary osteosarcoma, c) secondary osteosarcoma that developed during the malignization of benign tumors, or osteosarcoma, which developed as a complication of radiation treatment (the so-called "induced" tumor), e) Ewing's sarcoma e ) chordoma, g) chondrosarcoma, h) lymphoma (not Hodgkin's).
III. Spinal lesions with leukemia
IV. Metastatic lesions of the spine

Currently, many authors consider eosinophilic granulomas not as true tumor lesions, but as a variant of a kind of disruption of cellular immunological reactivity, which proceeds with local tissue damage - the so-called. Histiocytosis from Langerhans cells.

WF Enneking et al. (1980,1983) used a different concept of "staging", defining it as the degree of invasiveness of growth of the bone vertebral tumor. It should be borne in mind that this classification was created before the introduction and introduction into the diagnostic practice of MRI. According to Enneking, the latency stage S1 (from the English stage) corresponds to a clear delineation of the tumor from the surrounding bone tissue by the so-called "capsule" and a clinically asymptomatic course. In this stage, pathological fractures can occur or the tumor can be accidentally detected by routine radiography. For the stage of active growth of S2 is characterized by growth of the tumor, causing gradually increasing pain in the back. The tumor extends beyond the vertebra, its growth is accompanied by the formation of a pseudocapsule, formed due to the perifocal inflammatory reaction and the germination of the vessels into soft tissues. The stage of aggressive growth of S3 is characterized by thinning of its own tumor capsule, its ruptures or the absence of tumor restriction from surrounding tissues. Pseudocapsules are expressed in this case, adjacent soft tissues are abundantly vascularized. Clinically, pathological vertebral fractures and spinal cord compression are often detected.

Even more in detail, a surgical classification of spinal tumors was developed, named WBB named after the authors who proposed it: JN Weinstein, S. Vo-riani, R. Biagini (1997). This classification is zonal-sectoral, because it is based on the determination of the position of the tumor in a zone or sector identified in the transverse section of the spine.

The following position (or spread) of the tumor corresponds to the definite authors of the zones: zone A - soft tissue parasol; zone B - superficial peripheral intraosseous; zone C - deep intraosseous ("central") localization (tumor belongs to the vertebral canal); zone D - extra-osseous epidural location; zone E - extraordinal intradural position. In the presence of metastatic lesions, the notation M

In addition, the transverse section of the spine is divided into 12 sectors, respectively, the sectors of the dial. Taking into account intra-organ microcirculation, the location of a malignant tumor within a given sector makes it possible to determine the necessary volume of ablastic resection of the vertebra, as well as to identify the zones subject to resection en block (single block):

• the defeat of sectors 4-9 (with lesion of at least one of the roots of the arch) is an indication for vertebral extirpation, while the removal of the vertebral body is carried out by the block, while the posterior elements can be removed fragmentarily;
• the lesion of sectors 3-5 or 8-10 is an indication for a 3/4 resection of the vertebra, with hemimedtebrrectomy on the side of the lesion carried out by the block, and the contralateral part of the arch is removed fragmentarily. The contralateral part of the vertebral body can be preserved;
• the defeat of sectors 10-3 is an indication for the removal of the whole arch of the vertebra by the block. It should be emphasized that when the sectors 10-3 are affected, the operation can be performed from an isolated rear access, with any other tumor localization the vertebra resection is always performed from two separate accesses to the anterior and posterior parts of the spine.

Japanese authors (Tomita K. Et al., 1997) propose own division of the vertebra into anatomical zones. According to this division, 5 zones are distinguished in the spine: 1 - the body of the vertebra, 2 - the roots of the arches and articular processes, 3 - the spine and transverse processes, 4 - the vertebral canal, 5 - the extraspinal localization, including the paravertebral tissues, the disk and the musculoskeletal apparatus the spine. Taking into account own division of the vertebra into anatomical zones, the authors proposed a surgical classification of spinal tumors, according to which three types of tumor lesion were identified: type A - intraosseous tumors with lesions: 1 - one of three intraosteal zones; 2 - roots of the arc and zone 1 or 3; 3 - all three intraosseous zones - 1 + 2 + 3; type B - extraossal spread of the tumor: 4 - any intraosseous localization + spread to the epidural space, 5 - any intraosseous localization + paravertebral spread, 6 - involvement of the adjacent vertebra; type M: 7 - multiple (polysegmentary) lesions and skip metastases (intragroup or "galloping" metastases). The above classification served as the basis for the developed by K. Tomita polysegmentary (multilevel) resections of the spine. These interventions, including one-stage en block resection of several vertebral bodies, are performed by the author from the rear access using original surgical instruments.

It should be noted that polysegmentary vertebral lesions are typical for systemic oncological diseases.