A spinal tumor is an abnormal mass of tissue within or surrounding the spinal cord and/or spinal column. These cells grow and multiply uncontrollably, seemingly unchecked by the mechanisms that control normal cells. Spinal tumors can be benign (non-cancerous) or malignant(cancerous). Primary tumors originate in the spine or spinal cord, and metastatic or secondary tumors result from cancer spreading from another site to the spine.
1. By the region of the spine in which they occur. These basic areas are cervical, thoracic, lumbar and sacrum.
2. By their location within the spine - Intradural-extramedullary
The bony spinal column is the most common site for bone metastasis. Estimates indicate that at least 30% and as high as 70% of patients with cancer will experience spread of cancer to their spine. The most common primary spine tumor (originated in the bony spine) is vertebral hemangiomas. These are benign lesions and rarely cause symptoms such as pain.
Common primary cancers that spread to the spine are lung, breast and prostate. Lung cancer is the most common cancer to metastasize to the bone in men, and breast cancer is the most common in women. Other cancers that spread to the spine include multiple myeloma, lymphoma, melanoma and sarcoma, as well as cancers of the gastrointestinal tract, kidney and thyroid. Prompt diagnosis and identification of the primary malignancy is crucial to overall treatment. Numerous factors can affect outcome, including the nature of the primary cancer, the number of lesions, the presence of distant non-skeletal metastases and the presence and/or severity of spinal-cord compression.
The cause of most primary spinal tumors is unknown. Some of them may be attributed to exposure to cancer-causing agents. Spinal cord lymphomas, which are cancers that affect lymphocytes (a type of immune cell), are more common in people with compromised immune systems. There appears to be a higher incidence of spinal tumors in particular families, so there is most likely a genetic component.
In a small number of cases, primary tumors may result from presence of these two genetic diseases:
In this hereditary (genetic) disorder, benign tumors may develop in the arachnoid layer of the spinal cord or in the supporting glial cells. However, the more common tumors associated with this disorder affect the nerves related to hearing and can inevitably lead to loss of hearing in one or both ears.
This rare, multi-system disorder is associated with benign blood vessel tumors (hemangioblastomas) in the brain, retinaand spinal cord, and with other types of tumors in the kidneys or adrenal glands.
Non-mechanical back pain, especially in the middle or lower back, is the most frequent symptom of both benign and malignant spinal tumors.
This back pain is not specifically attributed to injury, stress or physical activity. However, the pain may increase with activity and can be worse at night when lying down.
Pain may spread beyond the back to the hips, legs, feet or arms and may worsen over time — even when treated by conservative, nonsurgical methods that can often help alleviate back pain attributed to mechanical causes.
A thorough medical examination with emphasis on back pain and neurological deficits is the first step to diagnosing a spinal tumor. Radiological tests are required for an accurate and positive diagnosis.
Application of radiation to produce a film or picture of a part of the body can show the structure of the vertebrae and the outline of the joints. X-rays of the spine are obtained to search for other potential causes of pain, i.e. tumors, infections, fractures, etc. X-rays, however, are not very reliable in diagnosing tumors.
A diagnostic image created after a computer reads X-rays, a CT/CAT scan can show the shape and size of the spinal canal, its contents and the structures around it. It also is very good at visualizing bony structures.
A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology. An MRI can show the spinal cord, nerve roots and surrounding areas, as well as enlargement, degeneration and tumors.
A diagnostic test using Technectium-99. Helpful as an adjunct for identification of bone tumors (such as primary bone tumors of the spine), infection, and diseases involving abnormal bone metabolism.
Radiology studies noted above provide imaging findings that suggest the most likely tumor type. In some cases, however, a biopsy may be needed if diagnosis is unclear or if concern for malignancy vs benign tumor type. If the tumor is malignant, a biopsy also helps determine the cancer's type, which subsequently determines treatment options.
Treatment decision-making is often multidisciplinary, incorporating the expertise of spinal surgeons, medical oncologists, radiation oncologists and other medical specialists. The selection of treatments including both surgical and non-surgical is therefore made keeping in mind the various aspects of the patient’s overall health and goals of care.
Nonsurgical treatment options include observation, chemotherapy and radiation therapy. Tumors that are asymptomatic or mildly symptomatic and do not appear to be changing or progressing may be observed and monitored with regular MRIs. Some tumors respond well to chemotherapy and others to radiation therapy. However, there are specific types of metastatic tumors that are inherently radioresistant (i.e. gastrointestinal tract and kidney): in those cases, surgery may be the only viable treatment option.
Indications for surgery vary depending on the type of tumor. Primary (non-metastatic) spinal tumors may be removed through complete en bloc resection for a possible cure. In patients with metastatic tumors, treatment is primarily palliative, with the goal of restoring or preserving neurological function, stabilizing the spine and alleviating pain. Generally, surgery is only considered as an option for patients with metastases when they are expected to live 3 – 4 months or longer, and the tumor is resistant to radiation or chemotherapy. Indications for surgery include intractable pain, spinal-cord compression and the need for stabilization of pathological fractures.
For cases in which surgical resection is possible, preoperative embolization may be used to enable an easier resection. This procedure involves the insertion of a catheter or tube through an artery in the groin. The catheter is guided up through the blood vessels to the site of the tumor, where it delivers a glue-like liquid embolic agent that blocks the vessels that feed the tumor. When the blood vessels that feed the tumor are blocked off, bleeding can often be controlled better during surgery, helping to decrease surgical risks.
If surgery is considered, the approach to the tumor is determined by the tumor’s location within the spinal canal. The posterior (back) approach allows for the identification of the dura and exposure of the nerve roots. This approach is commonly used for tumors in the posterior aspect of the spinal column or to expose tumors inside the dura. Multiple levels can be decompressed, and multilevel segmental fixation can be performed if necessary. The anterior (front) approach is excellent for tumors in the front of the spine. This approach also allows for the reconstruction of defects caused by removal of the vertebral bodies.
This approach also allows placement of short-segment fixation devices. Thoracic and lumbar spinal tumors that affect both the anterior and posterior vertebral columns can be a challenge to resect completely. Not infrequently, a posterior (back) approach followed by a separately staged anterior (front) approach has been utilized surgically to treat these complex lesions.