26th June 2023

Spinal Tumours

Types of Spinal Tumours

Spinal tumours can be classified according to their location within the spine:

• Intramedullary tumour – located inside the spinal cord (5% of spinal tumours; the majority are ependymomas and astrocytomas, but also include haemangioblastomas).
• Intradural-extramedullary tumour – located inside the dura but outside of spinal cord. (40% of spinal tumours; these mostly consist of meningiomas and peripheral nerve sheath tumours).
• Extradural tumour – located outside the dura, e.g. in the bones, discs and paraspinal soft tissues (55% of spinal tumours, the majority of which are metastases from other systemic cancers).

In MRCP 1, you are not expected to be able to differentiate the different subtypes, however, a brief knowledge of their aetiology is useful.

Ependymomas

Ependymomas are a subtype of gliomas. These cells line the fluid-filled ventricles in the brain and the centre of the spinal cord. Ependymomas are linked to the autosomal dominant disease, neurofibromatosis type 2 (NF2).

Ependymomas

Image Source: Wikimedia Commons (2008). NF2 multiple intramedullary ependymomas 002, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:NF2_multiple_intramedullary_ependymomas_002.jpg (Accessed on: 30 January 2023).

Astrocytoma

Astrocytomas of the spinal cord are, in general, lower grade histologically than brain astrocytomas. They can be associated with neurofibromatosis type 1 (NF1). They are faster growing than ependymomas and the prognosis is worse. Surgery is the usual treatment choice, however, complete resection is rare due to their infiltrative nature. Radiotherapy and/or chemotherapy may also be used.

Haemangioblastomas

Haemangioblastomas are the third most common intramedullary spinal cord tumour, after ependymomas and astrocytomas. As with cerebellar haemangioblastomas, these are benign vascular tumours. They can be associated with Von Hippel-Lindau syndrome, as described earlier in this section. They are slow-growing and can be resected surgically. Endovascular embolisation may be required prior to surgical resection to minimise blood loss during surgery.

Haemangioblastoma.

Image Source: Wikimedia Commons (2007). Hippel Lindau, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:Hippel_Lindau.gif (Accessed on: 30 January 2023).

Meningiomas

A meningioma is a tumour that arises from the meninges. The meninges are membranes that cover and protect the brain and the spinal cord. There are three meningeal layers: dura mater; arachnoid mater; pia mater.

Risk factors include previous high dose ionising radiation and previous trauma. There is also an association with neurofibromatosis type 2.

Spinal meningioma on MRI.

Image Source: Wikimedia Commons (2009). Meningeom im Spinalkanal MRT, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:Meningeom_im_Spinalkanal_MRT.jpg (Accessed on: 30 January 2023).

Investigation and Management 

A full neurological examination followed by imaging is required in all presentations suspicious of a possible spinal lesion. MRI can be used to identify spinal pathologies and aid diagnosis by distinguishing characteristics of the lesion. MRI can also be useful in prognostication and neurosurgical planning.

Whole spine MRI is the first line imaging choice to investigate patients with new back pain with focal neurology, or other red flag features, particularly in those with a history of cancer. If a possible spinal malignancy is identified, a CT chest/abdomen/pelvis is useful for staging to identify any primary lesion or other metastases. Biopsies may be taken for histological diagnosis.

Management of the lesion depends on its aetiology. If there is evidence of metastatic cord compression, the management is with flat bed rest, high-dose dexamethasone with PPI cover, and urgent discussion with clinical oncology for consideration of radiotherapy to the affected area.

The neurosurgical MDT (neurologists, neurosurgeons/spinal surgeons, oncologists, psychologists, neuroradiologists and specialist nurses) are essential in making management decisions and supporting the patient through their diagnosis.