Tumours of the Spine

Osteoid Osteoma

  • Common in spine posterior elements
  • May cause scoliosis (lesion lies at apex of convexity of curve)
  • Children often affected
  • If no scoliosis, treat with NSAIDs
  • If scoliosis present, resect early – curve resolves over 18 months
  • RF ablation under CT or XR guidance – risk of neural injury in spine

Osteoblastoma

  • Older patients - Posterior elements
  • Painful
  • 50% have neurologic involvement
  • Treatment: Nothing or Resection & posterior fusion

Aneurysmal Bone Cyst

  • 2nd decade
  • Posterior elements but can spread to anterior elements
  • Beware, may be present within a more sinister lesion
  • Treatment: Excision or radiotherapy
  • Fusion if extensive excision required
  • Risks: Bleeding & recurrence

Haemangioma

  • Usually asymptomatic
  • Causes pain if fractured
  • ‘Jailhouse’ vertebrae appearance
  • Rarely causes neurologic compromise
  • Radiotherapy can control pain after fracture
  • Anterior excision & fusion if chronic pain or neurology
  • Risk: Severe bleeding

Eosinophilic Granuloma

  • Aka Langerhans cell histiocytosis
  • Hallmark is vertebra plana
  • Children < 10 years
  • Biopsy to confirm diagnosis (EG is ‘great masquerader’)
  • Most are self-limiting
  • Expect 50% reconstitution of vertebral height
  • Radiotherapy if chronic pain

Giant Cell Tumour

  • Adults >40 years usually
  • Destroys the vertebra in an expansile fashion
  • Needs resection & grafting +/- stabilization of spine
  • Radiotherapy not recommended
  • High recurrence rate

Multiple Myeloma

  • Osteopenic, lytic vertebrae
  • Multiple lesions possible
  • Can cause fracture and pain
  • Treatment: Radiotherapy and chemotherapy
  • Surgery uncommonly needed, only for neurologic compromise & instability

Chordoma

  • Axial spine from occipitocervical junction to sacrum
  • Sacrum most common
  • Large mass and intra-abdominal compression effect
  • Treatment: Resection of tumour with Radiotherapy
  • Radiosensitive but difficult to achieve good margins
  • High recurrence rate and nerve sacrifice during resection

Osteochondroma

  • Usually cervical spine posterior elements
  • Can cause pressure effects
  • Snapping scapula syndrome
  • Treatment: Resection if symptomatic or features of malignant change

Neurofibroma

  • Present as enlarged intervertebral foramina on lateral imaging

Ewing’s, Osteosarcoma & Chondrosarcoma

  • Rare in spine
  • If present, prognosis is poor
  • May be metastases from a long bone primary
  • Treatment: Chemotherapy & Radiotherapy
  • Surgical excision may be needed – radical surgery

Lymphoma

  • Ivory vertebra appearance
  • Needs radiotherapy and chemotherapy

Fibrous Dysplasia

  • 60% with polyostotic FD will have a spinal lesion
  • Posterior elements
  • Often causes scoliosis

Metastatic Spinal Disease

Epidemiology

  • 97% of all spinal tumours are metastatic
  • 3rd most common site of metastases after lung & liver
  • Even more common over 40 years

Common Sources

  • Lung, Breast, Thyroid, Kidney, Prostate
  • Colon & GI Cancers occur but less common

Location

  • Thoracic (70%), Lumbar (20%), Cervical (10%)

Aetiology

  • Spine is highly vascular & has a large surface area
  • Batson’s plexus – valveless system
  • Slow flow through endplates

Classification

  • Intradural – arise from the neural elements
    • Intramedullary – from the cord
    • Extra-medullary – from the nerve roots
  • Extra-Dural – From the bony elements

Scoring Systems – Tokuhashi Score (Revised)

  • Estimates patient life expectancy and guides surgical decision-making
  • 86% accuracy in prospective studies
  • High score is better (max 17)
  • 6 criteria:
    1. General Status
    2. Neurologic deficit (Frankel – complete, incomplete, normal)
    3. Visceral metastases
    4. Extra-spinal bone metastases
    5. Number of vertebral metastases
    6. Primary site of tumour

Diagnosis

History

  • Systemic symptoms
  • Back pain, neurologic deficit

Examination

  • Pain on palpation over spine
  • Neurologic deficit
  • Screen for myelopathy & cauda equina

Imaging

X-ray: - Malignant disease tends to spare the discs (very avascular) - Originates in vertebral body then spreads to pedicles - 30% involvement till apparent on X-ray - Pedicles often first abnormality seen

MRI: - Malignant tumours dark on T1 & high signal on T2 - Sensitivity & specificity high - Improved further with contrast – differentiates from infection - To differentiate from compression fracture: - Look for soft tissue mass - Pedicle involvement – only in tumour

Management

Problems encountered: - Pain - Neurologic compromise - Instability - Disease control

Options: - Radiotherapy for pain relief & mild neurologic dysfunction - Disease control locally

Radiosensitive metastases: - Sensitive: Prostate, Lymphoma, Breast (70%) - Resistant: Renal, Thyroid, Lung, Melanoma, GI tumours

Surgical Decompression: - Goals of surgery need to be clear (Curative vs. Palliative) - Metastatic disease is usually an anterior process - Anterior wide excision, decompression & stabilization preferred - Add posterior stabilization if multiple levels treated or lesion is in the posterior elements (rare)

Vertebroplasty: - Good pain relief in metastases - Common in breast cancer & myeloma - Not advised if instability or neurologic compromise present

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