Editing Spinal tumor

{{Short description|Neoplasms located in either the vertebral column or the spinal cord}}

'''Spinal tumors''' are [[neoplasm]]s located in either the [[vertebral column]] or the [[spinal cord]].<ref name=":0">{{Cite book |editor1-last=Arnautović |editor1-first=Kenan I. |editor2-last=Gokaslan |editor2-first=Ziya L. |year=2018 |title=Spinal Cord Tumors |location=Cham, Switzerland |publisher=Springer |isbn=978-3-319-99438-3 |oclc=1084270205}}</ref> There are three main types of spinal tumors classified based on their location: extradural and intradural (intradural-intramedullary and intradural-extramedullary). Extradural tumors are located outside the [[dura mater]] lining and are most commonly [[Metastasis|metastatic]].<ref name=":3">{{Citation|last1=Gossman|first1=William|title=Cancer, Intramedullary Spinal Cord Tumors|date=2019|url=http://www.ncbi.nlm.nih.gov/books/NBK442031/|work=StatPearls|publisher=StatPearls Publishing|pmid=28723060|access-date=2019-12-03|last2=Hoang|first2=Stanley|last3=Mesfin|first3=Fassil B.}}</ref> Intradural tumors are located inside the dura mater lining and are further subdivided into intramedullary and extramedullary tumors. Intradural-intramedullary tumors are located within the dura and spinal cord parenchyma, while intradural-extramedullary tumors are located within the dura but outside the spinal cord parenchyma. The most common presenting symptom of spinal tumors is nocturnal back pain.<ref name=":0" /> Other common symptoms include [[muscle]] weakness, sensory loss, and difficulty walking.<ref name=":0" /> Loss of bowel and [[Urinary bladder|bladder]] control may occur during the later stages of the disease.<ref name=":4">{{Cite journal|last=Balériaux|first=D. L. F.|date=1999-08-01|title=Spinal cord tumors|journal=European Radiology|language=en|volume=9|issue=7|pages=1252–1258|doi=10.1007/s003300050831|pmid=10460357|s2cid=6586168|issn=1432-1084}}</ref>

The cause of spinal tumors is unknown. Most extradural tumors are metastatic commonly from breast, prostate, lung, and kidney cancer.<ref name=":1">{{Citation|last1=Burton|first1=Matthew R.|title=Cancer, Conus and Cauda Equina Tumors|date=2019|url=http://www.ncbi.nlm.nih.gov/books/NBK441878/|work=StatPearls|publisher=StatPearls Publishing|pmid=28722908|access-date=2019-12-03|last2=Mesfin|first2=Fassil B.}}</ref> There are many genetic factors associated with intradural tumors, most commonly [[Neurofibromatosis type I|neurofibromatosis 1]] (NF1), [[Neurofibromatosis type II|neurofibromatosis 2]] (NF2), and [[Von Hippel–Lindau disease|Von Hippel–Lindau]] (VHL) syndrome.<ref name=":0" /> The most common type of intradural-extramedullary tumors are [[meningioma]]s and [[Nerve sheath tumor|nerve-sheath tumors]].<ref name=":2">{{Cite web|url=https://www.aans.org/|title=Spinal Tumors – Types, Symptoms, Diagnosis and Treatment|website=www.aans.org|language=en|access-date=2019-12-03}}</ref> The most common type of intradural-intramedullary tumors are [[ependymoma]]s and [[astrocytoma]]s.<ref name=":5">{{Cite journal|last1=Mechtler|first1=Laszlo L.|last2=Nandigam|first2=Kaveer|date=2013-02-01|title=Spinal Cord Tumors: New Views and Future Directions|journal=Neurologic Clinics|series=Spinal Cord Diseases|volume=31|issue=1|pages=241–268|doi=10.1016/j.ncl.2012.09.011|pmid=23186903|issn=0733-8619}}</ref> Diagnosis involves a complete medical evaluation followed by imaging with a CT or MRI. A biopsy may be obtained in certain cases to categorize the lesion if the diagnosis is uncertain.<ref name=":0" /><ref name=":1" /><ref name=":2" />

Treatment often involves some combination of surgery, radiation, and chemotherapy.<ref name=":0" /><ref name=":1" /><ref name=":2" /> Observation with follow-up imaging may be an option for small, benign lesions.<ref name=":1" /> Steroids may also be given before surgery in cases of significant cord compression.<ref name=":0" /> Outcomes depend on a number of factors including whether the tumor is benign or malignant, primary or metastatic, and location of the tumor. Treatment is often [[Palliative care|palliative]] for the vast majority of metastatic tumors.<ref name=":2" />

==Signs and symptoms==
The symptoms of spinal tumors are often non-specific, resulting in a delay in diagnosis. Spinal nerve compression and weakening of the vertebral structure cause the symptoms. Pain is the most common symptom at presentation.<ref name=":0" /><ref name=":4" /><ref name="Nambiar">{{cite journal|last=Nambiar|first=Mithun|author2=Kavar, B|date=2012|title=Clinical presentation and outcome of patients with intradural spinal cord tumours|journal=Journal of Clinical Neuroscience|volume=19|issue=2|pages=262–6|doi=10.1016/j.jocn.2011.05.021|pmid=22099075|s2cid=11919425}}</ref> Other common symptoms of [[spinal cord compression]] include muscle weakness, [[sensory loss]], numbness in hands and legs, and rapid onset [[paralysis]]. [[Fecal incontinence|Bowel]] or [[Urinary incontinence|bladder incontinence]] often occur in the later stages of the disease.<ref name=":4" /> Children may present with spinal deformities such as [[scoliosis]].<ref name=":0" /><ref name=":3" /> The diagnosis is challenging, primarily because symptoms often mimic more common and benign degenerative spinal diseases.<ref name="Hamamoto">{{cite journal|last=Hamamoto|first=Yasushi|author2=Kataoka, M.|author3=Senba, T.|author4=Uwatsu, K.|author5=Sugawara, Y.|author6=Inoue, T.|author7=Sakai, S.|author8=Aono, S.|author9=Takahashi, T.|author10=Oda, S.|date=9 May 2009|title=Vertebral Metastases with High Risk of Symptomatic Malignant Spinal Cord Compression|journal=Japanese Journal of Clinical Oncology|volume=39|issue=7|pages=431–434|citeseerx=10.1.1.624.6511|doi=10.1093/jjco/hyp039|pmid=19429929}}</ref><ref name=Ribas>{{cite journal|last=Ribas|first=Eduardo S. C.|author2=Schiff, David |title=Spinal Cord Compression|journal=Current Treatment Options in Neurology|date=1 May 2012|doi=10.1007/s11940-012-0176-7|pmid=22547256|volume=14|issue=4|pages=391–401|citeseerx=10.1.1.613.5814|s2cid=25396373}}</ref>

Spinal cord compression is commonly found in patients with metastatic malignancy.<ref name=Holt>{{cite journal|last=Holt|first=T.|author2=Hoskin, P. |author3=Maranzano, E. |author4=Sahgal, A. |author5=Schild, S.E. |author6=Ryu, S. |author7=Loblaw, A. |title=Malignant epidural spinal cord compression: the role of external beam radiotherapy|journal=Current Opinion in Supportive and Palliative Care|date=6 March 2012|volume=6|issue=1|pages=103–8|doi=10.1097/spc.0b013e32834de701|pmid=22156794|s2cid=40059786}}</ref> [[Back pain]] is a primary symptom of spinal cord compression in patients with known malignancy.<ref name=Reith>{{cite journal|last=Reith|first=W.|author2=Yilmaz, U. |title=[Extradural tumors].|journal=Der Radiologe|date=December 2011|volume=51|issue=12|pages=1018–1024|doi=10.1007/s00117-011-2152-8|pmid=22198141|s2cid=2875418}}</ref> Back pain may prompt a [[bone scan]] to confirm or exclude spinal metastasis. Rapid identification and intervention of metastatic spinal cord compression is necessary to preserve neurologic function.<ref name=Jennelle>{{cite journal|last=Jennelle|first=Richard L. S. |author2=Vijayakumar, Vani |author3=Vijayakumar, Srinivasan|title=A Systemic and Evidence-Based Approach to the Management of Vertebral Metastasis|journal=ISRN Surgery|date=2 August 2011|volume=2011|doi=10.5402/2011/719715|pmid=22084772 |pmc=3200210 |pages=719715 |doi-access=free }}</ref>

== Causes ==
The cause of the majority of spinal tumors is currently not known. Primary spinal tumors are associated with a few [[Syndrome|genetic syndromes]].<ref name=":0" /><ref name=":2" /> [[Neurofibroma]]s are associated with neurofibromatosis 1 (NF1).<ref name=":0" /> Meningiomas and [[schwannoma]]s are associated with neurofibromatosis 2 (NF2).<ref name=":0" /> Intramedullary [[hemangioblastoma]]s can be seen in patients with von Hippel-Lindau disease.<ref name=":2" /> Spinal cord [[lymphoma]]s are commonly seen in patients with suppressed immune systems.<ref name=":2" /> The majority of extradural tumors are due to metastasis, most commonly from breast, prostate, lung, and kidney cancer.<ref name=":1" />

==Pathophysiology==
The [[spinal cord]] is a long, cylindrical anatomical structure that is located within the [[Spinal cavity|vertebral cavity]]. It runs from the [[foramen magnum]] of the skull to the [[conus medullaris]] at the lumbar spine.<ref name=":0" /> Most symptoms from spinal tumors occur due to compression of the spinal cord as it plays a primary role in motor and sensory function.<ref name=":6">{{Cite book|url=https://link.springer.com/content/pdf/10.1007/978-3-540-44715-3.pdf|language=en-gb|doi=10.1007/978-3-540-44715-3|year=2007|isbn=978-3-540-44714-6 |title=Surgery of Spinal Tumors }}</ref> The spinal cord is surrounded by three layers known as the spinal [[meninges]].<ref name=":6" /> These are the [[dura mater]], [[arachnoid mater]], and [[pia mater]]. Spinal cord tumors are classified based on their location within the spinal cord: intradural (intradmedullary and extramedullary) and extradural tumors.{{citation needed|date=July 2021}}

Intradural tumors are located within the dura mater.<ref name=":0" /> These are further broken down into intramedullary and extramedullary tumors. Intradural-intramedullary tumors are located within the spinal cord itself, with the most common being [[ependymoma]]s, [[astrocytoma]]s, and [[hemangioblastoma]]s.<ref name=":7">{{Cite journal|last1=Chamberlain|first1=Marc C.|last2=Tredway|first2=Trent L.|date=2011-06-01|title=Adult Primary Intradural Spinal Cord Tumors: A Review|journal=Current Neurology and Neuroscience Reports|language=en|volume=11|issue=3|pages=320–328|doi=10.1007/s11910-011-0190-2|pmid=21327734|s2cid=14866999|issn=1534-6293}}</ref><ref name=":5" /><ref name="Nambiar" /> Intradural-extramedullary tumors are located within the dura but outside of the spinal cord parenchyma, with the most common being [[meningioma]]s and [[nerve sheath tumor]]s (e.g. [[schwannoma]]s, [[neurofibroma]]s).<ref name=":2" /><ref name=":7" /><ref name="Nambiar" /> Extradural tumors are located outside the dura mater most commonly in the vertebral bodies from metastatic disease.<ref name=":0" />

Common primary cancers in metastatic spinal tumors includes breast, prostate, lung, and kidney cancer.<ref name=":0" /><ref name=":1" /><ref name="Hamamoto" /> It is important to diagnose and promptly treat metastatic tumors as they can lead to long-term neurologic deficit from epidural [[spinal cord compression]].<ref name=":0" /> Primary extradural tumors are rare and most arise from surrounding bony and soft tissue structures, including [[Ewing's sarcoma]], [[osteosarcoma]], and vertebral [[hemangioblastoma]]s.<ref name=":0" />

==Diagnosis==
=== Medical examination ===
The diagnosis of spinal tumors is challenging, as the symptoms can be non-specific and often mimic more common and benign degenerative spinal diseases. A comprehensive medical examination is necessary to look for signs or symptoms that may point towards a more serious condition. This includes a complete [[Neurological examination|neurological exam]] focusing on any motor or sensory deficits.<ref name=":2" /> Patients with either benign degenerative spinal disease or spinal tumors often present with back pain. A patient with [[radiculopathy]] or [[myelopathy]] raises suspicion for a more serious condition.<ref>{{Cite journal|last=Bilsky|first=Mark H.|date=2005-11-01|title=New therapeutics in spine metastases|journal=Expert Review of Neurotherapeutics|volume=5|issue=6|pages=831–840|doi=10.1586/14737175.5.6.831|pmid=16274340|s2cid=32071879|issn=1473-7175}}</ref>

=== Imaging ===
Imaging is often the next step when the diagnosis is unclear or there is greater suspicion for a serious condition that may need immediate intervention. Common types of medical imaging include [[X-ray]]s, [[CT scan|computer tomography scan]] (CT), [[Magnetic resonance imaging]] (MRI), [[myelography]], and [[Bone scintigraphy|bone scans]].<ref name=":0" /><ref name=":2" /> MRI is the imaging of choice for spinal tumors.<ref name=":0" /> The MRI protocol that is most frequently used includes [[Relaxation (NMR)|T1-weighted]] and [[Relaxation (NMR)|T2-weighted]] sequences, including contrast enhanced T1-weighted sequences.<ref name=":0" /> [[Magnetic resonance imaging|Short-TI Inversion Recovery]] (STIR) is also commonly added to the MRI protocol for detecting spinal cord tumors.<ref name=":0" /> Myelography may be used as a substitute when the patient cannot undergo an MRI or it is unavailable.<ref name=":0" /> X-rays and CT are more commonly used to view the bony structures.<ref name=":2" /> They are less frequently used for spinal cord tumors, however, since they cannot reliably detect them.<ref name=":2" /><ref name="Segal">{{cite journal|last=Segal D|first=Constantini S. C.|author2=Korn, Lidar|date=14 May 2012|title=Delay In Diagnosis of Primary Intra Dural Spinal Cord Tumors|journal=Surg Neurol Int|volume=3|page=52|doi=10.4103/2152-7806.96075|pmc=3356987|pmid=22629489 |doi-access=free }}</ref> [[Bone scan]]ning may be used as a supplementary imaging modality for tumors involving bony structures of the spine.<ref name=":2" />

==Treatment==
Treatment greatly varies depending on the type of spinal cord tumors, goals of care, and prognosis.<ref name=":2" /> The primary forms of treatment include surgical resection, radiotherapy, and chemotherapy.<ref name=":2" /> [[Glucocorticoid|Steroids]] (e.g. [[corticosteroids]])<ref name="Ribas" /> may be administered if there is evidence of [[spinal cord compression]]. These do not affect the tumor mass itself, but tend to reduce the inflammatory reaction around it and decrease the overall volume of the mass impinging on the spinal cord.{{citation needed|date=July 2021}}

=== Surgery ===
Surgery has several indications depending on the type of tumor, which includes complete resection, decompression of the nerves, and stabilization.<ref name=":1" />  An attempt at total gross resection for a possible cure is an option for patients with primary spinal cord tumors.<ref name=":1" /> Extramedullary tumours are more amenable to resection than intramedullary tumours, and even possible to be operated through microendoscopic or pure endoscopic approaches.<ref>{{cite journal |last1=Dhandapani |first1=S |last2=Karthigeyan |first2=M |title="Microendoscopic" versus "pure endoscopic" surgery for spinal intradural mass lesions: a comparative study and review |journal=Spine J |date=Sep 2018 |volume=18 |issue=9 |pages=1592–1602 |doi=10.1016/j.spinee.2018.02.002 |pmid=29452284 |s2cid=3834414 |url=https://doi.org/10.1016/j.spinee.2018.02.002|url-access=subscription }}</ref><ref name="Nambiar" /> In patients with metastatic tumors, treatment is palliative with the goal of improving the patient's quality of life.<ref name=":2" /> In these cases, indications for surgery include pain, stabilization, and spinal cord decompression.<ref name=":2" />

=== Non-surgical treatment ===
Observation, [[chemotherapy]], and [[Radiation therapy|radiotherapy]] are possible options as an adjunct to surgery or for tumors not amenable to surgery. Intradural-extramedullary tumors are often benign, so observation with follow-up imaging is an option in cases where the lesions are small and the patient is asymptomatic.<ref name=":1" /> Radiotherapy and chemotherapy may be administered alone or in conjunction with surgery. The choice of chemotherapy or radiotherapy is a multidisciplinary process and depends on the [[Grading (tumors)|histological grade]], type of tumor, and amount of surgical resection achieved.<ref name=":1" /> In cases where radiotherapy is chosen, radiation is usually delivered to the involved segment in the spinal cord and the uninvolved segment above and below the involved segment.<ref name="Ribas" />

The combination of [[minimally invasive surgery]] and [[radiation]] or [[chemotherapy]]  is a new technique for treating spinal tumors.<ref>{{cite web | url=http://www.nydailynews.com/life-style/health/cancer-spreads-spine-new-operation-cut-hospital-recovery-time-article-1.163951 | title=When cancer spreads to the spine, a new operation can cut both hospital and recovery time - NY Daily News| website=[[New York Daily News]]| date=13 April 2010}}</ref> This treatment can be tailored to the particular tumor of the [[Vertebral column|spine]], either metastatic or primary.<ref>{{cite web | url=http://www.mountsinai.org/patient-care/service-areas/neurosurgery/areas-of-care/spine-disorders/spine-tumor/diagnosis-and-treatment | title=Spinal Tumors &#124; Mount Sinai - New York}}</ref> Some suggest that direct decompressive surgery combined with postoperative radiotherapy, provide better outcomes than treatment with radiotherapy alone for patients with spinal cord compression due to metastatic cancer.<ref name="Patchell">{{cite journal|last=Patchell|first=Dr. Roy A.|author2=Tibbs, Phillip A. |author3=Regine, William F. |author4=Payne, Richard |author5=Saris, Stephen |author6=Kryscio, Richard J. |author7=Mohiuddin, Mohammed |author8=Young, Byron |title=Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial|journal=The Lancet|date=20 August 2005|volume=366|issue=9486|pages=643–648|doi=10.1016/S0140-6736(05)66954-1 |pmid=16112300|s2cid=7761862}}</ref><ref name="Furlan">{{cite journal|last=Furlan|first=J.C.|author2=Chan, K.K. |author3=Sandoval, G.A. |author4=Lam, K.C. |author5=Klinger, C.A. |author6=Patchell, R.A. |author7=Laporte, A. |author8=Fehlings, M.G. |title=The combined use of surgery and radiotherapy to treat patients with epidural cord compression due to metastatic disease: a cost-utility analysis|journal=Neuro-Oncology|date=May 2012|volume=14|issue=5|pages=631–640|doi=10.1093/neuonc/nos062|pmid=22505658|pmc=3337309}}</ref>

==References==
{{Reflist}}

{{Medical resources
|   ICD10          = {{ICD10|C|72|0|c|69}}
|   ICD9           = {{ICD9|192.2}}
|   DiseasesDB     = 31483
|   ICDO           =
|   OMIM           =
|   MedlinePlus    = 001403
|   eMedicineSubj  = orthoped
|   eMedicineTopic = 49
|   eMedicine_mult = {{eMedicine2|med|2993}}, {{eMedicine2|radio|169}}
}}
{{Nervous system tumors|state=expanded}}
{{Authority control}}

{{DEFAULTSORT:Spinal Tumor}}
[[Category:Nervous system neoplasia]]