Patients may have similar symptoms to other pathologies such as disc herniations or stenosis from spondylosis that cause spinal cord or nerve root compression. This may include pain, decreased sensation, or motor weakness. For example, when a patient has signs of myelopathy (spinal cord compression) or radiculopathy (nerve root compression), the initial work-up will include imaging, often an MRI. Sometimes, instead of degenerative findings, the MRI may reveal neoplastic (tumor) pathology in or around the cervical, thoracic, lumbar, or sacral spine. Symptoms will vary based on location in the spine and the degree of compression.
The types of spinal tumors are often broken down into osseous tumors (tumors in the bones of the spine), epidural tumors, intradural intramedullary tumors, and intradural extramedullary tumors. Osseous tumors can include osteoblastoma or hemangioma.. Epidural tumors can occur with metastatic cancer traveling from other areas of the body. Intradural intramedullary tumors can include glial tumors such as astrocytoma or ependymoma occurring within the spinal cord. Intradural extramedullary masses can include schwannoma or meningioma. These are just some basic examples of the different types of tumors that occur within or around the spinal column, spinal cord, or nerve roots.
Typically, you would not be able to see a spinal tumor on the outside of the body. However, a spinal tumor’s effect on a patient’s neurological exam may be quite evident.
You can diagnose a spinal tumor based on MRI with contrast typically. MRI is very effective in evaluating soft tissue masses, particularly within the spinal cord or around the nerve roots. CT would be helpful for evaluating tumors within the bone.
How was this one discovered? Does a patient get numbness or pain in the body?
This tumor was discovered following an event where the patient was on a trampoline and experienced low back pain and intermittent left anterior groin pain. She went to her doctor and an MRI was performed revealing a large 5 cm intradural extramedullary mass extending from L1-L3 with splaying of the nerve roots bilaterally. Based on imaging, the preliminary diagnosis was a myxopapillary ependymoma. Pathological specimen analysis revealed the final diagnosis to be a myxopapillary ependymoma.
A patient can definitely get numbness or sensory changes, pain, or weakness in the body depending on what level in the spine a tumor is located, its size, and how nearby neurologic structures are being affected. Patients can have variable neurologic symptoms.
This mass was a tumor. A tumor is a very basic label for any neoplasm. There is often a distinction between malignant versus benign. A benign tumor typically grows more slowly and does not have evidence of necrosis on pathological specimen. This tumor was found to be a myxopapillary ependymoma. The World Health Organization has designated this a WHO Grade 2 tumor. This tumor is histologically benign but it is Grade 2 because it has a tendency to recur, similar to other ependymomas within the spinal cord or brain.
Carefully. This type of procedure would be done under the microscope. I use the microscope to get the very best visualization of the tumor and the nerve roots. Additionally, we use neuromonitoring that allows me to avoid neurologic injury to motor or sensory nerve roots in hopes of maintaining or improving the patient’s neurologic baseline. In these procedures, there can be a fair amount of nerve root manipulation in dissecting the tumor off the nerve roots.
I received great training in my neurosurgery residency and neurosurgery spine fellowship in the treatment of tumors in and around the spinal cord and nerve roots. These can be time-involved surgeries, but I prepare for these cases as if it were a marathon. I always aim to get a good night’s sleep and come into the operating room ready to help my patient.
This can be a lengthy procedure. The goal is to remove the tumor en bloc, while maintaining or improving the patient’s neurologic baseline. These procedures can also be complex. When we are performing the laminectomies, we do not want to cause iatrogenic instability in removing too much bone or disturbing the facet joints. Iatrogenic instability can lead to further surgery down the road. In the intradural tumor dissection and removal, we do not want to incise or injure any nerve roots. With closure, we want to have a watertight closure to avoid spinal fluid leaks.
This specific procedure took around 4-5 hours. We had to perform laminectomies extending from L1-3, followed by dural incision under the microscope, and careful intradural dissection, peeling the tumor away from the nerve roots. With a myxopapillary tumor, it is important to maintain the integrity of the tumor capsule to avoid spilling tumor cells and minimize the risk of recurrence.
Attention to detail and patience are very important, particularly under the microscope. Perhaps most importantly, the surgeon needs to be a great communicator and have a great collaborative team in the operating room. Every successful surgeon has a great team in the operating room that extends from the nursing staff, the anesthesia team, and to the neuromonitoring team. All of these folks are vital to achieving the very best patient outcomes!
Neurologically, patients may have some transient motor or sensory deficits following these surgeries that typically improve. This is often due to nerve root manipulation in the surgery. Patients often receive tremendous benefit with a good physical therapy or rehabilitation program.
The follow up process is important. Depending on the patient’s neurologic exam, it is important to see positive trends with return of neurologic function and return to daily activities of living. Additionally, I often would obtain a new MRI in 3 months or so. I would monitor the patients for any new or worsening neurologic symptoms. When these tumors are removed, it is often advised for the patient to receive radiation therapy to the resection cavity to lower the risk of recurrence. In the years that follow, surveillance MRI may be prudent in light of the risk of recurrence.
Post-surgical limitations are often the same as other surgeries, particularly in terms of bending, lifting, twisting. It can often be frustrating or even scary to patients after these surgeries who experience neurologic motor or sensory deficit. The surgeon must communicate well with the patient before the surgery and in the post-operative period.
Following the surgery, it’s important to remain active and mobile, particularly in the setting of weakness. Physical therapy is key. Radiation therapy is often applied to the resection cavity to avoid the risk of recurrence.
Dr. William Kemp is a fellowship-trained spine neurosurgeon at Virginia Spine Institute. As a minimally invasive and complex spine neurosurgeon, Dr. Kemp takes pride in utilizing his extensive knowledge of the nervous system to find answers for his patients and provide operative and non-operative solutions to help them reach their goals. His genuine passion for helping others drives a commitment to the highest standard of care and helps patients get back to enjoying life.
Learn more about Dr. Kemp.