The treatment depends on many factors including type, biological behavior and location of the tumour. It would not be possible to discuss all treatment options for all tumours here. The list below is a guide for common spinal tumours. Specific cases should always be discussed individually with a specialist (oncologist and spine surgeon).
Tumours of the vertebra (Extradural tumours)
Spinal metastases occur in around 10% of all cancers (see picture below). The most common tumours, which cause metastases, are cancers of the lung, breast, prostate, gut, melanoma (skin) and lymphoma. The most important part of the treatment is usually controlling the underlying cancer. The National Institute for Clinical Excellence in the UK (NICE) has issued guidelines regarding the management of these cases.
The role for surgery is usually restricted to decompression and stabilization of the spine. It is important to remember that surgery cannot cure the disease and usually only deals with its complications of spinal cord compression and instability due to erosion of the vertebra. Surgery is usually done in combination with other forms of treatment, for example radiotherapy. Complication rates are usually higher, if surgery is done after rather than before radiotherapy. The decision to treat should be made in consultation with a multidisciplinary team. The overall prognosis for the patient usually depends on the behaviour of the underlying cancer and not the spine operation. However, quality of life can be significantly improved by preventing paralysis, incontinence and reduction in pain (see also metastatic spinal cord compression).
Myeleoma/Plasmocytoma is a tumour from the blood producing cells in the vertebra. Treatment should be supervised by a specialist (Haemoncologist). Surgery is rarely necessary and restricts itself to cases of compression of the spinal cord and instability causing progressive deformity. Vertebroplasty or kyphoplasty can be a very good way of controlling the pain and adding some stability.
Haemangiomas are benign lesions of the spine. The majority of these tumours are found incidentally on MRI scan. The appearance is usually typical and biopsies are not necessary. They rarely require any treatment. In case of symptomatic tumours, surgery can consist of decompression, stabilization or vertebroplasty.
Intradural – extramedullary tumours
Meningiomas arise from the sac containing the spinal cord (dura). The cause is usually unknown apart from very rare cases (for example many years following radiotherapy to the spine for other conditions or genetic defects in patients with type 2 neurofibromatosis). Meningiomas are more common in women and usually occur in middle-aged patients. The most common site is in the thoracic spine and is almost never seen in the sacral area. They usually present with signs of slowly progressive myelopathy, which might develop over months or years. The tumour is usually benign. The diagnosis can be made in the majority of cases with a contrast enhanced MRI scan although they can look like neurofibromas. Treatment of choice is surgery, which usually cures it. There is a small chance of recurrence even many years after surgery.
Neurofibromas are tumours from the sheath of nerve roots (see picture below). In most cases they are single tumours but can occur in large numbers in a condition called neurofibromatosis type 2. They can cause sensory disturbance or pain along the nerve it arises from but also compression of the spinal cord. Small tumours can be completely asymptomatic. Like in meningiomas, the diagnosis can be mad with a contrast enhanced MRI scan although neurofibromas and meningiomas can look very similar.
Intradural – intramedullary tumours
Astrocytomas occur in the brain and spinal cord (see picture below). They are classified in different grades depending on certain histological features. Some are diffusely infiltrating the spinal cord (grade 2-4) and therefore cannot be resected surgically. However, the pilocytic astrocytoma has often a clear margin between tumour and spinal cord and can be resected. High grade tumours (grade 3&4) might need radiotherapy in addition to surgery.
Ependymomas also arise from cells within the spinal cord (see picture below). Like for astrocytomas an MRI scan with contrast is necessary and sometimes a biopsy is indicated before definite treatment. If the diagnosis is certain on MRI, the best treatment is surgical resection. In the case of incomplete resection or recurrence radiotherapy might be indicated. Unfortunately, these tumours can spread via the cerebrospinal fluid (CSF) to other parts of the spine and brain. Therefore, all patients should have an MRI scan of the entire spine and brain before and after any treatment.