Spinal and Spinal Cord Tumors Are Not a Single Disease
Spinal tumors are divided by location into three: extradural (outside the dura — mostly metastases and bone tumors), intradural-extramedullary (within the dura but outside the cord — often meningioma and nerve-sheath tumors), and intramedullary (within the cord). The intramedullary group is the least common (about 4-10% of all spinal tumors) and, because it involves the cord's own tissue intertwined with critical neural structures, is among the most demanding spinal operations. They are more common in children than adults. The location of the tumor, its type and the patient's neurological status are weighed together to determine the approach.
Which Tumor Types Are Seen?
Among intramedullary tumors the most common type in adults is ependymoma; it usually sits in the midline, is well demarcated and often contains a cystic component, making it more amenable to en bloc (total) resection. The second most common, astrocytoma, grows infiltratively, has indistinct borders and often cannot be totally resected (more common in children). Hemangioblastoma is a benign vascular tumor, a proportion of which is associated with von Hippel-Lindau disease. More rarely, ganglioglioma, lipoma, epidermoid/dermoid cysts, lymphoma and intramedullary metastases occur. Most tumors within the dura but outside the cord (meningioma, schwannoma) are benign and generally do well with surgery.
Symptoms and Diagnosis
In intramedullary tumors symptoms usually begin slowly and insidiously; the time to diagnosis may be months to years. The most frequent first complaint is pain; pain at the tumor level, worse at night and of a dural-stretch type is typical, and central (neuropathic) pain may also occur. As it progresses, weakness, loss of fine motor skill, difficulty walking, selective sensory loss and balance problems are added; advanced cases show bladder-bowel problems. The gold standard for diagnosis is contrast MRI; it shows the tumor level, extent, cystic component, accompanying syringomyelia and the contrast-enhancement pattern, and helps distinguish ependymoma from astrocytoma. Definitive diagnosis, however, is by histopathology; angiography may help in vascular tumors.
Treatment: Microsurgery and Monitoring
The basis of treatment is microsurgery that achieves the widest possible safe resection while protecting neurological function. Surgery is performed with an operating microscope, an ultrasonic aspirator and intraoperative neurophysiological monitoring (motor and sensory evoked potentials); this monitoring follows cord function in real time during surgery and reduces risk. In well-demarcated ependymoma and hemangioblastoma total resection is often possible; in infiltrative astrocytoma the aim is safe debulking and tissue diagnosis. For high-grade, partially removed or recurrent tumors, radiotherapy and, in selected cases, chemotherapy are considered. Some small, asymptomatic lesions (especially the multiple hemangioblastomas in von Hippel-Lindau) can be observed; that is, not every tumor means immediate surgery.
Postoperative Course, Prognosis and Realistic Expectations
In the early postoperative period the neurological status is monitored closely; because temporary sensory disturbance and weakness can occur, early rehabilitation is important. Physiotherapy and, when needed, bladder management support recovery; additional treatment is planned according to the histopathology result, and regular MRI follow-up is done for recurrence. Prognosis depends on the tumor type, its grade and, most importantly, the preoperative neurological status: outcomes are good in totally resected benign ependymoma and hemangioblastoma, and more limited in infiltrative and high-grade tumors. A good preoperative neurological status is among the strongest determinants of functional outcome — which is why early diagnosis is critical. We do not promise a guaranteed outcome; expectations are shared openly before surgery.