The choice of surgical treatment in spinal tumors depends on criteria such as the type and localization of the tumor, the presence of neural pressure, the involved part of the affected vertebra, whether it causes spinal instability, the biology of the tumor, the expected life expectancy of the patient, and the success expected from subsequent treatments.
There are several well-established indications for the surgical approach in the treatment of spinal tumors. These: (one)persistent pain that does not respond to non-surgical applications such as chemotherapy, radiotherapy or corset, (2)progressive neurological deficit during or after radiotherapy, (3)the tumor is resistant to radiotherapy, (4)need for diagnosis (5)the growth of the tumor mass and the need to decompress the neural elements by histopathology, ( 6)major destruction of the vertebral bone architecture or the presence of spinal instability.
BENEFICIAL SPINE TUMORS
According to Dahlin’s series of 8542 tumor cases, approximately 8% of primary benign bone tumors involve the spine and sacrum. On the other hand, it has been determined that 20-40% of primary spinal tumors are benign lesions. Benign bone tumors of the spine, like benign bone tumors located in other localizations, tend to involve patients at an early age. Dahlin reported that 60% of benign bone tumors involve people in the second and third decades. It is suggested that benign tumors tend to involve the upper portions along the spine.
Most common benign bone tumors osteochondroma, osteoblastomaand osteoid osteomais . Giant cell tumor, eosinophilic granuloma, hemangioma and aneurysmal cystare the most common lesions.
Pain is the most common complaint. Pain is usually radicular or local. Levin et al. reported that pain was almost always localized in their study involving patients with benign tumors without cervical involvement.
Osteoblastoma and osteoid osteoma typically originate from the posterior elements and may compress the nerve roots. In 28% of patients, nerve root pain accompanies the disease.
neurological damage Compression of the mass may be due to ischemic reasons or pathological fracture. Myelopathy often occurs when tumoral involvement is in the cervical or thoracic region. Levine et al. reported that the incidence of sensory loss was 14% and the incidence of focal motor deficit was 7%.
ennekingbenign spinal tumors, Silent (Stage-1), Active (Stage-2)or Offensive (Stage-3) classified as. Extensive removal (resection) of the tumor is recommended in stage-3 lesions. If the patient has or is likely to have a neurological deficit, this procedure should be done by relaxing and preserving the neural structures.
Boriani et al. recommend removing the anterior spine if the tumoral mass is located between 4-9 of the clock dials, and the posterior spine should be removed if it is located between 1-3 and 10-12, when the six o’clock is placed in the watch dial to show the front of the spine and the 12 o’clock to show the back. If resection will cause spinal instability, stabilization and fusion of the vertebral column is absolutely necessary after extensive resection. Complete removal of the vertebral body from the anterior makes such an approach inevitable.
osteochondroma, It is the most common benign tumor of the skeletal system. It is usually asymptomatic and tends to regress. 50% of symptomatic patients are 20 years or younger. The lesion can originate from any part of the vertebra, but more often involves the body and the arches and lamina. In Albrecht’s series, the lesion was detected in the lumbar region in 34% of patients. Symptoms of osteochondroma are usually due to the mass effect of the tumor. Histopathological examination reveals a cartilaginous cap covered with a fibrous membrane.
Aneurysmal bone cysts It has been reported that 11% of the patients are located in the spine. Generally, the patient is under the age of 20, and 95% of them present with back and low back pain. Surgical resection is successful in treating the lesion completely. According to Turker et al., deformity and deterioration of the stability of the spine are inevitable as a result of surgical removal. Therefore, spinal instrumentation and long-distance spinal freezing (fusion) are required.
Hemangiomas of the vertebral body was detected in 12% of autopsy samples. Symptomatic vertebral hemangiomas are usually encountered in the 3rd and 4th decade of life. Lesions are often located anterior to the vertebral body. Symptoms usually develop as a result of “ballooning” of the vertebral body, enlargement, or compression of neural elements by fracture fragments as a result of pathological fracture. According to Fox and Onafrio, about 30% of patients develop neurological damage. According to Geib and Bridwell, the indication for surgery is the presence of pathological fractures with neurological deficits.
Eosinophilic granuloma, It is the most common localized form of histiocytosis-X syndromes and is a benign solitary lesion. It is reported that there is 7-15% involvement in the spine. Most patients are under the age of 20. Identified instability or neurological compression caused by pathological fractures requires surgical intervention.
Giant cell tumor It is seen in the spine at a rate of 1-18% and is more common in women. As with other benign spinal tumors, local pain is the most common symptom. Since the typical location of giant cell tumors is the distal part of the spine, urinary and fecal incontinence can be seen in 20-80% of patients due to neurological compression. Geib and Bridwell recommend en bloc resection if possible because of the 10-50% risk of recurrence and Malignant degeneration.
MASTER TUMORS ORIGINATING FROM THE SPINE
It has also been suggested that 80% of tumors originating from the spine (primary) in adults are malignant. Ozaki et al., in their study in which they presented the results of 31 patients with spinal tumors, reported that there were 4 patients with benign and 6 primary malignant spinal tumors. It was determined that 1.2 vertebrae were involved in patients with benign tumors and 1.8 vertebrae in patients with malignant tumors.
There are many publications stating that pain is the primary complaint in primary malignant tumors, starting from the level of the involved vertebrae, spreading and continuing throughout the day, being so severe that it does not respond to medication. Levine suggested that this was due to the enlargement of the tumor mass and the compression of the neural structures of the vertebrae, especially the pathological fractures caused by bone destruction. Unilateral radicular pain was detected in more than 20% of the patients. This pain pattern is more common in cervical and lumbar spine involvement.
It has been determined that neurological damage may occur by direct spread of the tumor on the spinal cord and nerve roots or by bone compression resulting from pathological fractures. In a series of the Mayo Clinic, it was found that 4% of patients with spinal tumors were misdiagnosed as hemi disc disease.
The most common tumor in many studies on primary malignant tumors is multiple myeloma . The tumor also involves other hematopoietic flat bones, most commonly seen between the ages of 50-75. Painful, pathological fractures may occur with the expansion of the tumor within the bone and neurological deterioration may occur.
plasmacytoma is a bone marrow-derived neoplasm containing malignant plasma cells. It is similar to solitary lesions in lymphoid tissue and manifests itself as solitary lesions in bone. It was determined that 25-50% of the patients had spinal involvement. It was determined that most of the lesions were located in the back region and the patients were generally over 50 years of age. It has been reported that 50% of the patients have neurologic deficits and 30% have paraplegia. The 5-year survival rate is reported to be approximately 70%.
lymphoma Bone involvement has been reported in approximately 13% of patients with Spinal involvement was reported in 15% and spinal canal compression in 3% of them. It was determined that the patients were usually between the ages of 40 and 60, and they frequently applied to the hospital with milk pain. According to Levine and Crandall, the chance of success increases with resection of the tumoral mass with a predatory approach, stabilization of the spine and concomitant chemotherapy. The survival rate of patients with non-Hodgkin lymphoma over 10 years has been reported as 30%.
malignant fibrous histiocytoma It is rarer than other primary malignant spinal tumors. In 1999, Salo et al. reported 239 cases of malignant fibrous histiocytoma operated between 1982 and 1996. They reported that 82% of the cases were over 50 years old, 30% metastasized, and the 5-year survival rate was 65%.
osteosarcoma It is a highly malignant tumor of the skeletal system, often involving the long bones and originating from the bone. It is reported to be the most common primary malignant bone tumor after myleloma. It was determined that 3% of all osteosarcomas involve the spine. It is known that osteosarcoma develops on the basis of benign lesions, Paget’s disease or fibrous dysplasia. It has been reported that almost all spinal osteosarcomas are stage II B, and they are usually high-grade sarcomas with extracompartmental spread. Levine and Crandal suggest that the best treatment is chemotherapy and aggressive surgical excision. It has been reported that the average life expectancy is 6-10 months.