primary intraspinal tumor
Introduction
Introduction to primary intraspinal tumor Intraspinal tumor refers to the primary tumor and metastatic tumor that grow in the spinal cord itself and the tissue structure (such as nerve root, dura mater, intraductal fat tissue, blood vessel, etc.) adjacent to the spinal cord in the spinal canal. Clinically, according to the positional relationship between tumor and spinal cord and dura mater, the intraspinal tumor is generally divided into intramedullary, extramedullary epidural and epidural. Extramedullary epidural tumors are the most common, followed by epidural tumors, and at least the intraspinal tumors. Intramedullary tumors accounted for 9% to 18%, extramedullary epidural tumors accounted for about 55%, epidural tumors accounted for about 25%, and dumbbell-shaped intraspinal tumors accounted for about 8.5%. basic knowledge The proportion of illness: 0.0025% Susceptible people: no specific population Mode of infection: non-infectious Complications: somatosensory disturbance
Cause
Primary intraspinal tumor cause
The main factors affecting the pathological changes of spinal cord compression are:
1. It is related to the location of tumor compression and the nature of nerve tissue structure
The tolerance of various spinal nerve tissues to stress is different: if the tumor is first stimulated by the nerve root and then destroyed; the gray matter is more resistant to tumor compression than the white matter; the pyramidal bundle in the white matter and the nerve fibers that sense the sense of the body and the sense of touch Thick (diameter 5m21m), the painful fiber is finer (less than 2m in diameter), the fine fiber is more tolerant than the crude fiber after compression, and the recovery is faster after the pressure is released. Generally speaking, at the beginning of the compression, the nerve The root is pulled, the spinal cord is displaced, and then deformed under pressure, and finally the spinal cord is degenerated, gradually causing neurological dysfunction of the tissue.
2. The effect of tumor on spinal cord blood circulation
Venous dilatation, hemorrhage and edema after venous compression; insufficient blood supply in the dominating area after arterial compression, hypoxia and dystrophies, causing spinal cord degeneration and softening, and finally causing spinal cord necrosis, gray matter is greater than white matter in tolerance to ischemia The fine nerve fibers are larger than the thick nerve fibers. It is reported that the dorsal surface of the spinal cord is blue in the operation, the nourishing artery is enlarged, and the drainage vein is significantly missing, but a small amount of small nourishing arteries can be seen under the microscope.
The course of intraspinal tumors is generally more than 1 year. The shortest symptoms are reported as 17 days, and the longest is 12 years. The average duration of intramedullary tumors is 11.6 months, and the average duration of extramedullary tumors is 19.2 months.
3. The hardness of the tumor is closely related to the degree of damage to the spinal cord.
Soft tumors, especially those with slow growth, give the spinal cord sufficient time to adjust its blood circulation, develop slower, milder symptoms, and the spinal cord function recovers faster and better after surgery. Hard tumors, even if they are small, because they are easy to embed In the spinal cord, any spinal activity can cause the tumor to cause contusion and gliosis of the spinal cord, and most of the postoperative recovery is not ideal.
4. It is related to the growth mode of tumor and its growth rate
Some intramedullary tumors mainly have dilated growth, some mainly invasive growth, the latter causes greater damage to the spinal cord, and the tumor grows slowly. Even if the spinal cord is stressed, the spinal cord is still compensatory, and the symptoms can be compared. Slightly; on the contrary, fast-growing tumors, especially malignant tumors, can easily cause acute complete traverse damage of the spinal cord. Emergency surgery is needed to relieve spinal cord compression. Even 1 to 2 hours of delay often has serious consequences.
Prevention
Primary intraspinal tumor prevention
There are no effective preventive measures for this disease.
If early detection of intraspinal tumors, early surgical treatment, most have achieved good clinical results, some patients with large intraspinal tumors or located in the high cervical vertebrae, may die after respiratory failure, or a period of time after surgery After recurrence, as for the recovery of spinal nerve function, it is related to the extent and timing of spinal cord compression.
Complication
Primary intraspinal tumor complications Complications
Accompanied by acute "stroke" spinal cord transverse syndrome, brain nerve damage and other diseases of the spinal canal tumor.
Symptom
Primary intraspinal tumor symptoms Common symptoms Sensory disorder Back pain Inflammation Muscle atrophy Spinal thalamus bundle Compressed spinal cord Transverse injury Motion conduction bundle Involved autonomic dysfunction Paralysis
When the spinal cord is compressed, the dyskinesia occurs before the sensory disturbance. In addition to the compression of the spinal cord tissue, it may be accompanied by blood circulation disorders, cerebrospinal fluid dynamics, and complications such as inflammation and adhesion. Therefore, the clinical manifestations show diversity. And complexity, generally the development of extra-osseous tumor compression symptoms are divided into three phases: (1) early compression: nerve root pain. (2) Compression progression: spinal cord hemisection syndrome (brown-sequard syndrome). (3) The complete compression period of the spinal cord: the transverse damage of the spinal cord, this classification is still the basis of the current clinical classification.
The clinical symptoms of extramedullary tumors generally manifest in three stages:
Cervical spinal nerve stimulation period (neural root pain)
In the early stage of the disease, the main symptoms are the stimulating symptoms of the corresponding structure. The most common symptom is neuralgia. The pain often spreads along the distribution of nerve roots. It is often paroxysmal, coughing, sneezing, and exerting stools can make the pain worse. "Night pain and supine pain" is a characteristic symptom of spinal canal tumors. In addition, it is accompanied by skin paresthesia, such as numbness and burning sensation. If the tumor is compressed from the ventral side, it can be expressed as a compressed segment. At or below the segmental muscles, twitching, muscle twitching, weakness, etc., the first symptom of intraspinal tumor is radiculitis pain accounted for 54% (mostly schwannomas, accounting for 60.8% of radicular pain), performance For neck and shoulder pain; night pain accounted for 35%, the first symptom of nerve conduction bundle compression accounted for 45.9%, manifested as pressure below the flat plane, motor and autonomic dysfunction.
Partial compression of the cervical spinal cord
As the tumor grows, on the basis of the original symptoms, the symptoms of spinal cord conduction bundle compression gradually appear. For example, the spinal thalamus bundle is compressed, and the painful temperature below the contralateral side of the lesion may decrease or disappear; the posterior bundle is compressed. Deep sensory sensation may occur; the motor conduction beam may be involved, which may cause upper motor neuron paralysis of the limb below the ipsilateral lesion segment, and the spinal cord hemisection syndrome is a specific symptom of extramedullary extramedullary tumor, but more atypical. Ni Bin et al reported 137 cases of intraspinal tumors, 102 cases of ascending paralysis in the history, 74 cases of extramedullary tumors; 10 cases of descending paralysis, 8 cases of intramedullary tumors; 4 cases of spinal cord injury syndrome .
Complete cervical compression
The development of the lesion causes transverse damage in the parenchyma of the spinal cord, and the pathological changes of the spinal cord gradually become irreversible. There are limb movements, sensory loss, autonomic dysfunction, and dysfunction of the bowel movements below the lesion.
Examine
Examination of primary intraspinal tumors
Spinal tube puncture and brain fluid examination
Dynamic changes of cerebrospinal fluid and increased protein content are important basis for early diagnosis of intraspinal tumors. When suspected as intraspinal tumors, quinine test and cerebrospinal fluid examination should be performed as soon as possible. Patients with intraspinal tumors should undergo routine serial examination of cerebrospinal fluid. It can be seen that the cerebrospinal fluid protein content is increased and the number of cells is normal, and the kinetic test (ie, the Quikan test) may show partial or complete obstruction.
X-ray film inspection
About 30% to 40% of patients can see bone changes. On the conventional lateral and lateral oblique slices, common signs are: (1) enlargement or destruction of the intervertebral foramen. (2) The enlargement of the spinal canal is manifested by a widening of the pedicle spacing. (3) Bone changes in the vertebral body and attachment, visible vertebral bone defects, pedicle destruction and so on. (4) intrathecal calcification, occasionally seen in a small number of meningioma, teratoma and hemangioblastoma. (5) paravertebral soft tissue shadow, because the tumor in the spinal canal is mostly benign, there is often no abnormal bone manifestation on the early x-ray film, sometimes only the pedicle spacing is widened in the late stage, the cortical bone of the spinal canal is thin, the spinal canal Expanding and other indirect signs, for dumbbells and other internal tumors, it can be seen that the enlargement of the intervertebral foramen, x-ray examination, can exclude spinal deformity caused by spinal deformity, tumors, etc., is still an indispensable routine examination.
Myelography
It is currently one of the effective methods for displaying lesions in the spinal canal. Cervical spinal canal angiography can be performed with lipiodol (such as iodophenyl ester) or iodine water contrast agent (such as amipique or omnipaque), especially through the cisterna magna. The drug angiography is easy to confirm, showing a cup-shaped defect or obstruction of the contrast agent on the non-disc plane. The literature reports 180 cases of schwannomas, of which 150 cases were seen by radiography: 106 cases of cup-like filling defects, horizontal section 18 cases, 7 cases of beveled cones, 5 cases of bell mouth, 4 cases of beads, omnipaque is the second generation of non-ionic iodine water-soluble contrast agent, clear, safe and reliable, according to spinal cord enlargement, displacement and arachnoid Lower luminal obstruction determines spinal cord tumors, combined with increased cerebrospinal fluid protein, to make a correct diagnosis, due to adhesions, etc., sometimes the obstruction plane does not necessarily represent the true boundary of the tumor, Ni Bin et al reported 137 cases of intraspinal tumors, 4 cases of obstruction plane and surgical exploration results A difference of 1/4 to 1 vertebral body, unless a second angiography is performed, a single angiography can only determine the upper or lower bound of the tumor, and only the shape of the obstruction, the involvement of the bone can not determine the nature of the tumor. However, myelography can determine the location of the lesion, and then ct scan or mri examination to obtain more information on tumor lesions.
Ct check
The ct scan has sensitive density resolution, and can clearly display the spinal cord, nerve root and other tissue structures in the cross section. It can clearly show the soft tissue shadow of the tumor and contribute to the diagnosis of the tumor in the spinal canal. This is the traditional image. The method is not available, but the ct scan site, especially as the first imaging examination, needs to be determined according to the clinical signs. It is possible that the tumor site is missed due to inaccurate positioning, and ct can basically determine the tumor in the spinal canal. Segmental distribution and lesion range, but difficult to distinguish from normal spinal cord parenchyma, ctm (ct plus spinal cord angiography) can show the relationship between the whole spinal cord and tumor, and identify the tumor and syringomyelia in the spinal cord.
Mri check
Magnetic resonance imaging is an ideal method for examination. It has no side effects of ionizing radiation. It can observe the spinal cord image in three dimensions. It can show the boundary between tumor tissue and normal tissue, the location, size and extent of the tumor, and directly delineate the tumor. It shows its longitudinal and lateral expansion and its relationship with surrounding tissue structure. It has become the first choice for the diagnosis of spinal cord tumors. mri is more advantageous for distinguishing intramedullary and extramedullary tumors. MRI imaging of intramedullary tumors can be seen in the spinal cord. Expanded, in different pulse sequences, tumors show different signal intensity, which can be differentiated from syringomyelia. Extramedullary tumors can be located according to their relationship with the dura mater. The accuracy is high, and the mri sagittal imaging shows that the tumor is bordered. Clear long t1, long t2 signal area, but mainly t1, with obvious enhancement effect, some cystic changes, axial image shows that the cervical spinal cord is squeezed to one side, the tumor is oval or crescent For the dumbbell-shaped tumor protruding outward through the intervertebral foramen, the continuity of the intra-spinal and extra-thoracic mass can be seen. Because the mri directly performs sagittal imaging, the spinal cord range is compared with the ct scan. Large, this is unmatched by ct, and the mri can show the size, location, and tissue density of the tumor, especially the application of the paramagnetic contrast agent gd-dtpa can clearly show the contour of the tumor, so mri is diagnosed and Surgical positioning is very important, in this respect ct or ctm is far less than mri.
Diagnosis
Diagnosis and diagnosis of primary intraspinal tumor
diagnosis
Primary tumors in the cervical spinal canal are not uncommon, but due to the nature and location of the tumor, the clinical manifestations are complex and diverse, which brings certain difficulties to the diagnosis. In the past 10 years, the emergence of new nonionic iodine water-soluble contrast agents, ct and mri Application, so that the tumor site in the spinal canal mainly depends on myelography, ct scan or mri and other auxiliary examinations, especially to accurately identify intramedullary tumors and extramedullary tumors, but also depends on imaging examination, Ni Bin et al reported 137 cases There is no complete paraplegia in the spinal canal, and the time from onset to diagnosis is significantly shorter than in the past. The improvement of imaging examination plays an important role, but any advanced equipment can not replace clinical routine examination, comprehensive understanding of medical history, nervous system Checking and locating, for the identification of spinal cord tumors and spinal degenerative diseases, has important guiding significance for the determination of imaging examination sites and the interpretation of image information. Only the characteristics of imaging examinations are selected, and the application is selected according to the actual situation, and the structure is tight. Clinically, the imaging examination of spinal cord tumors can be more accurate.
The diagnosis of intraspinal tumors should identify the following aspects:
With or without intraspinal tumor
The early diagnosis of intraspinal tumors is extremely important, familiar with its early clinical manifestations, and the diagnosis is given before the spinal cord is not severely stressed, and the corresponding treatment is given at the same time, so that there is a greater possibility of achieving better therapeutic effects. The basic clinical manifestations of intraspinal tumors are segmental neurological symptoms and spinal cord compression symptoms below the compression plane. Nerve root pain is the most common in early symptoms, followed by dyskinesia, such as limb muscle atrophy, muscle weakness, and sensory disturbances. The dynamic changes of cerebrospinal fluid and the increase of protein content are important basis for the early diagnosis of intraspinal tumors. When it is suspected that the spinal canal is the same as the tumor, the Quikan test and cerebrospinal fluid examination should be performed as soon as possible.
The first symptom of high cervical spinal cord extramedullary compression disease is numbness of the fingertips, which is multi-finger from one finger to the proximal end. In addition, there is neck pain with numbness of the distal upper limbs, followed by limb weakness. And chest or waist banding, so patients with neck and shoulder pain should routinely perform neurological examination, and pay attention to gait. If there is limb sensation, movement, reverse change, the possibility of intraspinal tumor should be considered. Corresponding imaging studies.
Intraspinal or intramedullary tumor
1. Intramedullary tumor: common clinical pathological type is glioma (epenomyema, astrocytoma); nerve root pain is less common; its sensory changes are most obvious in the lesion segment, and develop from top to bottom , segmental distribution, sensory separation; may have lower motor neuron symptoms, muscle atrophy; pyramidal tract signs appear late and not obvious, spinal cord hemisection syndrome is rare or not obvious; spinal canal obstruction appears late or not Obviously, the protein content of cerebrospinal fluid is not obvious, and the symptoms are not obvious after the cerebrospinal fluid is released; the ridge pain is rare, and the bone changes in the spine are rare.
2. Extramedullary tumors: common clinical pathological types are neurofibromas, meningioma; radiculopathy is more common, and has the value of localization diagnosis; sensory changes in the distal extremities feel significant changes, and from the bottom up, no Sensory separation phenomenon; pyramidal beam sign appeared earlier and significant, lower motor neuron symptoms were not obvious, spinal cord hemisection syndrome was more common; spinal canal obstruction appeared earlier or obvious, cerebrospinal fluid protein increased significantly, release cerebrospinal fluid due to myeloid The external tumor moves down and the symptoms worsen; the ridge pain is more common, especially in the epidural tumor, and the bone mineral changes in the spine are more common.
Location diagnosis of cervical segment of tumor
The positioning of the spinal cord compression plane mainly depends on the following aspects:
1. The spinal cord is affected by root pain or root distribution in the area dominated by the compression site of the tumor.
2. The plane in which the sensory disorder lies should have no difficulty in diagnosing the spinal compression plane during the complete compression of the spinal cord, but it is too late. Many authors point out that radiculopathy is a common first symptom and important for early localization diagnosis. After the nerve root is destroyed by compression, the local segmental sensation is lost. After the spinal thalamus bundle is compressed, because it is arranged in a layered manner in the spinal cord, the early sensory loss plane of the extramedullary tumor does not really indicate the segment where the tumor is located. Nerve root pain and spinal cord thalamic bundle symptoms exist simultaneously, and when the planes of the two are inconsistent, the nerve root pain has a more positive positioning value.
3. The muscles innervated by the tumor compression zone have a delayed sputum. In the motor system, the tumor compresses and stimulates the anterior horn of the spinal cord or the anterior root of the spinal nerve, causing the lower motor neuron, which is more obvious in the neck enlargement area. Higher positioning value.
4. The reflex associated with the segment where the tumor is located disappears. Because the spinal cord and spinal nerve root in the plane of the tumor are compressed, the reflex arc is interrupted and the reflection is weakened or disappeared, but deep reflection enhancement occurs below this plane, and the shallow reflex is weakened. Or disappear, or accompanied by pathological reflexes.
5. Changes in autonomic function, no sweat or less sweat below the tumor plane, but its location is not as reliable as the sensory plane, and has little significance for cervical spinal cord tumors.
Differential diagnosis
Cervical spondylosis should be differentiated from cervical spondylotic myelopathy. Clinically, it is mainly based on age characteristics, clinical manifestations and x-ray or ct scan. Cervical spondylosis is due to degenerative changes in the cervical spine and loss of elasticity. The intervertebral disc protrudes into the spinal canal, or due to bone spurs behind the cone, small joint hyperplasia, hypertrophy or calcification of the ligamentum flavum, and even thickening of the lamina, causing the spinal cord to be compressed, resulting in a series of symptoms of impaired neurological function. And physical signs, clinically, all middle-aged or older, limbs or trunk numbness, weakness or signs of upper motor neuron damage, the symptoms of good or bad symptoms are small waves of progressive aggravation, should be suspected of cervical spondylosis, however, The clearest and most explicit means of identification is mri examination, the most reliable differential diagnosis based on a comprehensive analysis of mri combined with clinical presentation.
High cervical spinal cord extramedullary schwannomas, the early stage of neurofibromatosis is difficult to distinguish from cervical spondylosis, Shan Hongkuan et al reported 7 cases of high cervical spinal cord extramedullary tumors, early diagnosis of cervical spondylosis, and different forms of treatment The self-conscious symptoms have a certain degree of improvement. Among them, 4 cases of X-ray films have degenerative lesions in the cervical spine, which is very confusing with cervical spondylosis. The reason may be that the growth of schwannomas is slow, the cervical spinal canal is relatively wide, and there is a certain reserve gap. Tumors are often associated with 1 or 2 nerve roots. Symptoms of nerve root irritation often occur in the early stage. When the lesion develops further, the spinal cord is involved, and limb paralysis, chest and lumbar tract sensation, or sphincter dysfunction and respiratory disturbance are observed. Sometimes the nerve roots stimulate the symptoms in good and bad, showing a wave-like evolution without the performance of progressive spinal cord compression.
The cervical spinal canal tumor is different from the cervical vertebra disease identification point:
1. Cervical slanting plain film intervertebral foramen enlargement or laminar bone thinning can support the diagnosis of extramedullary schwannomas;
2. Cervical spinal canal angiography, especially through the cerebellar medullary injection angiography is easy to diagnose;
3. MRI examination of the cervical spinal cord: the sagittal plane often shows a long-length t1 and long-t2 weighted signal with clear edges, and a tumor effect with obvious enhancement effect, often accompanied by a tumor center long t1 and a long t2 weighted mixed signal, while the axis The eccentric and crescent-shaped tumor images can be seen and the spinal cord is squeezed to one side. On the t1-weighted image, the tumor signal is weaker than the spinal cord; on the t2-weighted image, the spinal cord signal is slightly stronger than the spinal cord signal;
4. The protein content of cerebrospinal fluid in patients with intraspinal tumors is greater than 2g/l.
Spinal arachnoiditis: The incidence of infection and trauma is rare in patients with cervical vertebrae. The symptoms are fluctuating, diverse and irregular. Myelography is a typical patchy distribution.
Spinal tuberculosis: According to the medical history, clinical manifestations and imaging findings are easy to distinguish between the two.
Syringomyelia: Sudden onset, common in the lower neck and upper thoracic segments of adults aged 20-30 years. Most segments on one or both sides have sensory separation and no motor nerves, no spinal obstruction, mri The examination can be clearly diagnosed and differentiated from intramedullary tumors.
