Treatment of Spinal Cord Tumors

Spinal cord tumors are a diverse group of neoplasms (abnormal growths) that can significantly affect a person’s neurological function and overall quality of life. Surgical intervention remains the cornerstone in spinal cord tumor management, which aims to achieve a delicate balance between tumor removal (resection) and preservation of neurological function. Radiotherapy also plays a crucial role in the management of spinal cord tumors, whereas chemotherapy has a limited role.

Understanding the types of spinal cord tumor based on their location helps guide treatment decisions and surgical approaches. These tumors can be classified broadly as being intramedullary, intradural-extramedullary, and extradural on the basis of their location relative to the spinal cord and its protective coverings.

The aim of surgery for a spinal cord tumor is primarily to achieve the best possible outcome for the patient, balancing the need for tumor removal while preserving neurological function. The overarching goals typically include the following.

• Tumor removal: The primary goal of surgery is to remove as much of the tumor as is safely possible. Complete or partial removal of the tumor can help alleviate pressure on the spinal cord and surrounding structures and reduce symptoms such as pain, weakness, and sensory changes.
• Neurological preservation: Preserving neurological function is of utmost importance. Surgeons strive to avoid damaging the spinal cord during tumor removal. Achieving this goal involves careful planning, skillful techniques, and often intraoperative monitoring to ensure preservation of the patient's sensory, motor, and autonomic functions.
• Symptom relief: Spinal cord tumors can cause various neurological symptoms, including pain, numbness, weakness, and difficulties with movement and coordination. The surgeon aims to relieve these symptoms by removing the tumor and thus reducing pressure on its surrounding neural structures.
• Biopsy and diagnosis: When complete removal is not feasible, surgery might involve taking a small sample (biopsy) of the tumor for diagnosis. Knowing the tumor type is crucial for determining further treatment strategies.
• Facilitating adjuvant therapies: After surgery, patients might require additional treatments such as radiation therapy or chemotherapy. Surgery can create a better environment for these therapies to work by reducing the tumor burden.

The diverse nature of spinal cord tumors calls for a tailored approach to their surgical removal. The exact steps of the surgery will depend on the type, size, and location of your tumor and the extent of invasion. The following is a general outline.

• Incision—The surgeon makes an incision in the back or neck over the area where the tumor is located. The size and location of this incision depend on the specifics of the tumor.
• Exposing the spinal cord—The surgeon gently moves muscles and other tissue aside and often removes bony parts of the spine to expose the spinal cord and the tumor.
• Microscopic exploration—A special microscope is used to see the area with high magnification, which enables the surgeon to work with precision and delicacy.
• Tumor removal—Using fine instruments, the surgeon carefully removes the tumor. The goal is to remove as much of it as safely as possible while avoiding damage to the spinal cord and surrounding nerves. For intramedullary tumors, delicate dissection within the spinal cord tissue might be necessary. For intradural-extramedullary and extradural tumors, the surgeon works to separate the tumor from the surrounding structures, such as the spinal cord or the dura mater.
• Neuromonitoring—Throughout the surgery, the surgical team monitors neurological function using techniques such as somatosensory evoked potentials and motor evoked potentials, which helps to ensure the health of the spinal cord and nerves during the procedure.
• Closure—Once the tumor is removed, the surgeon closes the area using stitches or staples and might use special materials to promote healing and minimize scarring.

After you wake up and your vital signs are stable, you'll be transferred to a hospital room. You'll receive pain management, and the medical team will monitor your recovery. Physical therapy might be initiated over the next few days to help you regain mobility and strength.

Spinal cord tumor surgery is a complex and delicate procedure that aims to remove the tumor while preserving neurological function. The specific steps can vary based on individual factors, and your surgical team will make decisions in your best interest. Open communication with your medical team, asking questions, and following postoperative instructions are all important aspects of a successful surgical experience and recovery.

Spinal cord tumor surgery is a complex procedure that carries potential risks and complications, like any major surgical intervention. It's important to note that although these complications are possible, they do not occur in every case. The risks can vary based on factors such as the type of tumor, its location, the patient's overall health, and the skill of the surgical team. The following are some potential complications.

• Neurological deficits—Deficits are a significant concern with spinal cord surgery. Despite careful planning and monitoring, there is a risk of damage to the spinal cord, which could lead to new or worsened neurological deficits. Such deficits can include weakness, sensory changes, difficulty walking, or loss of bladder or bowel control.
• Infection—Surgical procedures carry a risk of infection at the incision site or deeper in the surgical area. Infections can cause pain, swelling, and fever and might require additional treatment, such as antibiotics or drainage.
• Bleeding—Bleeding can occur during or after surgery. Although surgical techniques are designed to control bleeding, excessive bleeding might require further intervention, such as another surgery or a blood transfusion.
• Cerebrospinal fluid (CSF) leak—The CSF that surrounds the spinal cord might leak out of the incision site after surgery, which can lead to headaches, infections, or the need for additional procedures to repair the leak.
• Nerve root injury—During surgery, nerve roots exiting the spinal cord might be inadvertently damaged, which can lead to pain, sensory changes, or muscle weakness.
• Spinal deformity—Removal of bone to expose the tumor during surgery can lead to spinal instability and changes in the curvature of the spine, usually years after surgery.
• Instrumentation failure—Spinal surgeries can involve the use of implants, such as screws, rods, or plates, to stabilize the spine. In some cases, these implants can loosen, break, or shift and require further surgical intervention.
• Scar tissue formation—Scar tissue can develop around the surgical site or on the spinal cord itself. Excessive scar tissue can lead to nerve compression and neurological symptoms.
• Recurrence—Incomplete removal of the tumor or an aggressive tumor type could lead to tumor regrowth, necessitating further treatment.
• Longer-term pain—Some patients can experience chronic pain after surgery as a result of nerve damage, scar tissue, or changes in the spinal anatomy.
• Impaired healing—Factors such as age, overall health, and the presence of other medical conditions can influence the healing process.

It is crucial to discuss potential complications before surgery with your neurosurgeon, who will provide you with information about the specific risks relevant to your case and answer any questions you might have. The surgeon will work diligently to minimize these risks and provide the best possible care to ensure a successful outcome.

The outcomes of surgery to remove a spinal cord tumor can vary widely depending on factors such as the type and location of the tumor, the patient's overall health, the extent of the surgery, and the skill of the surgical team. Having realistic expectations about the outcomes is important. Your medical team will provide you personalized information about what to expect based on your specific case. Open communication with your health care providers and active participation in your recovery plan can contribute to achieving the most favorable outcome possible.

The role of radiotherapy in the treatment of spinal cord tumors is significant and multifaceted. Also known as radiation therapy, it plays a crucial role in managing spinal cord tumors by using focused radiation to target and destroy tumor cells. Its role can vary depending on the type of tumor, its location, the patient's overall health, and the treatment plan devised by the medical team. The following are the key roles that radiotherapy plays in the treatment of spinal cord tumors.

• Adjuvant (accessory) therapy—After surgical removal of a spinal cord tumor, residual tumor cells might be left behind. Radiotherapy serves as an adjuvant therapy that targets the remaining tumor cells to inhibit growth and reduce the risk of tumor recurrence.
• Primary treatment—When surgery is not feasible because of the tumor's location or the patient's health, radiotherapy can be used as the primary treatment method. It aims to control the tumor's growth, prevent additional damage to the spinal cord, and improve the patient's quality of life.
• Presurgical treatment—Radiotherapy can be administered before surgery to shrink the tumor, which makes it more manageable for surgical removal. This approach can improve the success of surgery and minimize potential damage to the spinal cord during tumor removal.
• Palliative care—For a tumor that is inoperable or has reached an advanced stage, radiotherapy can be used to provide palliative care. Palliative radiotherapy aims to alleviate pain, improve symptoms, and enhance the patient's comfort and quality of life.
• Combination therapy—Radiotherapy can be combined with other treatments such as chemotherapy or a targeted therapy. This combination approach aims to enhance the treatment's effectiveness by attacking the tumor from multiple angles.
• Recurrent tumors—If a spinal cord tumor reappears after initial treatment, radiotherapy can be used as a salvage therapy to control tumor growth and manage symptoms.

Radiotherapy can be administered through various modalities, each tailored to the specific characteristics of the tumor, its location, and the patient's overall health. These modalities ensure that the radiation is effectively delivered to the tumor while minimizing damage to surrounding healthy tissues. The following are the primary modalities of radiotherapy.

• External beam radiotherapy (EBRT)—the most common form of radiotherapy. It involves delivering radiation from a machine outside the body. Different techniques are used to target the tumor precisely, including the following.
  • 3D conformal radiotherapy (3D-CRT)—shapes the radiation beams to match the tumor's shape, minimizing exposure to healthy tissue
  • Intensity-modulated radiation therapy (IMRT)—uses computer-controlled beams that vary in intensity, enabling precise sculpting of the radiation dose around complex tumor shapes
  • Volumetric modulated arc therapy (VMAT)—an advanced form of IMRT; the machine rotates around the patient, delivering radiation in continuous arcs while adjusting beam intensity
• Stereotactic radiosurgery (SRS)/stereotactic body radiation therapy (SBRT)—can deliver high doses of radiation with extreme accuracy and is used for small, well-defined tumors; often involves just one or a few treatment sessions. SRS is typically used for tumors in the brain or spinal cord, whereas SBRT extends the technique to tumors in other parts of the body.
• Proton therapy—uses protons (charged particles) instead of x-rays to deliver radiation. Protons can be controlled to stop at a specific depth within the body, minimizing damage to healthy tissues beyond the tumor. This precision is especially beneficial for tumors near critical structures.

Radiotherapy for spinal cord tumors can have both short-term and long-term adverse effects. The specific adverse effects experienced can vary on the basis of factors such as the type and dose of radiotherapy, the location of the tumor, the patient's overall health, and individual sensitivity. It's important to note that not all patients will experience the same adverse effects, and some might experience none at all.

Short-term adverse effects

• Fatigue
• Skin reactions
• Nausea and digestive issues

Long-term adverse effects

• Nerve damage
• Spinal cord damage
• Bone fractures
• Late-onset radiation scarring
• Secondary cancers

It is very important to communicate any adverse effects to your health care team so that they can provide guidance and support in managing these effects. Before starting treatment, your medical team will discuss potential adverse effects with you and provide strategies to minimize them. Regular follow-up appointments after treatment allow your health care providers to monitor your progress and address any long-term effects that may arise.

Chemotherapy can play a limited role in the treatment of a spinal cord tumor, depending on various factors, including the type of tumor, its location, the extent of the disease, and the overall health of the patient.

Chemotherapy is used more commonly for tumors that originate from other parts of the body but have spread to the spinal region. In these cases, chemotherapy can be used to target cancer cells throughout the body, including those in the spinal cord area. Chemotherapy might also be considered if the tumor cannot be surgically removed (unresectable) or if radiotherapy alone is not sufficient.

It should be noted that chemotherapy has its own set of potential adverse effects, including nausea, fatigue, hair loss, and a weakened immune system. In addition, because the spinal cord is a delicate and crucial part of the nervous system, the use of chemotherapy for a spinal cord tumor must be approached with caution to avoid damaging healthy nerve tissue.

Observation, also known as watchful waiting, is a strategy used in the management of certain spinal cord tumors, particularly when the tumor is low grade, slow-growing, and not causing significant symptoms or complications. Observation involves closely monitoring the tumor's behavior and growth over time without immediately intervening with surgery, radiotherapy, or other treatments. This approach is typically considered when the potential risks and adverse effects of treatment might outweigh the benefits, given the tumor's characteristics and the patient's overall health.

Observation could be considered in the following scenarios.

• Low-grade tumors—Low-grade tumors are less aggressive and tend to grow more slowly. In these cases, especially when the tumor is not causing significant symptoms or affecting the patient's quality of life, observation might be a reasonable approach.
• Elderly or frail patients—For elderly patients or those with significant coexisting health conditions (comorbidities), the risks associated with surgical intervention or aggressive treatment might outweigh the potential benefits. Observation can be a suitable choice to avoid unnecessary stress on the patient.
• Asymptomatic tumors—If the tumor is not causing symptoms or neurological deficits, and imaging indicates minimal growth, observation might be chosen to avoid the potential risks and complications associated with treatment.
• Risk of treatment outweighs benefits—In some cases, the risks of surgery or radiotherapy might be particularly high because of the tumor's location or the patient's health status. If the potential benefits of treatment are limited, observation might be a more prudent approach.

During the observation period, regular imaging (such as MRI) is done to track the tumor's growth and any changes. The frequency of these scans depends on the tumor's characteristics and the medical team's recommendations.

The decision to transition from observation to active treatment is based on careful monitoring and specific criteria set by the medical team. If the tumor starts growing rapidly, causing symptoms, or posing a higher risk, treatment options might be reevaluated.

The choice to opt for observation should involve a comprehensive discussion. The potential benefits and risks of observation, as well as the possibility of future interventions, should be explored thoroughly to make an informed decision.

• Surgery is the cornerstone of treatment for spinal cord tumors
• The exact surgical technique used will depend on the tumor size and location
• The ultimate goal of surgery is to remove as much of the tumor as possible while trying to protect the healthy spinal cord
• Radiotherapy is used as an adjunct to surgery to destroy any residual tumor cells
• Chemotherapy is rarely used for spinal cord tumors; it is usually enlisted as a last-ditch effort

• American Association of Neurological Surgeons (AANS): Spinal tumors
• National Cancer Institute: Related organizations
• Cancer Support Community: Brain and spinal cord tumors
• Glioma Foundation Center
• Collaborative Ependymoma Research Network (CERN) Foundation