Spinal Cord Tumor Surgery

Surgery is a daunting experience. However, it can be an important step in the management and treatment of a spinal cord tumor. Although surgery might be necessary for providing an accurate diagnosis, alleviating symptoms, and/or preventing further injury, every operation comes with inherent risks and potential complications. Read on to learn more about surgical treatment for spinal cord tumors.

Surgical procedures can differ slightly depending on the location and type of the spinal cord tumor. Spinal cord tumors are generally classified by their location.

• Intramedullary tumors—grow within the spinal cord. They typically arise from glial cells (cells that nourish the spinal cord and support its function). Most of these tumors are benign. In addition, these tumors occur very rarely; only 5% to 10% of spinal tumors grow directly on the spinal cord. Examples include ependymoma, astrocytoma, hemangioblastoma, and lipoma.
• Intradural-extramedullary tumors—located within the dura, the thin sheath that protects the spinal cord, but outside of the spinal cord itself. Most of these tumors develop on the nerves that branch from the spinal cord to deliver messages throughout the body. Examples include meningioma, schwannoma, neurofibroma, hemangioblastoma, and paraganglioma.
• Extradural tumors—develop outside of the dura and are the most common type of spinal tumor. Most (55%) spinal tumors occur outside of the spinal cord. These lesions are typically caused by either the spread (metastasis) of cancer cells from elsewhere within the body or bone cancer arising from the vertebrae. They can also develop in the blood vessels, cartilage, and tissues that surround and support the spine. 

The approach to spinal tumor treatment also depends on the nature of the tumor. Primary spinal tumors are those that arise from the spine or spinal cord. They are typically benign and slow-growing and don't spread outside their current location.

In contrast, secondary tumors develop because of cancerous cells spreading from elsewhere in the body. Patients with a secondary spinal tumor and metastasis typically have a higher burden of disease and might opt for care that maximizes quality of life rather than length of life.

Surgery can be performed to obtain a diagnosis, relieve symptoms, and prevent progression of spinal cord injury. In some cases, surgical removal of the tumor can provide a cure.

Surgical removal of a piece of tumor tissue for analysis under a microscope (biopsy) can confirm the diagnosis and provide information about the exact tumor type and degree of aggressiveness. Some tumor types are more amenable to complete surgical removal.

Most primary spinal tumors are benign and do not typically spread or invade the surrounding tissues. However, such tumors can compress the spinal cord or associated nerves as they grow. Patients who experience this compression can develop symptoms such as pain, difficulty walking, loss of balance, numbness, tingling, loss of bowel and/or or bladder control, and muscle weakness. Spinal tumor treatment generally aims to alleviate or prevent further progression of these symptoms.

Surgery can provide immediate decompression of the spinal cord, alleviate symptoms, and remove the tumor to prevent further growth and potential spread. This treatment option can be favorable for patients with acute and significant symptoms.

Radiation therapy and/or chemotherapy are other treatment options that can be used in combination with surgery. The best treatment plan is unique to your individual case and should be discussed with your medical team based on the exact diagnosis.

The cost and logistics of surgery can also be a source of concern. Spinal cord tumor surgery is typically covered by insurance, but you should check with your specific insurance plan to obtain an accurate cost estimate.

When scheduling the surgery, anticipate taking several weeks off from work, especially if your job involves heavy lifting or other physically demanding tasks. Having the support of family or friends at home during this recovery period can be invaluable as you heal and regain strength.

Spinal cord tumor surgery involves removal of the bony roof of the spinal canal (laminectomy) and microsurgical removal of the tumor (resection). Depending on the complexity of your case, the surgery could last for several hours or more than 10 hours.

Cervical and lumbar spine tumor surgeries differ in the location of the incision along the back (upper back for cervical, lower back for lumbar). In addition, the surgeries for intramedullary and extramedullary spinal cord tumors differ in whether the spinal cord must be incised to reach the tumor. Despite these variations, the general process of surgery will typically be as follows.

The procedure starts with an incision in the back. In some cases, the procedure might be performed from the front of the body. The length of the incision depends on the number of spinal levels affected by the tumor. Soft tissues such as fat, muscle, and connective tissues are dissected away or pulled (retracted) to the side until the vertebrae are exposed. Then, the bony roof of the spinal canal is removed to reveal the protective dura covering the spinal cord.

If the tumor is outside of the dura (extradural), the tumor will be visible in this space. If the tumor is intradural, the surgeon will make an incision along the dura to expose the spinal cord tumor within it. If the tumor is intramedullary and within the spinal cord tissue itself, another incision will be made along the length of the spinal cord to reach the tumor.

Depending on the location of the tumor, more bone may be removed to provide better surgical access for tumor removal. Once the tumor is reached, it is carefully dissected from the surrounding tissues. Tumor resection can be performed en bloc, which means that the entire tumor is carefully removed as one piece, or in multiple smaller portions.

If extensive bone removal is necessary, the surgeon might decide to perform a spinal fusion to stabilize the spine. This procedure involves placing bone grafts between 2 spinal bones. Metal screws, rods, and/or plates can be used to hold the bones in place while they begin to fuse into a single solid piece. When the tumor is removed and the operation is complete, the dura, muscles, and skin are sewn (sutured) back together.

To minimize bleeding during the operation, the doctor might perform a procedure before the surgery called a preoperative embolization. This procedure involves insertion of a thin flexible tube (catheter) into a blood vessel in the groin that is then advanced upward toward blood vessels that supply the spinal tumor. Once the tube is in place, the doctor injects an embolic agent such as a special glue to block these vessels, which reduces bleeding during the operation and provides better visualization and resection of the tumor.

After surgery, you will likely stay in the hospital for several days. During this time, the treatment team will provide pain medications and closely monitor you for any complications. Initially, you may experience fatigue and discomfort, but over the course of the week, your stamina and energy level should gradually improve.

If any neurologic deficits are observed after surgery, physical therapy might be recommended to aid in the recovery of lost functions. Although you may start feeling almost back to normal within 4 to 6 weeks, it could be necessary to continue with physical therapy for an extended period of time to optimize your recovery.

Regular follow-up appointments and periodic imaging tests will be scheduled to monitor for potential tumor growth. These visits are important for ongoing surveillance and to ensure timely intervention if any concerns arise.

Spine surgery is a major procedure that carries serious potential risks. The spinal cord is approximately 1 cm in its widest diameter and is densely packed with millions of neurons that communicate information between the brain and body. Although the presence of a tumor can disturb this structure, surgical instruments can also cause harm. Complete paralysis is one of the most feared complications of spinal cord tumor surgery. However, this complication is rare, especially with modern tools that can monitor nerve function throughout the procedure (neuromonitoring).

The tumor's location in relation to the spinal cord also determines the likelihood of complications. In general, the closer and stickier the tumor is to the spinal cord or its branching nerve roots, the more challenging tumor removal becomes and the higher the risks associated with the procedure. Thus, surgery to remove an intramedullary tumor located within the spinal cord itself is associated with a higher risk than that for an intradural-extramedullary or extradural spinal cord tumor.

The following complications or side effects can occur in approximately 20% to 30% of patients after surgical removal of a spinal cord tumor.

• Infection: Surgical site infections can develop after spinal cord surgery. These infections can affect the incision site, surrounding tissues, or even deeper structures such as the bone and intervertebral discs. Antibiotics and/or surgical incision and drainage can be used to control the infection.
• Bleeding: Surgery on the spine carries the risk of bleeding, both during the procedure and afterward. Excessive bleeding might require blood transfusions or additional surgical intervention to control the source of the bleeding.
• Blood clots: Surgery and immobilization can increase the risk of developing blood clots, known as deep vein thrombosis. If a blood clot travels to the lungs, it can cause a potentially life-threatening condition called a pulmonary embolism. Depending on the exact situation, medications may be administered or removal of the blood clot (embolectomy) may be performed.
• New or worsening neurologic deficits: Although spinal cord surgery aims to address conditions affecting the spinal cord, there is a potential risk of nerve damage or injury to the spinal cord during the procedure. Such damage can result in neurologic deficits such as sensory abnormalities (numbness, tingling, pain), motor impairment (weakness, paralysis), and bladder dysfunction. Physical therapy can help to improve at least some function over time.
• Cerebrospinal fluid leakage: A leak can occur if the protective covering of the spinal cord (dura mater) is breached during surgery and incompletely repaired, which can lead to complications such as headache, infection, and an abnormal collection of cerebrospinal fluid (pseudomeningocele). If the leak is persistent, a catheter may be placed to drain fluid for several days, or surgical closure may be performed.
• Spinal deformity: Removal of bone to access the tumor during surgery can lead to spinal instability and changes in the curvature of the spine. This deformity could progress and develop years after the surgery; it is reported more commonly in children and in adults whose tumor involved surgery to multiple spinal segments. If severe, repeat surgery may be necessary.
• Failed fusion: After spinal fusion is performed, there is a risk of fusion failure or of a vertebra slipping forward onto the bone below it (pseudoarthrosis). This complication occurs when the bones do not fuse together properly, leading to ongoing instability or the need for revision surgery.
• Instrumentation failure: Spinal surgery can involve the use of implants, such as screws, rods, and/or plates, to stabilize the spine. In some cases, these implants can loosen, break, or shift, requiring further surgical intervention.

Throughout the entire surgical process, extensive measures are taken to prevent complications. One such measure is electrophysiologic monitoring (neuromonitoring), which involves real-time assessment of spinal cord function by monitoring individual nerves and nerve roots. This monitoring enables the surgeon to periodically evaluate nerve integrity and take necessary steps to preserve them during the procedure.

In addition, the likelihood of complications during or after the surgical removal of a spinal cord tumor can be influenced by factors such as the patient's age, medical history, current medications, and overall health status. Therefore, doctors conduct thorough evaluations to assess the patient's condition before recommending any surgical procedure. These evaluations help to minimize risks and optimize patient outcomes.

The objectives of spinal cord surgery generally include complete tumor removal, alleviation of symptoms, and prevention of further tumor and symptom progression. The following factors can influence the likelihood of a positive outcome from and the success rates after spinal cord tumor surgery.

• Tumor type: Certain tumor types, such as ependymomas and hemangioblastomas, often exhibit a distinct tissue plane between the tumor and the spinal cord or nerves, which facilitates easier dissection and complete removal. In contrast, tumors such as astrocytomas and neurofibromas can infiltrate or closely attach to nerves, making it more challenging to extract the entire tumor without damaging surrounding nerve fibers.
• Tumor grade: A higher tumor grade typically indicates a more aggressive tumor. Consequently, high-grade tumors have a higher likelihood of recurring even after surgical removal. Low-grade tumors, however, are typically benign and slow-growing; complete surgical removal of a low-grade or benign tumor can be curative.
• Tumor location: The proximity of the tumor to the spinal cord can affect the difficulty of achieving complete resection. Intramedullary tumors situated near spinal cord fibers are often more challenging to completely remove than are intradural-extramedullary or extradural tumors, which are located outside of the spinal cord.

Specific surgical outcomes vary depending on the tumor’s characteristics, timing of surgery, the presence of other medical conditions, and even the surgeon and institution. In the case of benign extramedullary tumors, such as a meningioma or schwannoma, outcomes are typically favorable, and the neurologic status of most patients improves after surgery. However, in other cases, such as in those with a high-grade intramedullary astrocytoma, surgery might be more challenging, and the overall outcome could be poor.

Once an exact diagnosis of your spinal cord tumor is obtained, discuss the specific outlook and prognosis with your neurosurgeon and medical team. Performing surgery on a spinal cord tumor demands meticulous care and attention to detail. The experience and expertise of the surgeon play a pivotal role in determining your likelihood of a favorable outcome after the procedure. We encourage you to explore our additional chapters for comprehensive guidance on finding a skilled neurosurgeon for your specific case.

• Spinal cord tumor surgery often involves removal of the bony roof of the spinal canal (laminectomy) and microsurgical removal of the tumor
• Complications of spinal cord tumor surgery can occur in 20% to 30% of cases and include infection, bleeding, cerebrospinal fluid leakage, neurologic deficit, blood clots, and spinal deformity
• Success of surgery depends on multiple factors such as tumor type and grade and the surgical skill of your neurosurgeon

• American Association of Neurological Surgeons (AANS): Spinal tumors
• Canadian Cancer Society (CCS): Supportive Care for Brain and Spinal Cord Tumors
• National Cancer Institute: Related organizations
• Cancer Support Community: Brain and spinal cord tumors
• Glioma Foundation Center
• Collaborative Ependymoma Research Network (CERN) Foundation