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13DIAGNOSIS OF SPINAL CORD AND SPINE NEOPLASMS
U. S. Mamedov, Z. R. Soxibova, D. I. Khodjaeva, Sh. N. Erkinova
Bukhara State Medical Institute
ABSTRACT
The article discusses the problem of neuro-oncological lesions of the spine and spinal cord from the point of view of modern neuroimaging. All three groups of these neoplasms were considered: intramedullary (astrocytomas, ependymomas, hemangioblastomas), extramedullary-intradural (neurinomas, meningiomas, subarachnoid metastases, dysembryogenetic tumors), extradural primary spinal tumors, secondary tumors (metastatic tumors, tumors growing into the spinal canal). MRI, including contrast enhancement, is the method of choice for the diagnosis of these lesions, especially intramedullary tumors and spinal canal tumors, allowing the best visualization of not only the neoplasm itself, its solid and cystic parts, but also the adjacent substance of the spinal cord, meninges and subarachnoid space. The possibilities of CT in the diagnosis of intramedullary tumors are limited, CT remains an important method for the diagnosis of extradural, dysembryogenetic and metastatic tumors, often complementing MRI data in relation to the state of bone structures and planning surgical treatment.
Keywords: spinal cord, spine, tumors, CT, MRI.
Spinal cord tumors are relatively rare and make up about 2% of all neoplasms, in the structure of malignant lesions of the central nervous system - 1.4-5%. In adults, the ratio between spinal and intracranial tumors is approximately 1: 4-1:6, the ratio in children is even less - 1:8-1: 20. Primary spinal cord tumors are extremely rare in children. Traditionally, tumors of the spinal cord and spine are divided into three groups:: 1) intramedullary: astrocytomas, ependymomas, hemangioblastomas; 2) extramedullary-intradural: neurinomas, meningiomas, subarachnoid metastases, dysembryogenetic tumors (lipomas, dermoids, epidermoids, teratomas); 3) extradural: primary (spinal tumors), secondary (metastatic tumors, ingrown tumors intervertebral canal). Intramedullary tumors Intramedullary tumors in the total structure of spinal cord tumors account for 10-18%. Mostly (according to some sources - up to 95%) They are represented by glial tumors, among which ependymomas (63-65%) and astrocytomas (24.5-30%) are more common, glioblastomas (7.5%), oligodendrogliomas (3%) and other tumors (2%) are less common. Some prevalence of astrocytomas over ependymomas was noted in children. In adults, astrocytomas are more common in the cervical spineастроцнтомм, and ependymomas are more common at the level of the spinal cord cone and belowэпенднмомм. Ependymoma is the most common
intramedullary tumor, accounting for about 13% of all spinal cord neoplasms and 65% of glial intramedullary neoplasms in adults. In men, ependymomas are slightly more common than in women. In 50-60% of cases, tumors are diagnosed at the level of the cone of the spinal cord and the roots of the horse's tail, followed by the cervical and thoracic parts of the spinal cord. Difference from the neck igrudny at the levels where the tumor causes thickening of the spinal cord, at the level of the cone and roots, it acquires all the properties of an extramedullary formation. Sometimes a tumor in this area can completely fill the spinal canal, reaching a length of 4-8 cm. Ependymomas belong to the category of benign, slow-growing tumors, but they are characterized by an abundant blood supply, which leads to the development of subarachnoid and intracancer hemorrhages. In 45% of cases, ependymomas contain cysts. Slow growth ofependymomas, especially at the level of the roots of the horse's tail, can lead to radiologically visible bone changes (a symptomElsbergDike). EecKornpacTHaflContrast-free computed tomography (CT) is not very informative, because roogeHCHBHyroit is difficult to differentiate isodensive tumor tissue from the spinal cord. With intravenous enhancement, the contrast agent accumulates variably in the tumor. эпeнgнмoмCT-myelography is more informative in the diagnosis ofMuenorpa^uaependymomas. At the same time, none of these methods can reliably distinguish between solid and cystic components of the tumor. эпeнgнмoммMagnetic resonance imaging (MRI) is undoubtedly a more informative method in the diagnosis of ependymoma components. T1-weighted MRI clearly demonstrates fusiform thickening of the spinal cord. When the tumor is located at the level of the roots of the horse's tail, a typically solid structure and isointensity with the brain in this mode are revealed. In T2-weighted images, the manifestations of ependymoma are not specific; its solid part usually has a hyperintensive signal, which, however, is less pronounced compared to the necrotic or cystic components. With intravenous amplification, a rapid and fairly homogeneous increase in the signal intensity from the tumor tissue is notedAstrocytoma is the second most эпeнrцнмoмbIcommon spinal cord tumor after ependymoma in adults, accounting for 20-30% of all intramedullary neoplasms. In adults, the peak occurrence occurs in the 3rd and 4th decades of life. BgeTCKonIn the child population, on the contrary, astrocytomas are observed more often thanependymomas, accounting for up to 4% of all primary tumors of the central nervous system. Up to 75% of astrocytomas are benign and 25% are malignant. In adults, astrocytomas are detected somewhat more often in the thoracic spinal cord than at the cervical level. In children, the tumor is more often localized in the cervical spinal cord. The tumor usually affects several segments of the spinal cord, with a tendency to spread to the entire spinal cord. About a third of astrocytomas contain cysts of various sizes. The possibilities of CT in the diagnosis of astrocytomas are limited. Segmental expansion of the spinal canal may occur, but bone changes астрoцнтoмare not very characteristic of astrocytomas. On CT, the tumor has a
heterogeneous structure. After intravenous injection of contrast agent, there is a nonuniform increase in the density of tumor tissue. CT-myelography more often than conventional CT reveals the presence of a spinal cord tumor by the characteristic thickening of the latter. At MRI in the T1 astrocytoma mode usually they are manifested more by a change in the contours of the spinal cord and its location than by the intensity of the signal. T2 images reveal an increased signal from both the tumor and the surrounding edema. Cystic and necrotic changes in the tumor tissue also have an increased signal in the T2 mode. In most cases, after the introduction of contrast agents for astrocytoma, as a rule, heterogeneous contrast is typical (Fig. 2).In cases of a pronounced increase, the differentiation of the tumor and peritumoral edema improves. Hemangioblastoma (GB) accounts for 1.6 to 4% of all spinal cord tumors, and in about 30% of cases it is one of the manifestations of the diseaseHippel-Lindau. GB occurs at any age, but more often in younger people (about 30 years old). It is usually localized in the spinal cord, affecting the thoracic region in 50% of cases and the cervical region in 40%. Due to the rich vascularization, HD can manifest clinically with signs of subarachnoid hemorrhage. In most cases, intramedullary metastases account for no more than 5% of all CNS metastatic processes. Contrast-enhanced MRI is the method of choice in assessing the state of the spinal cord substance, allowing you to demonstrate multiple foci of metastatic lesion. Extramedullary-intradural tumorsExtramedullary-intradural neoplasms in adults account for 53-68. 5% of all intradural tumors. Of these, neurinomas and meningiomas occur approximately equally - in 30-40% and 25% of cases, respectively. Tumors of other histological nature (angiomas, lipomas, metastases, etc.) are observed much less frequently. In the pediatric population, extramedullary-intradural tumors account for 10-15% of all neoplasms. Spinal cord is a solitary formation, but approximately 20% of patients have multiple lesions (especially with the diseaseHippel-Lindau). In 43-60% of cases, these tumors are combined with cysts, which, as a rule, have a large size and are located around the solid node of the tumor. Spinal angiography reveals a richly vascularized tumor node with large feeding arteries. Therefore, it is advisable to use selective spinal angiography in the diagnosis of hypertension. With contrast-enhanced CT, you can clearly visualize the GB node, where the contrast agent accumulates intensively. MRI usually detects a low-intensity signal from the tumor in T1 mode and an increased signal in T2 mode. Cystic cavities have a close cnHKBopoMor weakly hyperintensive sequin pattern. Mrsign. Additional administration of a contrast agent increases the informative value of the diagnosis, revealing the GB node that intensively accumulates contrast agent Rare pathological
processes affecting the substance of the spinal cord include metastases. Counts
Figure 1. Astrocytoma of the cervical spinal cord.
Of these, the most common are neurinomas, metastasis of primary intracranial tumors, congenital lipomas, and dermoids/epidermoids. Paragangliomas and teratomas are rarely diagnosed. Often diagnosed in adults, meningioma in childhood is practically not found (no more than 3%). For most neoplasms of this localization, a good delineation from the surrounding brain formations is typical. Spinal nerve root tumors neurofibromas and neurinomas (schwannomas) are more often observed in the cervical and thoracic regions, less often in the lumbar region. As a rule, the tumor is encapsulated and well-delimited, sometimes it may contain a cystic component and be combined with neurofibromatosis. Despite the fact that the neuroma is typically located extramedullary-intradural, in 15-25% of cases, the tumor can spread extradural through one or more intervertebral openings, taking on the shape of an hourglass. In neurofibromatosis, such tumors are usually multiple in nature.
The growth of neurinoma is accompanied by the development of typical bone changes, well defined by conventional spondylography. CT is significantly more informative than X-ray imaging in demonstrating the tumor itself and associated bone changes. Most neurinomas on T1-weighted MRI have a rounded shape, clear contours; the signal intensity from them does not differ much from the reflection of spinal cord tissue. The latter is pressed and pressed against the opposite wall of the spinal canal. On T0M0rpaMMaxT2 scans, neurinomas are usually hyperintensive compared to the spinal cord. Neurofibromas are more characterized by hypo-and low-intensity manifestations in relation to the spinal cord on T1 and T2-weighted MRI. The use of contrast enhancement significantly improves visualization of the size, internal structure, and extent of the tumor, both intraduraland paravertebral. A meningioma is a benign, slow-growing tumor that is primarily located intradurally, but can be purely extradural or extraintradural. Most often, meningiomas are localized in the thoracic spine. Most of them have an elongated shape and, unlike neurinomas, can be located on any surface of the spinal canal. The average age of patients is over 50 years, and women predominate among patients (80%). The tumor has a typically solid structure. Contrast-enhanced CT scans detect high-density tumors and show secondary bone hyperostosis and
calcifications in the meningioma stroma better than other methodsменингиомы. Just like spinal nerve tumors, meningiomas in most cases on T1-weighted MRI are isointensive compared to spinal cord tissue and are detected against the background of a low signal from the surrounding CSF. On T2 tomograms в режиме Т2 , meningiomas can have a variable signal from hypo- to hyperintensive. The introduction of contrast agents helps to improve the quality of diagnosis of meningiomas. The amplification of the MR signal from the tumor is intense and homogeneous. ВрядеМ the order of cases, you can visualize the dural attachment of the tumorMetastatic tumors usually originate from primary malignant intracranial tumors, such as medulloblastoma, and less often-anaplastic ependymoma, glioblastoma. Metastasis of ependymoma, pinealoma and papilloma of the vascular plexus occurs. Tumor cells spread through the subarachnoid space of the spinal cord with the flow of CSF. Damage to the spinal cord membranes is usually multiple in nature. In adults, intradural metastasis can occur in melanoma, lung cancer, breast cancer, and leukemia. Diagnosis of metastatic spinal cord lesion using MRI without contrast is possible mainly with the size of tumor nodes of 5 mm or more. Detection of smaller tumors is significantly difficult due to CSF pulsation, their isointensity with the brain in T1 mode, and hyperintensity in T2 mode. The greatest information in these cases is obtained on T1-weighted MRI on the background of contrast amplification. Dembryogenetic tumors (lipomas, dermoids, epidermoids, teratomas) account for less than 2% of all spinal cord tumors and are more often located in the lumbar spine. The embryonic origin of these neoplasms causes a frequent combination of the tumor with other congenital malformations of the spine and spinal cord. Among them, lipomas are characterized by the most typical MR manifestations -high signal intensity and globular mass structure in T1-weighted images (a smaller increase in intensity in the T2 mode), which, as a rule, are combined ссиндромомwith spinal cord tension syndrome and other spinal malformations. Dermoids, epidermoids, and teratomas have variable CT and MRI manifestations that reflect the predominant structure of the tumor.
Extradural tumors Features of extradural tumors in comparison with subdural ones are their histogenetic diversity, large size, prevalence of malignant forms, and pronounced structural changes in the vertebrae. According to some reports, extradural neoplasms account for up to 32% of all extramedullary tumors. They are divided into primary, arising from the tissues of the spine itself, and secondary (metastatic). At the same time, the latter make up the majority of extradural neoplasms and occur 3-4 times more often than primary spinal lesions. Separately, tumors that grow into the intervertebral canal are also isolated.
Primary extradural tumorsHemangioma belongs to the group of benign vascular tumors of the spine. According to autopsy data, its frequency ranges from 8.9 to 12.5%, and the percentage of clinically detected cases is much lower. According to the literature, in
66% of cases, tumors are solitary formations, and in 34% - multiple. In most cases, the thoracic spine is affected (60%), followed by the lumbar spine (29%) and verco -cervicalcalf (11%). Spondylography reveals a typical vertical striation of the body of the affected vertebra (due to thickening of the bone trabeculae). It is the thickened trabeculae that create the characteristic spotting of the vertebral body on axial CT scans. MRI is an extremely sensitive method for identifying hemangiomas, which are characterized by an increased signal in T1 and T2 modes and rounded contours. Osteochondroma is one of the most common bone tumors (up to 35.8%). It is localized in the spine in 3-7% of cases. The tumor is almost always detected in the projection of the posterior elements of the vertebra with a favorite lesion of the spinous process, usually in the thoracic and lumbar spine. Moreover, in 75% of cases, tumors are diagnosed in patients younger than 20 years. On survey radiographs, the tumor has the appearance of a formation on the pedicle or on its base with a cortical layer passing into the cortex of the surrounding bone. CT scans more accurately determine the extent of the tumor, the presence of a cartilage border (or inclusions), and its concomitant effect on the spinal canal. MRI reveals a heterogeneous structure with an increased MR signal from the cartilage component and a reduced signal from the calcified and ossified parts of the neoplasm. MRI shows the degree of spinal canal compression more clearly than CT scans. Osteoidosteoma accounts for 11-12% of all benign bone tumors, the frequency of localization in the spine is up to 10% of other localizations of this tumor. Most often, the posterior elements of the vertebra are affected, usually the lumbar (60%) and cervical (27%) spine. As a rule, the tumor has the appearance of an X-ray transparent node with possible small inclusions of calcium salts. CT scans reveal a zone of reduced density of small size and rounded shape with or without calcified areas. On MRI, the tumor has a heterogeneous structure. Petrifications in the stroma of the neoplasm and sclerosis of the surrounding bone appear dark in all scanning modes, while the uncalcified part is bright in T2 mode. Osteoblastoma is a rare benign tumor that makes up no more than 1% of all primary bone neoplasms. Although the tumor can affect any bone, it is estimated that its frequency within the spine reaches 50% of all cases. On radiographs and axial CT scans, osteoblastoma tends to grow expansively with thinning of the surrounding cortical bone layer. The tumor may have an X-ray transparent or ossified center and be combined with a pronounced sclerotic reaction of the surrounding bone. The boundaries of the tumor are always distinct. CT and MRI can additionally detect MflraoTKaHHtra soft-tissue paravertebral a component of the tumor. On T2-weighted MRIs, the tumor usually has an elevated MR signal surrounded by a thin rim of low signal (thinned cortical part of the bone). The heterogeneity of the internal structure is caused by bone trabeculae, hemorrhages, and petrifications (Figure 7). Osteoblastomas are characterized by heterogeneous contrast enhancement during MRI. The chordoma develops from the remnants of the notochord, from which
vertebrae and intervertebral discs are formed. In the structure of primary bone tumors, it is 4%. In 50% of cases, the chordoma is localized in the sacrum, in 35% - in the stingray, and only in 15-20% - in the vertebral bodies. Radiography in 50-70% of cases shows areas of bone destruction with amorphous petrifications. Additionally, the paravertebral component of the tumor can be determined. CT better demonstrates the volume of destruction and the internal structure of the chordoma. MRI, in contrast to CT, is less informative in assessing the area of bone destruction. At the same time, MRI better determines the prevalence of the lesion in general and for the epidural tissue in particular.
Secondary extradural tumorsKSecondary spinal tumors include metastases from other organs and tumors that grow into the spinal canal from paravertebral tissues (neuroblastoma, ganglioneuroblastoma). Metastatic tumors are one of the most common forms of tumors of the skeleton in general and the spine in particular. At the same time, the spine ranks second after the brain in terms of localization of metastatic damage to the central nervous system. According to autopsy data, tumors that metastasize tothe vertebral column can be distributed in the following order: myeloma, breast and lung cancer, prostate and stomach cancer, lymphoma, melanoma, malignant neoplasms of the bladder and kidneys, thyroid and pancreas, and some other organs. The average age of patients is about 60 years. The thoracic spine is a favorite site of metastasis localization (up to 68% of cases). There is a definite correlation between the initial growth of the primary tumor and the localization of vertebral metastases. So, tumors of the gastrointestinal tract often metastasize to the lumbosacral region, and breast tumors - to the thoracic spine. CKpHHHHroBoroRadionudide examination of the bone system should be considered one of the best methods of screening for suspected metastasespagnoHyKnngHoe. Among radioisotope methods, positron emission tomography of the whole body has recently become increasingly popular for searching for both the primary focus and the multiplicity of lesions. Spondylography reveals the lesion, as a rule, already in the late stages. The X-ray picture depends on the type of tumor growth: most often it is a destructive, osteolytic lesion of the vertebra, less often-osteoplastic changes (for example, with prostate metastases). A more informative diagnostic method is CT. It is especially useful in detecting the volume and prevalence of osteolytic lesions of vertebral elements, demonstrating the destruction of the cortical surface and the spread of the process through the epidural space or into the paravertebral tissues. It should be noted that the intervertebral disc in metastatic lesions, as a rule, is not involved in the pathological process. After intravenous contrast, the metastasis density increases according to CT data, which helps to better assess the degree of invasion of paravertebral tissues and epidural tissue. MRI is an extremely sensitive method for detecting metastases in the spine and epidural space. Multiple spinal lesions are a characteristic sign of metastasis. Differential diagnosis in the case of detection of a
single tumor node in the vertebral body presents a certain difficulty. MR manifestations of most vertebral metastases are non-specific and usually indistinguishable from primary spinal tumors. Metastatic vertebral lesions are characterized by a decrease in the signal relative to the adipose tissue of the vertebral bone marrow in the T1 mode. On T2-weighted images, such lesions show a different degree of signal change from hypo-to hyperintensive. The spread of the process through the epidural tissue and paravertebral tissues is well demonstrated by MRI ткани.
Neuroblastoma is a tumor that develops from primitive neuroblast cells. The latter are embryologically involved in the formation of the adrenal medulla and paravertebral parasympathetic ganglia. Most often, the tumor is diagnosed in childhood. Due to the characteristic spread of the tumor into the spinal canal through the intervertebral openingsспондилограммах, their expansion is determined on spondylograms. Additionally, erosion of the arch, excavation of the vertebral body and expansion of the spinal canal are detected. Axial CT scans and especially frontal MRI clearly visualize the large paravertebral component of the tumor with its typical finger-like spread into the spinal canal at several levels. MRI better demonstrates invasion of the epidural space and compression of the spinal cord. CT and MRI characteristics of the neoplasm depend on the intracancer components (petrifications, hemorrhages of various ages, cysts).
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