Spinal Cord Tumors

By: Divine Incillo

Shiela Marie Lara
OVERVIEW OF THE SYSTEM
Spinal Cord
- the cylindrical spinal cord, which is
approximately 17 inches (42cm long), is a
glistening white continuation of the brain
stem.
- like the brain, the spinal cord is
cushioned and protected by meninges

Function
- the spinal cord provides a two way
conduction pathway to and from the brain,
and it is a major reflex center.
The spine is made up of:

vertebrae, sacrum and coccyx bony sections that
house and protect the spinal cord (commonly called the
spine)

The vertebral body is the biggest part of a vertebra. It is
the front part of the vertebra, which means it faces into
the body.

spinal cord a column of nerves inside the protective
vertebrae that runs from the brain to the bottom of the
spine
disc a layer of cartilage between each vertebra that
cushions and protects the vertebrae and spinal cord
The Spine is divided into 5 sections
cervical the vertebrae from the base of the skull to the lowest
part of the neck

thoracic the vertebrae from the shoulders to mid-back

lumbar the vertebrae from mid-back to the hips

sacrum the vertebrae at the base of the spine
- The vertebrae in this section are fused and do not flex.

coccyx the tail bone at the end of the spine
- The vertebrae in this section are fused and do not flex.


The Spinal Nerves
The spine relays messages between the body and the
brain. These nerve messages control body functions like
movement, bladder and bowel control and breathing.
Each vertebra has a pair of spinal nerves that receive
messages from the body (sensory impulses) and send
messages to the body (motor impulses). The spinal
nerves are numbered from the cervical spine to the
sacral spine.

Number Part of Spine Function
C1 to C8
(8 pairs)
cervical
send messages to the back of the head, neck,
shoulders, arms, hands and diaphragm
T1 to T12
(12 pairs)
thoracic
send messages to the chest, some back muscles and
parts of the abdomen
L1 to L5
(5 pairs
lumbar
send messages to the lower parts of the abdomen
and the back, some of the legs and some parts of
the external genital organs
S1 to S5
(5 pairs)
sacral
send messages to the thighs, lower parts of the legs,
feet, most of the external genital organs, the groin
area, the bladder and the anal sphincter.
Spinal Cord Tumours
A spinal tumor is a cancerous (malignant) or
noncancerous (benign) growth that develops within or
near the spinal cord or within the bones of the spine.
Spinal cord tumours are classified based on their grade.
The gradtumour tells you how quickly it is growing and
how likely it is to spread.

Low-grade, or benign, tumours grow slowly. They dont
usually grow into surrounding tissues or spread to other
areas of the brain. Some low-grade tumours may
develop into high-grade tumours.

High-grade, or malignant, tumours grow quickly. They
can grow into nearby tissues and spread to other parts of
the brain or spinal cord. Malignant tumours that start in
the brain and spinal cord rarely spread outside the CNS.

Types of spinal tumors

Spinal tumors are classified according to their location in the spine.

Extradural (vertebral) tumors. Most tumors that affect the vertebrae have spread
(metastasized) to the spine from another site in the body often the prostate,
breast, lung or kidney. Although the original (primary) cancer is usually diagnosed
before back problems develop, back pain may be the first symptom of disease in
people with metastatic spinal tumors.

Cancerous tumors that begin in the bones of the spine are far less common.
Among these are osteosarcomas (osteogenic sarcomas) and Ewing's sarcoma, a
particularly aggressive tumor that affects young adults. Multiple myeloma is a
cancerous disease of the bone marrow the spongy inner part of the bone that
makes blood cells. Noncancerous tumors, such as osteoid osteomas,
osteoblastomas and hemangiomas, also can develop in the bones of the spine.

Intradural-extramedullary tumors. These tumors develop in the spinal cord's
arachnoid membrane (meningiomas) and in the nerve roots that extend out from the
spinal cord (schwannomas and neurofibromas). These tumors may be cancerous or
noncancerous.

Intramedullary tumors. These tumors begin in the supporting cells within the spinal
cord. Most are either astrocytomas or ependymomas. Intramedullary tumors can be
either noncancerous or cancerous. In rare cases, tumors from other parts of the body
can metastasize to the spinal cord itself.
As it grows, the tumor can affect the:

Blood vessels
Bones of the spine
Meninges
Nerve roots
Spinal cord cells


Metastatic spinal tumors

The spinal column is the most common site for bone metastasis.
Estimates indicate that at least 30 percent and as high as 70 percent
of patients with cancer will experience spread of cancer to their
spine.

RISK FACTORS
1. Inherited conditions
- An inherited, or genetic, condition is passed from parents to their children through
genes. People with the following inherited conditions have a higher risk of developing
brain and spinal cord tumours:

2. Neurofibromatosis
- Neurofibromatosis (NF) affects the nerves, muscles, bones and skin. Both
neurofibromatosis type 1 (von Recklinghausen disease, or NF1) and
neurofibromatosis type 2 (acoustic neuroma, or NF2) increase the risk for brain and
spinal cord cancer. But these cancers occur more often in people with NF1. Some
research shows that brain and spinal tumours caused by NF2 tend to be slow-
growing and non-cancerous.

3. Von Hippel-Lindau syndrome
- Von Hippel-Lindau (VHL) syndrome is rare. It makes blood vessels grow into knots
called angiomas. These knots occur in parts of the body that are rich in blood
vessels, such as the brain, spinal cord and adrenal glands.

4. Li-Fraumeni syndrome
- Li-Fraumeni syndrome increases the risk of developing a number of different types
of cancer, including brain tumours

5. Tuberous sclerosis
- Tuberous sclerosis is also called Bournevilles disease. It causes non-cancerous
tumours to develop in the brain and spinal cord, skin, heart or kidneys.

6. Turcot syndrome
- Turcot syndrome causes multiple growths, called polyps, in the colon. It also causes
tumours of the brain and spinal cord.

7. Basal cell nevus syndrome
- Basal cell nevus syndrome is also called Gorlin syndrome or nevoid basal cell
carcinoma syndrome. It causes problems with several organs and increases the risk
of developing different types of tumours, including brain and spinal cord tumours.

8. Cowden syndrome
- Cowden syndrome causes many hamartomas to develop in the skin, breast, thyroid,
colon, small intestine and mouth. Hamartomas are non-cancerous tumour-like
nodules, or lumps.

9. Weakened immune system
- The immune system is a complex group of cells and organs that defends your body
against infection, disease and foreign substances. When the immune system isnt
working well, you are at greater risk for primary central nervous system lymphoma
(PCNSL). People at high risk include those who:

take drugs to suppress their immune system after an organ transplant
have treatment, such as chemotherapy, that suppresses their immune system to
treat other cancers
have HIV or AIDS







The following are also unknown risk factors
for brain and spinal cord cancer:

exposure to electromagnetic fields
infections that weaken the immune system (for example, infection with Epstein-
Barr virus or human cytomegalovirus)
trauma to the head
medical conditions including epilepsy, multiple sclerosis and stroke
breast cancer
smoking and environmental tobacco smoke
diet (for example, eating cured meats or taking too many vitamin supplements)
contaminants in drinking water (for example, nitrite, chlorine or disinfection by-
products)
hair dye
tall adult height


SIGNS AND SYMPTOMS
The signs and symptoms of spinal cord tumours depend on how fast
the tumour is growing and the area of the spinal cord affected.

Slow-growing tumours have few signs and symptoms at first
because the spinal cord adjusts to the size of the tumour.

Fast-growing tumours cause signs and symptoms early because
the spinal cord cannot adjust to the sudden increase in the size of
the tumour.

Symptoms may include:

Abnormal sensations or loss of sensation:
Especially in the legs (may be in the knee or ankle, with or without shooting
pain down the leg)
Cold sensation of the legs, cool fingers or hands, or coolness of other areas
Back pain:
Gets worse over time
In any area -- middle or low back are most common
Is usually severe and not relieved by pain medication
Is worse when lying down
s worse with strain, cough, sneeze
May extend to the hip, leg, or feet (or arms), or all extremities
Fecal incontinence
Inability to keep from leaking urine (urinary incontinence)
Muscle contractions, twitches, or spasms (fasciculations)
Muscle function loss
Muscle weakness (decreased muscle strength not due to exercise):
Causes falls
Especially in the legs
Makes walking difficult
May get worse (progressive)
Tests and diagnosis
Spinal magnetic resonance imaging (MRI). MRI uses a
powerful magnet and radio waves to produce images of
your spine. MRI accurately shows the spinal cord and
nerves and yields better pictures of bone tumors than
computerized tomography (CT) scans do. A contrast
agent that helps to highlight certain tissues and
structures may be injected into a vein in your hand or
forearm during the test.
Computerized tomography (CT). This test uses a narrow
beam of radiation to produce detailed images of your
spine. Sometimes it may be combined with an injected
contrast dye to make abnormal changes in the spinal
canal or spinal cord easier to see.

Myelogram. In this test, a contrast dye is injected into
your spinal column. The dye then circulates around your
spinal cord and spinal nerves, making them easier to see
on an X-ray or CT scan. Because the test poses more
risks than does an MRI or conventional CT, a myelogram
is usually not the first choice for diagnosis. However, it
may be used to help identify compressed nerves and for
those who can't have an MRI.
Biopsy. The only way to determine whether a tumor is
noncancerous or cancerous is to examine a small tissue
sample (biopsy) under a microscope. If the tumor is
cancerous, biopsy also helps determine the cancer's
grade information that helps determine treatment
options. Grade 1 cancers are generally the least
aggressive, and grade 4 cancers, the most aggressive.
How the sample is obtained depends on your overall
health and the location of the tumor. Your doctor may
use a fine needle to withdraw a small amount of tissue,
or the sample may be obtained during surgery.
TREATMENT
Monitoring. Some spinal tumors may be discovered before they cause symptoms
often when you're being evaluated for another condition. If small tumors are
noncancerous and aren't growing or pressing on surrounding tissues, watching them
carefully may be all that's needed. This is especially true in older adults for whom
surgery or radiation therapy may pose special risks. If you decide not to receive
treatment for a spinal tumor, your doctor will likely recommend periodic scans to
monitor the tumor.

Surgery. This is often the treatment of choice for tumors that can be removed with an
acceptable risk of nerve damage. Newer techniques and instruments allow
neurosurgeons to reach tumors that were once considered inaccessible. The high-
powered microscopes used in microsurgery make it easier to distinguish tumor from
healthy tissue. Doctors also can test different nerves during surgery with electrodes,
thus minimizing nerve damage. In some instances, they may use sound waves to
break up tumors and remove the fragments. However, even with advances in
treatment, not all tumors can be removed completely.

When the tumor can't be removed completely, surgery may be combined with
chemotherapy or radiation therapy.

Recovery from spinal surgery may take weeks or longer, depending on the
procedure, and you may experience a temporary loss of sensation or other
complications, including bleeding and damage to nerve tissue.
Standard radiation therapy. This may be used following an
operation to eliminate the remnants of tumors that can't be
completely removed or to treat inoperable tumors. It also may be the
first line therapy for metastatic tumors. Radiation may also be used
to relieve pain or when surgery poses too great a risk.

Stereotactic radiosurgery (SRS). This newer method of delivering
radiation is capable of delivering a high dose of precisely targeted
radiation. In SRS, doctors use computers to focus radiation beams
on tumors with pinpoint accuracy and from multiple angles. This
approach has proved effective in the treatment of brain tumors, and
research is now under way to determine the best technique,
radiation dose and schedule for SRS in the treatment of spinal
tumors.
Chemotherapy. A standard treatment for many types of cancer,
chemotherapy uses medications to destroy cancer cells or stop
them from growing. Your doctor can determine whether
chemotherapy might be beneficial for you, either alone or in
combination with radiation therapy. Side effects may include fatigue,
nausea, vomiting, increased risk of infection and hair loss.

Other drugs. Because surgery and radiation therapy as well as
tumors themselves can cause inflammation inside the spinal cord,
doctors sometimes prescribe corticosteroids to reduce the swelling,
either following surgery or during radiation treatments. Although
corticosteroids reduce inflammation, they are usually used only for
short periods to avoid such serious side effects as osteoporosis,
high blood pressure, diabetes and an increased susceptibility to
infection.
NURSING MANAGEMENT
Providing preoperative care
Objectives of preoperative care includes recognition of neurological
deficits through ongoing assessment,pain control and management
of altered activities of daily living resulting from sensory and motor
deficits and bowel and bladder disturbances.
Patient is evaluated for coagulation disorders.A history of aspirin
intake has to be noted because aspirin can delay hemostasis
postoperatively.Breathing exercises are taught and demonstrated.

Assessing the patient after the surgery
Patient is noted for deterioration in neurological function.Frequent
neurological tests are done to assess the strength and sensation of
the upper and lower extremities.Assessment of the sensory function
involves pinching of the skin of arms,legs and trunk.Vital signs are
monitored at regular intervals.
Managing pain
Prescribed pain medication should be administered in adequate amounts
and at appropriate intervals to relieve pain and discomfort.Bed is kept flat
initially.The nurse turns the patient as a unit,keeping the shoulders aligned
and the back straight.Sidelying position is much comfortable,because this
imposes less pressure on the surgical site.Placement of a pillow between
the knees of the patient prevents knees flexion.

Monitoring and managing potential complications
If the tumor is in the cervical area,possibility of respiratory complications are
more.Nurse monitors the patient for asymmetric chest movement,abdominal
breathing and abnormal breathsounds.For high cervical tumor lesions the
ET Tube should be in place until adequate respiratory function is
ensured.Patient is encouraged to do deep breathing and coughing
exercise.Area over the bladder is palpated and a scanning is done to rule
out distension.Monitor for urinary dysfunctions,an intake and output chart is
usually maintained.Abdomen is auscultated for bowel sounds.Staining of
the dressing indicates leakage of CSF from the surgical site which can lead
to serious infection or inflammatory reactions in the surrounding tissue in
the post operative period.
PROMOTING HOME AND COMMUNITY
BASED CARE
Teaching patient self care

Patient is assessed for the ability to perform the activities
independently in the home.Patient with residual sensory
impairment is cautioned about the dangers about the
extremes in temperature ,They should be alerted to the
dangers of heating devices(eg:hot water bottles,heating
pads)..Patient is taught to check the skin
integrity.Patients with impaired motor functioning is
trained for use of assistive devices such as cane,walker
or wheelchair.Patient and family members are educated
regarding the pain management strategies,bowel and
bladder management and assessment of signs and
symptoms that should be reported.
Possible Complications
Incontinence
Life-threatening spinal cord compression
Loss of sensation
Paralysis
Permanent damage to nerves, disability from nerve
damage