Spine

Question 1

Most common benign spine tumors?

Answer 1

ABC, eosinophilic granuloma, giant cell tumor, hemangioma, neurofibroma, osteoid osteoma, osteoblastoma, osteochondroma

Question 2

Primary malignant spine tumors?

Answer 2

Less than 5% of all spine tumors: chondrosarcoma, chordoma, Ewing sarcoma, multiple myeloma, osteosarcoma

Question 3

Most common spine tumor?

Answer 3

Metastatic disease: breast, lung, thyroid, renal and prostate; usually in vertebra, spare disc.

Question 4

Most common site for skeletal metastasis?

Answer 4

Spine

Question 5

Benign spin tumors?

Answer 5

Tend to occur in children and involve the posterior elements.

Question 6

Malignant spine tumors?

Answer 6

Tend to occur in adults and involve the vertebral bodies.

Question 7

Most common region for spinal mets?

Answer 7

Thoracic spine

Question 8

Most common presenting complaint for spine tumor?

Answer 8

Pain (night pain very common)

Question 9

Acute onset or worsening pain in spinal tumors?

Answer 9

Suggests fracture.

Question 10

MRI for suspicion of spine tumor?

Answer 10

Order with IV gadolinium because more vascular regions will be highlighted.

Question 11

Specific labs for multiple myeloma?

Answer 11

SPEP and UPEP

Question 12

Definitive diagnosis of spinal tumor?

Answer 12

Biopsy (fine needle, core, or excisional). Consider CT or MRI guided. Tattoo the needle tract for excision later.

Question 13

Most widely accepted staging system for spinal tumors?

Answer 13

Weinstein, Boriani, and Biagini (WBB). Divides axial plane of vertebral body into 12 zones like a clock face. Also divides tissues from periphery inward into 5 zones (extraosseous tissues, intraosseous superficial, intraosseous deep, extraosseous epidural, extraosseous intradural).

Question 14

ABC lesion in spine?

Answer 14

Second decade of life; 20% w/i spine, mostly posterior elements; expansile lytic lesion with rim of reactive bone, fluid filled levels. Tx = arterial embolization, curettage, or en bloc resection (needs preop embolization).

Question 15

Eosinophilic granuloma in spine?

Answer 15

AKA Langerhans cell histiocytosis; first and second decade of life; affects vertebral body; vertebra plana commonly seen; histologic analysis critical to distinguish; intralesional corticosteroid injection once known; most resolve spontaneously.

Question 16

Giant cell tumor of spine?

Answer 16

Can be aggressive; typically occur in third decade of life; typically vertebral body; sacrum most commonly affected; expansile lytic lesion with soft-tissue involvement; tx = en bloc excision if possible, otherwise intralesional extracapsular excision; adjuvant radiation may increase success but 5-15% chance of high-grade sarcoma; recurrence rates lowest at tertiary tumor referral center (18% vs 83%).

Question 17

Hemangioma of spine?

Answer 17

Usually asymptomatic; large lesions may cause fracture, instability, or compression of neural elements; large lesion with vertical striations; speckled appearance on CT; MRI = increased signal intensity on T1 and T2; tx = percutaneous cement augmentation if needed and/or decompression/stabilization.

Question 18

Neurofibroma of spine?

Answer 18

Associated with neurofibromatosis; typically occur within dura; if in neuroforamen then classic dumbbell-shape; x-rays show penciling of rib heads, enlarged neuroforamina and vertebral scalloping; tx of symptomatic lesions with excision; if results in scoliosis then fuse.

Question 19

Osteoid osteoma of spine?

Answer 19

Typically in second decade of life; pain unrelated to activity, increased at night; pain resolves with NSAIDs; can cause painful scoliosis; CT = nidus of bone with sclerotic rim; bone scan = hot lesion; most common in posterior elements; resolution with NSAIDs can take 36 months; can be treated with radiofrequency ablation if far enough away from neurologic structures; excise lesions close to neurologic structures (associated scoliosis will resolve if excised w/i 15 months of onset).

Question 20

Osteoblastoma of spine?

Answer 20

40% occur in spine; most commonly in posterior elements of cervical and lumbar spine; similar to osteoid osteoma w/o relief from NSAIDs; lesion usually larger than osteoid osteoma (>2cm); expansile lytic lesion that may expand into soft tissues; tx with curettage or en bloc excision.

Question 21

Osteochondroma of spine?

Answer 21

Commonly affects posterior elements of cervical and upper thoracic spine; x-ray shows pedunculated mass; CT/MRI shows cartilage cap; asymptomatic lesions = no tx; 1% risk of malignant transformation into chondrosarcoma; 25% risk if multiple hereditary exostosis.

Question 22

Chondrosarcoma of spine?

Answer 22

Typically present in 5th decade; if in posterior elements, may be malignant transformation of osteochondroma; if in vertebral body, likely primary lesion; lytic lesion with poor margins and stippled calcifications; CT/MRI shows cartilagenous cap; tx = en bloc excision; proton/photon rads tx if not clean margins.

Question 23

Chordoma of spine?

Answer 23

Rare but most common primary malignant spine tumor in adults; typically 5th/6th decade; most common in sacrum then upper cervical spine; evolve from remnants of notochord with midline location; lytic or mixed lytic lesion; CT/MRI shows large soft tissue expansion; slow growing/insidious onset; sacral mass may have palpable lesion on rectal exam; tx = en bloc rsxn but high risk of bowel/bladder/sexual dsfxn (try to save bilat S2 or unilateral S2/3/4 nerve roots); survival rates 5-10 yrs; chemo targeted against molecular tyrosine kinase and angiogenesis pathways.

Question 24

Ewing sarcoma of spine?

Answer 24

2nd decade of life; pain/swelling/constitutional symptoms; most common in sacrum; neurologic symptoms common; moth-eaten appearance with poor margins; MRI shows soft-tissue extension; tx = neoadjuvent chemo, radiation, en bloc excision.

Question 25

Multiple myeloma of spine?

Answer 25

Most common primary malignant bone lesion; malignant transformation of plasma cells; 6th/7th decades; occasional neurologic deficits; punched out lytic lesions; lesions cold on bone scan; SPEP/UPEP +; tx = chemo/rads, bracing, bisphosphonates; combined tx with thalidomide and dexamethasone; vertebroplasty/kyphoplasty; may be solitary plasmacytoma can progress to MM but are highly radiosensitive; surgery for instability/neurologic signs; survival of plasmcytoma 60 months vs MM 28 months.

Question 26

Osteosarcoma of spine?

Answer 26

2nd decade of life; rare in spine; usually vertebral body; lytic, blastic or mixed; tx = neoadjuvant chemo and en bloc rsxn.

Question 27

Scoring system for spinal mets?

Answer 27

Tokuhashi; total of 15 points; 8 or less = palliative care; 9 to 11 = 6 months survival w/ palliative surgery; 12 or more = 1yr or greater survival and excisional surgery.

Question 28

Radiosensitivity of spinal mets?

Answer 28

High = myeloma and lymphoma; moderate = breast and prostate; resistant = lung, colon, renal cell, sarcoma, melanoma.