Spinal Conditions: Spinal Tumours and Infections
Spinal Tumours
Spinal tumours are abnormal growths that develop within the spinal cord or the bones of the spine. Spinal tumours can be benign (noncancerous) or malignant (cancerous), and can have a significant impact on a person's mobility and quality of life. Fortunately, spinal tumours are uncommon. Tumours can be primary (arising from the spine itself), secondary (arising from elsewhere in the body – otherwise known as spinal metastases) or they can arise from the blood and bone marrow in the spine (haematological).
Primary tumours account for less than 0.5% of all spinal tumours. They can be classified as tumours arising from the spinal column, extradural (the soft tissues outside of the linings of the spinal cord) and intra dural (inside the linings of the spinal cord). Spinal column tumours can be benign (such as Aneurysmal Bone Cysts, Giant Cell Tumours, Haemangiomas, Osteoid Osteomas and Osteoblastomas) or malignant (such as Chordomas, Osteosarcomas and Chondrosarcomas). Extra dural tumors are usually Schwannomas and Meningiomas. Intradural tumours can be extramedullary (outside of the spinal cord such as Schwannomas, Neurofibromas and Meningiomas) or intramedullary (arising from inside the spinal cord itself such as Ependymomas, Astrocytomas and Haemangioblastomas).
Haematological tumours account for 5 to 10% of spinal tumours and include conditions such as lymphoma, plasmacytoma and myeloma.
Spinal metastases are the commonest cause of spinal tumours and account for over 90%. The primary site is most commonly breast, lung, prostate, kidney and colon. In around 10% the primary cause cannot be found.
Symptoms of Spinal Tumours
The symptoms of spinal tumours can vary depending on the location and type of tumour. Some common symptoms of include: pain in the back or neck, numbness or tingling in the arms or legs, weakness in the arms or legs, loss of sensation in the arms or legs, difficulty walking or maintaining balance, loss of bladder or bowel control, and paralysis.
Diagnosis of Spinal Tumours
Spinal tumours are usually diagnosed following a detailed history, clinical examination, and radiological investigations of the spine. They are often detected during the workup (staging) of a patient with a known cancer diagnosis. Occasionally, they can be detected as incidental findings when investigating other conditions. MRI scanning of the whole spine is the imaging modality of choice. Subsequent imaging with a CT of the spine, chest, abdomen and pelvis is often performed in order to assess the bony anatomy of the spine, to determine the primary source of the tumour and whether there is spread to other organs in the body. Occasionally, CT SPECT, Bone scans and PET CT scans are performed. Erect X-Rays are sometimes performed to assess spinal stability. In addition, several blood tests are usually performed.
Treatment of Spinal Tumours
The treatment for spinal tumours will depend on the location, type, and severity of the tumour. In some cases, surgery may be necessary to remove the tumour and prevent further damage to the spinal cord and to stabilise the spine. Radiation therapy and chemotherapy may also be recommended to destroy cancerous cells and prevent the tumour from spreading. It's important to note that spinal tumours can have long-lasting effects on a person's mobility and quality of life. Rehabilitation and physical therapy may be necessary to regain strength and mobility, and additional medical care may be required to manage ongoing symptoms and complications.
Conservative Management of Spinal Tumours
Conservative management of spinal tumours involves non-surgical treatment options to manage symptoms and slow the growth of the tumour. The specific treatment options recommended will depend on the location, type, and severity of the tumour.
Observation and Monitoring: Some spinal tumours, especially benign ones that are not causing symptoms, may just be closely monitored with regular imaging studies like MRI or CT scans to check for growth or changes in the tumour.
Radiation Therapy: This is the use of high-energy beams to kill or shrink tumour cells. It can be used for primary spinal tumours or metastatic tumours that have spread to the spine from another location.
Stereotactic radiosurgery (e.g., CyberKnife, Gamma Knife): This is a specialized type of radiation therapy that delivers a high dose of radiation to a precise area, minimizing damage to surrounding healthy tissue.
Chemotherapy: Chemotherapy uses drugs to kill tumuor cells or stop them from growing. It's more commonly used for metastatic spinal tumours or certain primary spinal tumours that respond well to chemotherapy.
Hormonal Therapy: Some tumours, especially those related to breast or prostate cancer, may respond to hormonal therapy, which targets the hormones that fuel the growth of these cancers.
Targeted Therapy: This involves drugs that specifically target the changes in tumour cells that allow them to grow, divide, and spread.
Immunotherapy: This is a type of treatment that boosts the body's natural defences to fight the tumour. It uses substances made by the body or in a laboratory to improve or restore immune system function.
Pain Management: Pain is a common symptom of spinal tumours. Pain management can include medications (e.g., non-steroidal anti-inflammatory drugs, opioids), nerve block injections, and physical therapy.
Physical Therapy: Physical therapy can help manage symptoms by improving strength, flexibility, and overall function. It can also help reduce pain and improve mobility.
Bracing: In cases where the spinal tumour causes instability or risk of fracture, a brace might be used to provide additional support and reduce pain.
Vertebroplasty and Kyphoplasty: While these are minimally invasive procedures, they might be considered more conservative than major surgery. They involve injecting medical cement into vertebrae to stabilize fractures caused by spinal tumours.
Radiofrequency Ablation: this involves using heat to destroy cancerous cells and shrink the tumour. This procedure may be recommended for certain types of tumours, particularly those that are located near the spinal cord.
Surgical Management of Spinal Tumours
Surgical management of spinal tumours involves the removal of the tumour to prevent further damage to the spinal cord and surrounding tissues. The specific surgical options recommended will depend on the location, type, and severity of the tumour. Recovery after surgery will depend on the type of procedure performed, as well as the overall health and medical history of the patient.
Spinal surgery for patients with spinal tumours can be performed when the following pre-requisites are fulfilled: There is an indication present, the patient is willing to have surgery, the prognosis is greater than 3 to 4 months, the patient is physically fit enough to have surgery and finally, the surgery itself is technically possible.
The indications for spinal surgery on patients with spinal tumours are: Progressive / impending neurological deficit, spinal instability / collapse / deformity, patients paralysed <24hours due to spinal cord compression from a localised tumour, intractable pain (including those who are paralysed >24 hours), when histological confirmation of the tumour is required, when there is a growing tumour resistant to non-operative measures, when there is a relapse after / deterioration during radiotherapy, and when spinal cord radiotherapy tolerance has been reached.
Spinal Infections
Spinal infections are caused by bacteria, viruses, or fungi that enter the spinal cord or the bones of the spine. Spinal infections can be very serious and require prompt medical attention. This section refers to spinal infections such as epidural abscess, discitis, osteomyelitis, tuberculosis and surgical site infections. These conditions can require spinal surgical input. Meningitis refers to inflammation around the lining of the spinal cord and brain and is generally a medically treated condition.
Symptoms of Spinal Infections
Symptoms of spinal infections can vary depending on the location and severity of the infection. Acute infections such as an epidural abscess (collection of pus around the spinal cord) can present with acute fever (raised temperature), severe pain and neurological deficits (numbness or tingling in the arms or legs, weakness in the arms or legs, loss of sensation in the arms or legs, difficulty walking or maintaining balance, and rarely paralysis). More commonly, infections of the spine present with vague symptoms, chronic illness, low grade fever and back pain. They can sometimes present with progressive spinal deformity.
Diagnosis of Spinal Infections
The diagnosis is of spinal infections is often delayed, and symptoms can be present for several months. Back pain is the predominant symptom in more than 90% of cases, fever can be present in up to 50% and neurology deficits in around 15%. Spinal infections are more commonly seen in certain groups of patients. Patient risk factor / groups include: diabetics, intravenous drug abusers, immunocompromised patients, immigrants from certain regions, patients on steroids, recent spinal surgery, genitourinary conditions, renal failure, rheumatoid arthritis, adolescents, cardiac issues and the elderly.
Spinal infections are usually diagnosed following a detailed history, clinical examination, and radiological investigations of the spine. Patients with spinal infections tend to be unwell. Examination can reveal tenderness or swelling in the back or neck and potentially neurological deficits in the limbs. Imaging tests, such as X-rays, CT scans, or MRIs, along with blood tests are used to diagnose and evaluate the extent and severity of any spinal infection. Blood, urine, and sputum cultures are often taken to help isolate the causative organism and work out which antibiotics should be given. Occasionally, a direct biopsy (sample) of the spinal infection is required.
Types of Spinal Infection
Discitis / Vertebral Osteomyelitis: this is infection of an intervertebral disc (discitis) and/or infection of the vertebral bone (osteomyelitis). It is typically caused by a bacterial infection, most commonly Staphylococcus aureus. It can result from hematogenous spread (spread through the bloodstream), direct inoculation from surgery or trauma, or spread from adjacent infections. Presentation is usually with back pain, fever, and tenderness over the affected area. Neurological deficits can develop if the infection spreads.
Epidural Abscess: this is a collection of pus between the outer covering of the spinal cord (dura mater) and the bones of the spine. It can compress the spinal cord or nerve roots, leading to serious complications. It often arises from the spread of a nearby infection, such as discitis / vertebral osteomyelitis, or from hematogenous spread. Staphylococcus aureus is the most common causative organism. Presentation is usually with severe back pain, fever, and neurological deficits, including weakness, numbness, and bowel or bladder dysfunction.
Tuberculosis of the Spine: is a form of tuberculosis that affects the spine, making it one of the oldest diseases known to humankind. It primarily affects the thoracic portion of the spine. It is caused by the bacterium Mycobacterium tuberculosis. The spine is the most common site for skeletal tuberculosis. Presentation is usually with chronic back pain, spinal deformities, neurological deficits due to compression of the spinal cord, and systemic symptoms of tuberculosis like weight loss, night sweats, and fever.
Surgical Site Infections (SSIs) in Spine Surgery: this is an infection that occurs after spinal surgery in the area of the surgery. SSIs can be superficial (involving just the skin) or deep (extending to muscles, fascia, or even the spinal hardware and vertebrae). SSIs are usually caused by bacterial contamination during surgery. The most common pathogens include Staphylococcus aureus (including MRSA) and coagulase-negative staphylococci. Risk factors for developing an SSI include diabetes, obesity, malnutrition, smoking, prolonged surgical time, previous surgery at the same site, oncological procedures, preoperative radiotherapy and perioperative blood transfusion. Presentation is usually with redness, warmth, and swelling at the surgical site, drainage of pus, and fever. For deeper infections, there may be persistent pain, wound dehiscence (wound edges not staying together), and signs of systemic infection.
Treatment of Spinal Infections
The treatment for spinal infections will depend on the location, type, and severity of the infection. In some cases, antibiotics or other medications may be prescribed to treat the infection. Surgery may also be necessary to drain any abscesses or remove infected tissue. The goals of treatment in spinal infection are: early diagnosis, eradicate infection / treat sepsis, preserve spinal stability, prevent / reverse neurological deficits, pain relief and prevent / correct spinal deformity.
Discitis / Osteomyelitis is usually treated with prolonged antibiotic therapy. In some cases, surgical intervention may be needed to debride infected tissue, decompress nerves, stabilize the spine or correct deformity. Epidural Abscess usually requires urgent surgical intervention to drain the abscess and relieve pressure on the spinal cord combined with long-term antibiotic therapy. Tuberculosis usually requires long-term anti-tubercular drug therapy. In advanced cases, or when there's significant spinal deformity or neurological compromise, surgical intervention may be necessary. SSIs usually require initial empirical antibiotic therapy based on the likely organisms, and adjustments are made based on culture results. Regular wound cleaning and dressing changes are essential. In some cases, wound vacuum-assisted closure (VAC) therapy may be used. Surgical debridement (removal of infected tissue) is often required for deep SSIs. In cases with hardware contamination, removal might be necessary, though in some situations, the hardware can be retained if it's stable and if aggressive debridement and antibiotic therapy are pursued. Occasionally, antibiotic spacers and beads are placed in the surgical site after debridement to deliver a high concentration of antibiotics directly to the area.
It is important to note that most spinal infections (discitis and osteomyelitis) do not require specialist spinal surgical management. Treatment includes rest, brace treatment for pain relief and to prevent progressive spinal deformity, and a prolonged course of antibiotics. “Complicated” infections will require surgical input. This includes ongoing infection and sepsis despite antibiotic treatment, paralysis, abscess, and deformity.
Finally, spinal infections can have long-lasting effects on a person's mobility and quality of life. Rehabilitation and physical therapy may be necessary to regain strength and mobility, and additional medical care may be required to manage ongoing symptoms and complications (such as paralysis).
Surgical Management of Spinal Infections
Surgical intervention is required: when open biopsy Is needed for diagnosis, failure of medical management, drainage of epidural abscess causing neurological deficit or sepsis, decompression of spinal cord compression with neurological deficit, and correction of progressive or unacceptable spinal deformity / instability. The goals of surgery are: complete debridement of all non-viable and infected tissue, decompression of neural elements, long term stability through fusion, and correction of spinal deformity.
Further Information on Spinal Tumours and Infection
More information on spinal tumours and infections can be found in the Useful Links and Professional Guidelines sections of this site. Please note that some of these documents are written for health care professionals.
NICE Guidelines on Spinal Metastases and Metastatic Spinal Cord Compression
Spinal Infection Information from the American Association of Neurological Surgeons