Spinal-canal tumours: primary lesions, metastases and cord protection

Two different clinical groups

Primary spinal-canal lesions include intramedullary tumours such as ependymoma or astrocytoma, intradural extramedullary tumours such as meningioma or schwannoma, and primary vertebral bone tumours. Their biology, resectability and specialist teams differ.

Spinal metastases spread from cancer elsewhere. They may affect bone without cord compression, cause mechanical instability, or extend into the epidural space and compress the cord or cauda equina. NICE NG234 addresses this adult metastatic pathway; it does not cover primary spinal tumours or children.

Symptoms and what they mean

Persistent focal or night pain, pain around the chest or into a limb, progressive weakness, sensory change, hand clumsiness, gait deterioration or sphincter dysfunction can occur. Pain alone is common and often musculoskeletal; symptoms and examination must fit the lesion's level and mechanism.

A slowly growing benign lesion can still injure the cord through compression. Conversely, an incidental vertebral lesion may not be the cause of pain.

Assessment and tests

• Detailed neurological examination including strength, sensation, reflexes, gait and sphincter history.
• MRI of the relevant spinal region, often with contrast; broader imaging when symptoms or tumour spread require it.
• Assessment of spinal stability, mechanical pain and disease outside the spine for suspected metastases.
• Specialist radiology, pathology and multidisciplinary review before biopsy when a primary vertebral bone tumour is possible; an unplanned biopsy or decompression can compromise definitive surgery.
• NICE NG234 is a UK evidence reference for adults with spinal metastases or MSCC, not a local timing guarantee.

Observation and non-operative care

Selected small asymptomatic schwannomas, meningiomas or indolent intramedullary lesions may be monitored with neurological examination and interval MRI when there is no threatening compression or growth. This is an individual specialist decision.

For metastases, radiotherapy, systemic anticancer treatment, pain support, rehabilitation and selected stability procedures may be appropriate. Radiotherapy treats tumour and non-mechanical pain but cannot repair mechanical instability.

For adults with neurological symptoms or signs of suspected MSCC, UK NICE NG234 recommends that clinicians start corticosteroid treatment promptly while definitive assessment and treatment are arranged. Steroids are not routine for every spinal metastasis and can affect diagnostic tissue when lymphoma or myeloma is suspected. Do not start, stop or change steroid treatment yourself; follow the treating team's instructions.

The role of surgery

For a primary lesion, surgery may provide diagnosis, decompression and maximum safe removal. A clear plane may permit complete removal of some ependymomas, meningiomas or schwannomas; infiltrating spinal astrocytoma may require biopsy or limited decompression to avoid cord injury.

For adult MSCC, surgery may combine decompression and stabilisation when there is progressive deficit, surgically accessible high-grade compression, instability, collapse, mechanical pain or a need for tissue. Fitness, cancer biology, radiotherapy options, extent of disease and personal goals remain central.

Uncertainty and follow-up

Evidence for rare primary spinal tumours often comes from specialist series rather than randomised trials. Apparent extent of removal must be balanced against neurological function. In metastatic disease, trial results apply to selected patients and do not make surgery automatically superior.

Follow-up intervals depend on pathology, molecular features where relevant, extent of treatment, stability and neurological trajectory. No scan alone can provide a personal prognosis.