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Background: Spinal cord tumors constitute a heterogenous group of neoplasms arising from various spinal compartments, including the spinal cord parenchyma, meninges, nerve roots, vessels or adjacent structures. Their anatomical location within the spinal cord renders them clinically significant due to potential for neural compression and resultant morbidity. MRI remains the imaging modality of choice, given its superior soft tissue resolution and multiplanar capabilities. Our study aimed to evaluate the imaging characteristics of spinal tumors encountered in our tertiary care centre. Methods: A retrospective observational study was conducted, analyzing the MRI data from patients diagnosed with spinal tumors over a defined period. Inclusion criteria encompassed patients who underwent contrast enhanced MRI spine and were radiologically diagnosed. A total of 16 patients were included in the study. Data was analyzed descriptively and results were compared with published imaging guidelines. Results: Among the 16 patients (mean age: 52 years), the most prevalent tumor was metastatic disease (n=6,37.5%) involving the vertebral bodies in thoracic, lumbar spine. Nerve sheath and meningeal tumors, including schwannomas (n=2,18.75%) and meningiomas (n=2, 12.5%) demonstrated classical imaging appearances with uniform enhancement, dural tail sign and foraminal extension. Intramedullary tumors included ependymoma, astrocytoma. The ependymoma was located in the lumbar region showing central hyperintensity and peripheral T2 hypointense rim. The astrocytoma showed ill-defined margins, syrinx formation and patchy enhancement in the cervical spinal cord. The case of hemangioblastoma showed predominant flow voids, solid-cystic nature on MRI. Hematological neoplasms (multiple myeloma and acute myeloid leukemia) demonstrated infiltrative marrow changes and homogenous vertebral enhancement. Conclusion: This retrospective study reinforces the crucial role of MRI in delineating the morphological features of spinal tumors, facilitating accurate localization and differential diagnosis. Metastatic tumors remain the most common spinal neoplasms with a predilection for the thoracolumbar spine. Comprehensive imaging evaluation enables effective clinical decision making, particularly in resource constrained centers.
Spinal cord tumors represent a diverse group of neoplasms that can arise from the cord, nerve roots, meninges, vessels or metastasize from distant primary sited. These tumors account for approximately 2-3% of central nervous system tumors causing significant morbidity due to their location and possible compression on cord(1)(2). These present significant diagnostic and therapeutic challenges due to their diverse pathology and location which is crucial for appropriate management and treatment planning.
Clinically patients with spinal tumors may present with nonspecific symptoms such as localized or radicular pain, progressive motor weakness, sensory disturbances, or sphincter dysfunction. Due to insidious onset and overlap with degenerative or inflammatory spinal disorders, spinal tumors, leading to delays in treatment. Early detection helps decrease morbidity and mortality, thereby improving quality of life (3).X-rays serves as initial screening tool for spina lesions but has limited sensitivity, often detecting changes only after significant bone destruction has occurred. Computed Tomography(CT) offers superior spatial resolution for assessing cortical bone, calcifications and osseous remodeling. However, its limited soft tissue contrast diminishes its role in evaluating intramedullary or intradural lesions(4). Magnetic Resonance Imaging (MRI) plays a vital role in the evaluation of spinal cord tumors, offering superior soft tissue contrast and multiplanar capabilities. The ability to differentiate between intramedullary, intradural and extradural lesions as well as characterize tumor features, surgical planning and follow-up making MRI the imaging modality of choice for evaluation of spinal tumors (5)(6). Diffusion weighted imaging (DWI), MR spectroscopy and perfusion imaging techniques are increasingly being explored to improve diagnostic accuracy(7)(8).
The radiological spectrum of spinal tumors is broad. Metastatic tumors being the commonest spinal tumors. Common intramedullary neoplasms include ependymomas and astrocytomas, whereas schwannomas and meningiomas predominate in the intradural extramedullary compartment (9)(10). Extradural lesions are most frequently metastatic, with breast, prostate and lung carcinomas representing common primary sources (11). These often demonstrate vertebral body destruction, epidural extension, and possible cord compression, necessitating prompt diagnosis and early treatment (12).
Despite advances in imaging, spinal tumors remain a diagnostic challenge due to their rarity and overlapping features among different subtypes. Moreover, variation in tumor distribution, differences in MRI protocols and inclusion of rare entities make it necessary to generate institution specific imaging profiles. This retrospective evaluation of MRI features in spinal tumors can yield valuable insights into diagnostic pitfalls, patterns of tumors presentation and regional epidemiological trends.
The Retrospective observational study was conducted in the ‘Department of Radiodiagnosis and Imaging Sciences, Jorhat Medical College and Hospital, Jorhat Assam’ for a period of 1 year from December 2023 to December 2024. Patients diagnosed with spinal tumors based on MRI were identified from the hospital information system. A total of 15 cases of either gender were included in the study who underwent MRI spine in 1.5 Tesla General Electric (GE) MRI scanner in supine position with the spine coil.
Imaging protocol:
Image analysis
The scans were reviewed by a senior radiologist with 20 years of experience. The scans were assessed from following imaging features:
Relevant clinical information, including patient name, age, gender, symptoms, treatment approach and follow-up data when available was collected from electronic medical records and requisition.
Diagnosis was made based on radiological features and clinical context.
No histopathological confirmation was available due to conservative management or loss to follow-up.
Inclusive criteria
Patients of any age and gender.
Patients with spinal lesions suggestive of tumors on MRI.
Exclusion criteria
Patients with proven infective or inflammatory or traumatic lesions, later determined not to be neoplastic.
Postoperative or treated spine cases where the baseline MRI scans were unavailable.
Lesions clearly representing degenerative, congenital or vascular malformations rather than tumors.
Patients with hemangiomas with classical signal patterns (Hyperintense on T1, T2 sequences) were excluded to focus on lesions of clinical and diagnostic relevance.
Out of the 16 patients included in the final analysis of the study. The cohort consisted of 10 males and 6 females, with an age range of 35 to 72 years (mean age 52 years). The clinical presentation varied, with the most common symptoms being back pain, neurological deficits, and cord compression. The median duration of symptoms prior to imaging was 4 months (range: 2 weeks to 8 months).
Tumor Distribution and Types
The study encompassed a wide spectrum of spinal tumors, both primary and secondary, with a significant representation of metastatic lesions. The distribution of tumor types is as follows:
Metastatic tumors (n=6, 37.5%)
The majority of metastatic lesions involved the vertebral bodies, with epidural extension seen in 2 cases.
The primaries of metastasis were lung carcinoma (1 cases), anterior mediastinal lymphoma (1 case), cholangiocarcinoma (1 case) and testicular germ cell tumor (1 case).
Imaging characteristics included hypointense lesions on T1-w images, heterogenous enhancement on post-contrast studies. The lesions involved the predominantly the vertebral body at multiple levels with varying degrees of involvement of the pedicles, posterior elements, sacrum.
Representative case: 45-year-old gentleman presenting with back pain and generalized body pain for 5 months.
Hematological infiltrations of spine (n=2,12.5% of cases)
The patient was a known case of multiple myeloma (n=1, 6.25%) presenting with diffuse lytic lesions involving the skull, spine, upper limbs and was evaluated by MRI lumbar region. It showed extensive infiltrations with T1 hypointensity, T2/STIR hyperintensity and post contrast enhancement of the involved vertebrae along with multiple small punched out lytic lesions involving the vertebral bodies, posterior elements, pelvic bones was noted. The intervertebral disc space was preserved. These findings were consistent with diffuse infiltrative pattern of multiple myeloma.
Meningioma--Meningiomas, often arising from the meninges, present as well-defined, extra-axial masses. They merit attention for their propensity to exhibit distinct characteristics on MRI.
Representative case: A 63-year-old female presented with localized back pain and mild left upper limb weakness for 6 months.
Our study retrospectively evaluated 16 patients with MRI evidence of spinal tumors, assessing the MRI characteristics of both intramedullary and extramedullary lesions. Our sample included 6 metastatic lesions (37.5%), 5 nerve sheath or meningeal tumors (schwannomas and meningiomas) (31.25%), and number of rare intramedullary lesions such as ependymoma, astrocytoma, and hemangioblastoma, along with hematological infiltrations (12.5%) of spine including leukemia and myeloma. Metastasis was the most frequent encountered pathology (n=6 of 16 cases, 37.5 percentage of all cases) in our study with involvement of the thoracolumbar region in all the patients, this is concordant with previous literature as the study by Ciftdemir M et all with spinal metastases constituting approximately 97% of all spinal tumors, with the thoraco-lumbar spine approx. 70% and lumbo-sacral region constituting approx. 20% and cervical region being the least frequent region. The thoracolumbar region being the most commonly involved segment due to its rich venous plexus (4). Our MRI findings of T1 hypo-intensity, T2 hyperintensity and contrast enhancement at multiple vertebral levels corroborate the imaging criteria established by Lubdha M Shah et al (13).
The 31.25 % incidence of schwannomas and meningiomas in our study aligning with the literature and study by Koeller and Shih et all (14) that reports these tumors as common intradural extramedullary neoplasms. These tumors have characteristic MRI appearances demonstrating iso to hypo-intensity of T1, variable T2 signal and avid homogenous contrast enhancement as evidenced by Koeller K et al and Serratrice N et al (15).
The distribution of intramedullary tumors in our study, 1 ependymoma, 1 astrocytoma, 1 hemangioblastoma aligns with their known rarity. Ependymomas, though the most frequent intramedullary tumor in adults, showed central hyperintensity, peripheral hemosiderin cap (cap sign) on T2 weighted images and uniform post contrast enhancement. These findings align with those established by Koeller k et al who noted the ependymomas are typically iso to hypointense on T1 WI, Hyperintense on T2 WI, cap sign and demonstrate homogenous enhancement on post contrast studies (14).These characteristic findings were also observed by Kobayashi et al(16).
The cervical lesion with illdefined borders, iso to hypointense on T1 WI and mildly hyperintense on T2 WI, with associated syrinx formation and minimal enhancement of the solid component was diagnosed as possible astrocytoma. In literature, spinal astrocytomas are described as poorly marginated, infiltrative, and hypointense to isointense on T1 WI, hyperintense on T2 WI with variable enhancement depending on the grade of lesion as evidenced by Kim D et al(17). Syrinx formation is associated with astrocytoma as documented by Kim D et al and Hersha A et al (17)(18).
The thoracic intradural, eccentric intramedullary lesion with exophytic component with solid and cystic components, flow voids, and avid enhancement, consistent with diagnosis of hemangioblastoma. These tumors are vascular in nature and the MRI hallmark features include flow voids, cystic morphology and intense enhancement of the solid nodule. Glasker S et all and Chou B et al also have emphasized the frequent presence of cystic appearance with mural nodules, flow voids in hemangioblastoma lesions, findings concordant with our observations(19)(20). However a frequent association (64%) of syrinx in hemangioblastoma cases by Chu B et al not seen in our study(19).
The hematogenous malignancies involving the spine in our study included leukemic and myelomatous infiltrations. The study by Dutoit J et al also found that myelomatous involvement of the spine showed multiple lytic lesions, T1 hypointensity, T2, STIR hyperintensity in diffuse involvement pattern. The researchers also found that focal lesions showed diffusion restriction and contrast enhancement on dynamic contrast enhanced imaging(21).
The leukemic infiltration in our study showed diffuse hypointensity on T1 hypointensity, hyperintensity on T2, and homogenous post contrast enhancement of the vertebral body. This is consistent with descriptions by Navaroo S et al, who reported that the bone marrow involvement include T1 hypointensity, Hyperintense T2 signal and gadolinium enhancement of the lesion along with peritumoral edema visualised on T2 weighted sequences(22). The absence of a soft tissue mass or focal epidural and paraspinal component and presence of a smooth, homogenous marrow replacement pattern, favored a leukemic origin over lymphoma as also described by Navaroo S et al (22).
This retrospective observational study provides a focused evaluation of MRI characteristics of spinal tumors across 16 tumors, classified based on compartment location and characteristic imaging appearances. The diagnosis were established through comprehensive radiological assessment and clinico-radiological correlation, reflecting real world diagnostic challenge in settings where tissue confirmation is not feasible or indicated. The study encompassed a spectrum of pathologies including intramedullary tumors (ependymoma, astrocytoma, hemangioblastoma), intradural extramedullary lesions (meningioma, schwannoma) and extradural or marrow-infiltrating lesions (metastasis, leukemic infiltration, multiple myeloma), highlighting the diversity of spinal tumor presentations.
MRI is invaluable in lesion localization, characterization, and differentiation. Features such as central cord location with a T2 hyperintense cap in ependymoma, solid-cystic morphology with flow voids in hemangioblastoma, dural tail sign in meningioma and diffuse marrow signal changes in leukemic and myelomatous infiltration were pivotal in guiding radiologic diagnosis. These imaging patterns were found to be consistent with published literature, validating the accuracy of MRI in non-invasive diagnostic stratification.
They study reaffirms the central role of MRI in evaluation of spinal tumors, especially in contexts where biopsy or surgery is deferred. This study underscores the value of a pattern-based approach in the interpretation of spinal neoplasms and supports the continued use of MRI as primary diagnostic modality for initial evaluation, follow-up, and treatment planning.
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