Respiratory System, Pneumonia, Chronic Pulmoary Obstructive Disease (COPD)- Emhysema, Chronic Brochitis, Brochiectasis, Asthtma, Carcinoma of lung

Respiratory system is very important in clinical setting. Every doctor must be aware about this system. As oxygen is important for life, similarly understanding of the respiratory system is essential for sustaining the medical practice of any doctor. Good aspect of this fact is that anybody can learn the entire respiratory system in a very simple way and theory of the respiratory system can be understood in one page and its usual practice in clinical setting makes every doctor confident in understanding of the respiratory system.

Common symptoms of diseases of the respiratory system are dyspnea, cough, fever, hemoptysis, chest pain, weight loss. So, just knowing the details about each symptom can help in making a provisional diagnosis of diseases of the respiratory system.

History-

Dyspnea or Dyspnoea is difficulty in breathing which may be in the form of breathlessness.

Cough may be dry of with sputum ( Expectoration).

Dry cough is commonly seen in Legionella.

Purulent Sputum- Klebsiella ( Thick Red Currant Jelly like sputum )

So, the history taking is important in making a diagnosis of respiratory system. History of tubercular contact is common in Tuberculosis. History of smoking is common in COPD and lung carcinoma. History of significant weight loss is common in Tuberculosis and lung carcinoma.

Clinical Examination of patients should be done in a systematic manner. Start with

Inspection- 

On inspection alone certain diagnosis of respiratory system can be made. Measure respiratory rate, observe the pattern of the breathing ( abdominothoracic or thoracoabdominal), Dyspnea, use of accessory muscles of respiration, movement of the chest, any structural abnormality of the chest wall, curvature of the spine ( kyphosis, scoliosis ), any tumor of the chest, e.g., chondroma.

Palpation-

Extent of chest expansion can be measured by placing both palm across the spine and asking the patient to take deep breath.

On palpation of the chest wall cutaneous emhysema can be detected. Cutaneous emphysema is the air in the subcutaneous tissue of the chest and it feels like crepitations while compressing sknn over the chest wall. 

Vocal fremitus is examined by placing the ulnar aspect of the hand over different areas of the chest wall feeling the vibration of the sound with and while patients produces repetitive words like one, one , one. Vocal fremitus is decreased in pleural effusion but it is increased in pneumonia.

Extent of any bony tumor like chondroma of the ribs or costochondral junction can be felt by palpation.

Fracture of the ribs can be detected on palpation. Tenderness of the chest wall can be detected on palpation. Any paraspinal collection or cold abscess can also be detected on palpation which is very common in Tuberculosis.

Percussion-

Placing the middle finger of of one hand over the chest wall and tapping with index finger of other hand will commonly elicit tympanic or dull percussion over the chest wall. The normal percussion sound over the lungs is tympanic. In hemothorax the percussion will be dull. In hydropneuomathorax it will dull below and tympanic in upper part of pneumothorax. In Pneumonia ( Consolidation of the lungs ) it is dull but this is stony dull in case of pleural effusion. Tympanic sound is increased in case of emphysema of the lungs. In pneumothorax the percussion is hyperresonant.

Auscultation-

Auscultation is done with stethoscope and all doctors should own a stethoscope. The usual breath sound are either vesicular or amphoric. The breath sounds are inreased in consolidation ,i.e., in pneumonia. The breath sounds are decreased, i.e., muffled, in pleural effusion. Breath sounds will be decreased in hemothorax.

Crepts are heard in lung infection,  pulmonary edema.

Ronchi or whistle like sounds are heard in bronchoconstriction and in asthma.

So, the with clinical examination will be sufficient to make the diagnosis of  tension pneumothorax.

Pleural effusion, pneumothorax, hydropneumothorax, pneumonia, emphysema can be provisionally diagnosed on clinical examination itself. It can further be clearly diagnosed with chest X ray.

Investigations-

Chest X-Ray Postero-anterior view (PA) is very common radiological investigation. It helps in diagnosis of rib fracture, flail chest, pneumothorax, hydropneumorax, COPD, brochiectasis,  pleural effusion, Cor pulmonale, cardiomegaly, mediastinal widening, carcinoma ung, Tuberculosis, chest metastasis.

In Pnumonia, cosolidation or cavitation is seen on chest  ray depending upon type of pneumonia

       In consolidation, the lungs shadow appear radiopaque on chest x ray. 

                       Lobar consolidation is seen in pneumococcal pneumonia.

                       Bibasal consolidation is seen in Legionella pneumonia.

                       Patchy shadows- Chlamydia psittaci. If Bilateral then Mycoplasma.

     In cavitation, pneumonia is due to

                      Bilateral cavitation- Staphylococcal

                      Upper lobe cavitation- Klebsiella

    Bilateral perihilar interstitial shadowing is seen in Pneumocystis carnii pneumonia.

Tram line ang ring shadows are seen in brochiectasis. 

Spirometry can diagnose the restrictive and obstructive disease of the lungs. 

      FEV1 is helpful in the diagnosis of asthma.

V/Q scan ( Ventilation perfusion scan) 

CT scan or HRCT ( High resolution CT scan)  of the chest helps in the diagnosis of brochiectasis, and lung carcinoma.

Pulmonary angiography- clot in the 5th order pulmonary artery can be seen in Pulmoary embolism which usually occurs on 10th post operative day. 

Bronchoscopy and biopsy

Montoux test, sputum culture and sensitivity test is useful in diagnosis of Tuberculosis.

Legionella serology

Treatment of respiratory diseases

Tension pneumothorax- Tension pneumothorax is a medical emergency. Tracheal deviation is noticed in a patient who complaints of sudden shortness of breaths and neck veins are distended. Patient becomes cyanosed. So, needle thoracocentesis is done immediately.

Pneumororax oxygen, needle aspiration, chest tube drain. 

Hemothorax- chest tube drainage

Bronchogenic carcinoma- It can present with fever if there is secondary pneumonia and it requires antibiotic therapy. Surgery is for Non small cell lung cancer. Radiotherapy is treatment of choice if patient's age is more than 65 years. 

Bronchiectasis- steroid inhaler, antibiotics if there is associated infection. Postural drainage.

Pneumonia-

          Streptococcus pneumoniae- Ampicillin or cefuroxime

          Legionella- Erythromycin

          Staphylococcus- Flucloxacillin

          Pneumocystis carnii pneumonia- high dose co-trimoxazole, or pentomidine

          

Pulmonary embolism-Anticoagulant

Acute pulmonary edema- Patient develops acute breathlessness and cough productive of frothy and pink sputum. Patient cannot lie flat & on examination crackles are present both mid zones with scattered wheezes. Treat it with IV Frusemide.

Acute astham attack- young patient presents with breathlessness and becomes too breathless to speak. There is tachycardia. Chest x ray may be normal.  Treat with nebulized salbutamol.

Foreign body obstructing bronchial airway, patient is choked-Heimlich manoeuvre. Commonly observed that a person becomes suddenly breathless while eating. Person develos marked stridor, develops choking and drooling.

Pneumothorax and Pleural effusion- Needle aspiration. if recur, chest drain.

In PLAB examination, the common themes on which the questions are framed comprise of

1. Pneumonia- types of pneumonia, investigations, treatment of pnemonia

2. Hemoptysis- causes, investigations

3. Asthma- presentation, dignosis, treatment

4. Chest pain- causes, investigations, treatment

5. Breathlessness- causes, investigations

6. Pulmonary oedema- presentation, investigations, treatment

7, Cough- presentation, causes

8.Wheeze- investigation, treatment

9. Pleural effusion- presentation, investigations and treatment

     

                                                         Summary of Respiratory system 

Mechanical Ventilation ( Modes of Ventilators ) in Intensive Care Unit (ICU)

Start your understanding about the setting of ventilators. The respiratory support to a patient by mechanical means, i.e., through machines ( Ventilators) is known as Mechanical Ventilation ). There are basically 3 modes of ventilation, i.e., CMV, SIMV and CPAP. Once youunderstand this, then it is very easy to know all about mechanical ventilation in ICU.

 

ABG ( Arterial Blood Gas ) Interpretation

Doctors, Nursing staff and Paramedical staff working in emergency & ICU setting need to know the value of ABG. It helps in the diagnosis of the conditions where a patient may require a correction of the electrolyte imbalance, respirtory problems and certaion metabolic conditions and there may be requirement of mechanical ventilation.

Interpretation of ABG is very easy and one just need one page notes for interpretation of ABG. This image will make you confident of diagnosis of a patient who is on ventilator and may require some modification in the ventilator setting. 

  

 

Glioblastoma or Glioblastoma Multiforme (GBM)

Glioblastoma is most malignant and most frequent primary brain tumor. Glioblastoma Multiforme ( GBM) is also called WHO grade IV astrocytoma and it is the most malignant of the astrocytomas.
Incidence
 It accounts for 12-15% of all intracranial neoplasms and 60-75% of all astrocytic tumors.
Age 
It may manifest at any age, but preferentially affects adults, with a peak incidence at between 45 and 75 years of age. About 1% of patients are younger than 20 years old. primary GBM is more common in older adults between 60-75 years.
Secondary GBMs which constitute about 5% of all GBMs , usually occur about a decade or two decade earlier.
 Location
Cerebral hemispheres are the most common site in adults. Glioblastoma occurs most often in the subcortical white matter and deep periventricular white matter of the cerebral hemispheres. Most affectected sites are temporal, parietal frontal and occipital lobes. Combined fronto-temporal location is particularly typical.
Tumor infiltration often extends into the adjacent cortex and through the corpus callosum into the contralateral cerebral hemisphere. Glioblastoma is notorious for its rapid invasion of neighbouring brain structures. A very common feature is extension of the tumor through the corpus callosum into the contralateral hemisphere, creating the image of a bilateral, symmentrical lesion ( Butterfly glioma).
Glioblastoma of the basal ganglia and thalamus is not uncommon, especially in children. Glioblastoma of the brain stem( malignant brain stem glioma)is infrequent and often affects children.
20% of GBM are multifocal and of which 2-5% are synchronous.
Types of Glioblastoma and clinical features
Two forms of GBM are currently recognized: Primary ("de novo") GBM and secondary glioblastoma. Primary glioblastoma constitute majority, about more than 90%, , which arise de novo.
Secondary glioblastoma arise from a previously pre-existing lower grade glioma. While the two types share similar histology, they differ genetically. Neurofibromatosis type 1 ( NF1), Li Fraumeni and Turcot syndrome demonstrate an enhanced propensity to develop GBM.
The clinical history of the disease is usually short ( less than 3 months in more than 50% of cases). Unless the neoplasm has developed from a lower grade astrocytoma ( secondary glioblastoma).
Symptoms and signs of raised intracranial pressure ( headache, vomiting, papilledema) are common. Seizures , focal neurological deficits  are common. Sometimes patients may present with sudden stroke like features due to acute intratumoral hemorrhage ( in about 2% patients).
Histopathology
Glioblastoma on gross appearance look like Reddish-gray " rind of tumor, with necrotic core with marked peritumoral edema. It shows increased vascularity, and intra-tumoral hemorrhage.
The histopathological features include nuclear atypia, cellular pleomorphism, mitotic activity, vascular thrombosis, microvascular proliferation, and necrosis.
As the term glioblastoma " multiforme " suggests , the histopathology is extremely variable.  The varied tumor cells include: pleomorphic fibrillary astrocytes, gemistocytes, bipolar bland appearing but mitotically active small cells ( including " microglia")and large bizzare multinucleated giant cells. While some lesions show a high degree of cellular and nuclear polymorphism with numerous multinucleated giant cells, others are highly cellular, but rather monotonous.
GBMs generally have a high proliferation index (MIB-1), usually exceeding 10%.
Immunohistochemistry shows GFAP and olig 2 positivity. IDH-1 is very helpful in distingushing secondary GBM (positive) from primary GBM ( negative).
Radiology of Glioblastoma
At least 90 -95% of GBM demonstrate a thick, irregular, enhancing "rind" of tumor surrounding a necrotic core.
CT scan of brain: Most GBMs demonstrate a hypodense central mass surrounded by an iso-to moderately hyperdense rim on non-enhanced CT scan. Hemorrhage is common but calcification are rare. marked mass effect and significant hypodense peritumoral edema are typical ancillary findings.
Contrast Enhanced Computerized Tomography (CECT) of Brain reveals strong but heterogenous irregular rim enhancement. In highly vascular GBMs prominant vessels are seen as linear enhancing foci adjacent to the mass.
MRI of Brain: T1W1 image shows poorly marginated mass with mixed signal intensity . Subacute hemorrhage is common. T2/FLAIR image shows heterogenous intensity with extensive vasogenic edema. Necrosis, cysts, hemorrhage at various stages of evolution are seen. Fluid-debris level is seen in some cases.
Contrast Enhanced magnetic Resonance Imaging ( CE MRI) of brain shows strong but irregular contrast enhancement with central non-enhancing core.
DWI MR : most GBMs do not restrict on diffusion weighted imaging.
DTI may show increased fractional anisotropy and disrupted white matter tracts from tumor invasion.
MR spectroscopy (MRS) may show elevated choline peak and decreased NAA.
On imaging the differential diagnosis of GBM is usually Metastasis and Abscess. Metastasis is usually multiple and occur at gray-white matter junction and non-infiltrating. Intracranial abscess is usually thinner with more regular rim which usually restrict on DWI.

Treatment of Glioblastoma
Neurosurgery and Radiation Oncology intervention: Craniotomy and tumor decpmpression. The cytoreductive surgery followed by chemo and radiotherapy.

Sources:
1. WHO classification of Tumours of the central nervous system Edited by David N.Louis, Hiroko Ohgaki, Otmar D. Wiestler , Webster K.Cavene
2. Handbook of Neurosurgery by Mark S. Greenberg

Decompressive Craniectomy(DC), Decompressive Hemicraniectomy, Cranioplasty and Duraplasty

Decompressive craniectomy and decompressive hemicraniectomy are the similar termnologies which are used interchangeably to describe a wide frontotemporoparietal craniotomy on one side of the cranium to reduce the intranial pressure.
This procedure is commonly done in cases of traumatic brain injury and middle cerebral artery ( MCA) infarcts. About 10-15% patients with MCA infarct suffer from progressive clinical detrioration due to increased brain swelling, raised intracranial pressure (ICP) and subsequent herniation. Such space cupying infarct is commonly referred to as malignant MCA infarct. Edema associated with these infarcts is usually observed between the second and fifth day after the index event. Malignant MCA infarct is associated with poor prognosis.Its fatality rate is about 80% and most survivors are left with severe diability. Medical management of malignant MCA infarction is generally ineffective and requires a surgical intervention in the form of decompressive craniectomy for its relief. Surgical decompression reduces the risk of death or disability. An observation study conducted at AIIMS, Delhi had reported that patients who were operated within 48 hours from onset of smptoms and who were less than 60 years old showed better clinical improvement following decompressive craniectomy.
All patients with life threatening malignant MCA infarction indicated to undergo (DH) on the basis of clinical assessment basedon National Institute of Health Stroke Scale [ NIHSS], Glasgow oma scale (GCS) and neuroimaging.

Criteria for Surgery in cases of malignant MCA infarct are:
                        *NIHSS score more than 16
                         * GCS score less than 13
                         * Decrease in level of consciousness
                          * Clinical signs of herniation
                          *Presence of radiological evidence

A large Fronto temoporo pariental free bone craniotomy of about 12 centimeter to 15 centimeter is elevated with lax duraplasty. The free bone is placed in the subcutaneous fat pocket in the right iliac region of lower abdomen inferolateral to the umbilicus. When patient improves the cranioplasty is done with the same preserved bone.
DH in large MCA stroke patients leads to markedly improved survival and better functional outcome ( motor and language) and recovery in motor and ahasia recovery is progressive and sustained after 1 year.[1]
Decompressive craniectomy was originally decribed by Cushing. It is used in cases of refractomy intracranial hypertension where convenional therapies have failed. The technique involves removal of a large bone flap and opening the dura. The dura may be left open as it is or a graft may be used to enlarge the volume of the dural compartment. Once the period of intracranial hyertension has settled and patinet has improved, cranioplasty is done with the preserved free boen cranial flap. Study conducted at AIIMS by Sinha et al has reported that DC can ameliorate the secondary damage due raied ICP in cases of traumatic brain injury (TBI).

References
1. Long term outcome of decompressive hemicraniectomyin patients with malignat MCA infarcts: A prospective observational study. VK Rai et al , AIIMS, Delhi in Neurology India, 2014
2. Decompressive craniectomy in traumatic brain injury : a single center, multivariate analysis of 1,236 patients at a tertiary care hospital in India. Sumit Sinha et al, Neurology India
3. Ramamurthy and Tandons' Manual of Neurosurgery

Non-contrast CT scan of head of the patient after 6 months of Middle cerebral infarction showing a large area of the infarct with large craniectomy defect. Now patients' CT scan does not suggest any midline shift so patient may undergo cranioplasty.

Craniotomy bone flap is preseved in the subcutaneous fat in the right iliac fossa region in abdomen.

           

ANTIBIOTICS

Antibiotics are the medicines which are used to treat infections. Infections may be due to bacteria, fungi or virsuses. Almost everyone suffers from infection someimes in his life time.

Being infected is a bad feeling and everybody dislikes it. Sometimes, these infections are so dreaded that it is better to get immunity against such bad infections. So, vaccines are used to present such bad infections, Commonly used vaccines are BCG ( to prevent Tuberculosis), DPT ( to prevent Diphtheria, Pertusis and Tetanus), Anti Hepatitis B Surface antigen Vaccine ( to prevent infection against hepatitis B), Polio vaccine, etc.

But, all infections are not so dangerous, like common cold, sore throat, and small furuncle or small reddish pimple. Such infections usually subside by themselves due to the immunity of our own body. This immunity is mainly provided by white blood cells (WBCs) and lymphocytes present in our body. These act like Policemen patrolling our internal security. These security personnel detect and kill the foreign microbials or microorgaisms like bacteria.

Sometimes, infecions may overwhelming and required to be treated with antibiotics. Like common cold not subsiding and persisting for longer duration with superadded bacterial infection or sinusitis. Or, sore throat associated with yellowish sputum with cough and fever. So, we need to take antibiotics to treat such infections.

Infections may be superficial or deep, local or systemic. The infection depends upon virulence or the microorganism, resistance of the person, and living conditions. Like persons with diabetes with uncontrolled blood sugar level and patients on long term steroids have low resistance or immunity against the infecive microrgansms. Person living in crowded places with other people infected with communicable diseases are prone to acquire infections of the airborne diseases like tuberculosis, influenza, etc.

Skin infections are commonly caused by Staphylococcus aureus and Streptococcus. Invention  of Penicillins in 1928 by Scottish researcher, Alexander Flemming, made a great difference to the outcome of patients with infecions.

Sir Alexander Fleming

Sir Alexander Fleming was a Scottish physician, microbiologist, and pharmacologist. His best-known discoveries are the enzyme lysozyme in 1923 and the world's first antibiotic substance benzylpenicillin from the mould Penicillium notatum in 1928. The simple discovery and use of the antibiotic agent has saved millions of lives, and earned Fleming – together with Howard Florey and Ernst Chain, who devised methods for the large-scale isolation and production of penicillin – the 1945 Nobel Prize in Physiology/Medicine.

Penicillin was effective against fatal infections caused by bacteria. But, over time, these bacteria outsmarted the drug and developed resistance to these drugs. But, consistent efforts by the physicians, microbiologists, pharmacologists, biotechnologists and other inventors led to the development of many anti-microbial drugs which are commonly known as antibiotics.

So, commonly uses antibiotics are penicillins, cephalosporins, tetracyclines, macrolides, quinolones, anti-viral drugs, anti-fungal drugs, etc.

Common bacteria are described as Gram positive or Gram- negative. Gram positive bacteria are stained positively by Gram stain. 

Some bacteria produce exotoxins and some produce endotoxins. 

Tbe bacteria which produce exotoxins are Cornyebacterium diphtheriae, Clostridium tetani, C.botulinum, C.perfringens, Bacillus anthracis, Staphylococcus aureus, Streptococcus pogens ( all are examples of Gram positive bacteria).

Gram negative bugs which produce exotoxins are E.coli, Vibrio cholerae, and Bordetella pertusis. 

Endotoxin is a polysaccharide and is found in the cell wall of Gram-negative bacteria. 

Some bacteria do not stain well with Gram-stain, like Treponema, Rickettsia, Mycoplasma, Legionella pneuophila, Mycobacteria and Chlamydia.

For treponemes-darkfield microscopy and fluorescent antibody staining is used. 

Mycobacteria are acid-fast bacilli. Legionella is stained with silver stain.

Gram positive bacteria are broadly classified in 2 groups; Cocci and Bacilli.

Gram positive cocci are classified into two; catalase positive clusters ( Staphylococcus) and catalase negative chains ( Streptococcus). 

Catalase postive staphylococci are further classified into two groups as Coagulase positive ( S.aureus) and coagulase negative [ Staphylococcus epidermidis ( Novobiocin sensitive) and Staphylococcus saprophyticus ( Novobiocin resistant ].

Gram postive and catalase negative chains of cocci are Strptococcus. On the basis of hemolysis Streptococci are divided into 3 categories: Green ( partial ) hemolysis; Sterptococcus pneumoniae, Clear hemolysis Streptococcus pyogens ( group A Bacitracin sensitive), S.agalactiae ( group B, Bacitracin resistant) and 3rd category of streptococci with no hemolysis examples are Enterococcus ( E.fecalis) and Peptostreptococcus( anaerobe).

Exapmple of Gram positive bacilli ( rods) are: Clostridium ( anaerobe), Cornyebacterium, Listeria and Bacillus.

Gram negative bacteria which appear pink are broadly classified into three groups : Cocci, C0ccoid rods and rods. 

Gram negative cocci are Neisseria mningitidis and N.gonorrhoeae. These two are differentiated on the basis of Maltose fermenter chacteristic. N. menigitidis is Malose fermenter and N. gonorrhoeae is Maltose noferenter.

The examples of cgram negative coccoid rods are Hemophlus influenzae, Pasteurella, Brucella and Bordetella pertusis.

Gram negative rods are further subdivided into two subtypes based Lactose fermenter characteristic. Lactose fermenter gram negative rods are Klebsiella, E,coli and Enterobacter which are Fast fermenter and Citrobacter, and Serratia Slow fermenters.

Lactose nonfermenter gram negative rods are subdivided into two groups, based on oxidase property. Oxidase positive are Pseudomonas and oxidase negative are Shigella, Salmonella and Proteus.

Penicillin C is for intravenous use and Penicillin V is for oral use. 

Penicillin binds penicillin-binding proreins , blocks transpeptidase cross-linking of cell wall and activates autolytic enzymes. It is bactericidal for gram positive cocci and rods, gram negative cocci and spirochetes.

Methicillin, nafcillin have narrow spectrum and used against penicillase resistant Staphyloccus aureus.

Ampicillin, Amoxicillin have wider spectrum, penicillanse sensitive, also combined with clavulanic acid ( penicillanase inhibitor) to enhance spectrum. Amoxicillin has greater oral bioavailability than ampicillin. These two extended-spectrum penicillin and are useful against certain gram positive bacteria and gram negative rods ( Hemophilus influenzae, E.coli, Listeria monocytogens, Proteus mirabilis, Salmonella and enterococci). 

Carbenicillin, Piperacillin and Ticarcillin are extended spectrum penicillin and useful against Pseudomonas  and gram negative rods , susceptible to penicillanase, used with clavulanic acid.

Cephalosporins are beta lactam drugs. It inhibits cell wall synthesis 

Imipenem

      Imipenem is a broad spectrum, beta lactamase-resistant carbapenem. It is always administered with cilastatin which is inhibitor of renal dihydropeptidase 1 to decrease inactivation in renal tubules. Ii is used against gram positive cocci, gram negative rods and anaerobes. It is drug of hoice against Enterobacter. Its toxicity includes GI distress, skin rash, and CNS oxicity ( seizures).

Vancomycin

Aminoglycosides

Tetracyclines 

Macrolides

Chloramphenicol

Clindamycin

Sulfonamides

Trimethoprim

Fluroquinolones

Metronidazole

References: 

Wikpedia

Alexander Fleming (1881–1955): Discoverer of penicillin, Siang Yong Tan, Yvonne Tatsumura

Singapore Med J. 2015 Jul; 56(7): 366–367. doi: 10.11622/smedj.2015105

Intramedullary spinal cord Tumors

Intramedullary tumors are the tumors which are present in the spinal cord, i.e., inside the pial covering and substance of the spinal cord itself.

This diagram explains the location of the intramedullay tumors. Piamater is the innermost of three meninges ( Duramater, Arachnoid and Piamater). It covers the spinal cord. So the tumors outside of it may be IDEM ( intradural extramedullary) or extradural lesions. 

Spinal tumors are are classified as

 (1) extradural,

(2) intradural extramedullary, and

 (3) intradural intramedullary.

Extradural tumors are the most common spinal tumors and are usually of metastatic origin. 

Intradural Extramedullary (IDEM) tumors are mainly neurofibroma and meningioma.

Intradural intramedullary lesions comprise 20 to 30% of all primary spinal cord tumors.

Gliomas make up 80% of all intramedullary tumors. The gliomas are further subdivided into astrocytomas (60 to 70%) and ependymomas (30 to 40%). Hemangioblastomas are the third most frequent intramedullary spinal cord (IMSC) tumors, comprising 2 to 15% of all intramedullary tumors. Metastatic intramedullary tumors are rare but present in 2% of all intramedullary tumors. Lipomas are commonly associated with spinal dysraphism.

Intramedullary tumors constitute about 35-40% of all intraspinal tumors in children. In children intramedullary tumors are mainly developmental in origin, like dermoid, lipoma and epidermoid). In adults intramedullary tumors may arise later in life, like astrocytoma, ependymoma and hemangioblastoma.

Gliomatous and nongliomatous tumors constitute 90 and 10% respectively.

In 75% cases, the astrocytmas extend over 4 or less 4 vertebral segments. In some cases the lesions extends throughout the spinal cord, for example holocord astrocytomas.

Half of the central nervous system ependymomas are located in the spinal cord and, of these, 50% are located in the filum terminale. The next common site is the cervical cord.

Glioblastomas are not common.

Hemangioblastoms are rare, consist of less than 2% of primary spinal cord tumors.

Clinical presentation depends upon the site and size of the lesion.

MRI of spine with contrast is the investigation of choice.

                                  Intraoperative image of my adult patient where tumor is seen after posterior midline myelotomy. Histopathology of the tumor was suggestive of Pilocytic astrocytoma ( WHO grade 1 tumor)

The operating microscope, bipolar coagulators, intraoperative physiological monitoring ( somatosensory evoked potenial monitoring, motor evoked potential ) , microscissors, microdissectors, small tumor holding forceps, Cavitron Ultrasonic Surgical Aspirators (CUSA) , intraoperative USG ( Ultrasonography) are good for safe excision of intramedullary lesions.

References

Samartzis D, Gillis CC, Shih P, O'Toole JE, Fessler RG. Intramedullary Spinal Cord Tumors: Part I-Epidemiology, Pathophysiology, and Diagnosis. Global Spine J. 2015;5(5):425-35. And references as numbered below

Mechtler L L, Nandigam K. Spinal cord tumors: new views and future directions. Neurol Clin. 2013;31(1):241–268.

Grimm S, Chamberlain M C. Adult primary spinal cord tumors. Expert Rev Neurother. 2009;9(10):1487–1495.

DeSousa A L, Kalsbeck J E, Mealey J Jr, Campbell R L, Hockey A. Intraspinal tumors in children. A review of 81 cases. J Neurosurg. 1979;51(4):437–445.

Mandigo C E, Ogden A T, Angevine P D, McCormick P C. Operative management of spinal hemangioblastoma. Neurosurgery. 2009;65(6):1166–1177.

Ravi Ramamurthy. Spinal Intramedullary Tumours. Chapter 130, Volume 2, in Textbook of Operative Neurosurgery, B.I Publications Tvt Ltd, New Delhi, Pages1107-1113.