The most common presenting symptom in patients with IMSCT is a pain, which classically worsens at night when the patient is recumbent and can be diffuse or radicular in nature. If the dermatomal distribution is unusual for a disk herniation, IMSCT should be suspected.  The pain also can be local, causing stiff neck or back, and can be described as burning and bilateral. As IMSCT can impinge on the motor or sensory nerves, sensory changes such as paresthesia can be seen, followed by motor disturbances as the second or third most common complaint.  In children, gait disturbance frequently is seen.  In addition to motor weakness, patients also can have clumsiness and ataxia, atrophy, muscle twitches, fasciculations, and decreased deep tendon reflexes. Loss of bowel and bladder function can occur at a later stage and can lead to retention, incontinence, or impotence. In children, diagnosis is especially difficult, where IMSCT can remain asymptomatic for a long time. Children can have nonspecific complaints, and their symptoms can be misperceived as clumsiness, although scoliosis can be seen in 30% of patients.

Following the identification of symptoms, magnetic resonance imaging (MRI) is the preferred modality to characterize IMSCT for further treatment planning. MRI can show the size, location, length, extent of surrounding edema, the presence of the cord-tumor interface, and associated cysts or syringomyelia. Although each of the three common types of IMSCT has a particular T1-, T2-, and contrast-enhanced T1 weighted imaging pattern, differentiation between them based on imaging alone remains difficult. Both ependymomas and astrocytomas span multiple vertebral segments, enhance with contrast, are hypo- or isointense on T1-weighted, and are hyperintense on T2 weighted images. Ependymomas often are located centrally within the spinal cord leading to symmetric expansion, occupy the whole width of the cord, and enhance diffusely with a well-defined border. Astrocytomas tend to be positioned more eccentrically, can be non-enhancing or have an enhancing nodule or large satellite cysts, and usually, do not have a well-defined border. Intratumoral hemorrhage can be seen in both types, but are more common in ependymomas. Hemangioblastomas have homogeneous contrast enhancement compared to the more heterogeneous pattern found in astrocytomas or ependymomas. They also have mural nodules, are associated with syringomyelia, and can have significant surrounding edema. As they are highly vascularized tumors, spinal angiography is helpful to characterize feeding vessels and associated dilated pial veins from vascular shunting and can help in the consideration for pre-operative embolization.[9][5]

Surgical resection should be performed as soon as possible following a diagnosis of IMSCT, as outcomes correlate with the preoperative neurologic conditions, and observation can lead to further neurologic deficits, some of which are irreversible. The goals of surgical resection are to obtain tissue diagnosis, maximize tumor resection, and improve neurologic functions. Intraoperative somatosensory and motor evoked potentials are used to monitor for changes in neurologic function and help guide resection. The extent of total resection is greatly dependent on the presence of a clear plane between tumor and normal spinal cord tissue. Astrocytomas are infiltrative nonencapsulated tumors that are challenging to resect. For low-grade astrocytoma, if a plane can be developed between the tumor and spinal cord, gross total resection is an option; however, for high-grade astrocytoma or low-grade astrocytoma with no definable plane of resection, biopsy plus limited resection is recommended, as aggressive resection can lead to significant neurologic deficits. Postoperative radiotherapy can be used for high-grade astrocytomas. Ependymomas are benign with a distinct tumor and normal spinal cord interface, making gross total resection an option for cure. The rate of recurrence is dependent on the extent of tumor resection, and with the presence of a discrete surgical plane, gross total resection is reported in more than 90% of cases of ependymomas. Similarly, hemangioblastomas also can be resected circumferentially, and pre-operative embolization can attenuate their rich vascular supply. Complete excision is possible in 83% to 92% of patients with clinical improvements noted following resection. Generally, for IMSCT, better long-term outcomes are seen in patients with less preoperative deficits, and recurrence depends on the extent of resection and tumor histology. Adjuvant therapies, including radiotherapy and chemotherapy, are often reserved for tumor recurrence, high-grade lesions, or when there are contraindications to resection. Further research into novel treatment strategies is needed to improve outcomes, especially for astrocytomas with no clear surgical resection planes.[10][11][12]

• Benign lesions - Epidermoid cyst, lipoma
• Glial tumors - Ependymoma, Astrocytoma, Ganglioglioma
• Non-glial tumors - Hemangioblastoma, metastasis, lymphoma

The outcomes for patients with intramedullary spinal cord tumors are guarded. Those with neurological deficits are presentation have the worst outcomes. Patients with the metastatic disease rarely live beyond 12 months.[13] (Level V)

• Paralysis
• Complications related to bed-ridden state - deep vein thrombosis, bedsore, atelectasis
• Local spread of the lesion
• Death

Patients should be adequately counseled regarding the prognosis of the disease and expected neurological and functional outcomes.

Intramedullary spinal cord tumors are best managed by an interprofessional team that includes and neurosurgeon and neuro-critical care nurses experienced in monitoring these patients. Surgical resection should be performed as soon as possible following a diagnosis of IMSCT, as outcomes correlate with the preoperative neurologic conditions, and observation can lead to further neurologic deficits, some of which are irreversible. The goals of surgical resection are to obtain tissue diagnosis, maximize tumor resection, and improve neurologic functions. When surgeons cannot completely excise the lesion, adjuvant therapy may be tried.[14] The neuro-critical care nurse should monitor the patient's physical exam, focusing on any signs of progression of tumor involvement compressing the spinal cord. If new deficits develop, they should contact the surgeon in managing the case immediately. Pain control balanced again blunting the physical exam is also a challenge. A critical care specialist pharmacist should assist the clinician in evaluating pain medication choices and dosing as well as monitoring the patient for appropriate pain relief. an interprofessional approach will provide the best outcomes.