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Compression of the spinal cord by a metastatic tumor in the vertebral column is a common occurrence in many types of cancer Primary tumors of the spinal cord, however, are considerably less frequent In the Mayo Clinic series of 8784 primary tumors of the CNS, only 15 percent were intraspinal (Sloof et al) In distinction to brain tumors, the majority of intraspinal ones are benign and produce their effects mainly by compression of the spinal cord rather than by invasion Thus, a proportion of intraspinal tumors are amenable to surgical removal, and their early recognition, before irreversible neurologic changes have occurred, becomes a matter of utmost importance Anatomic Considerations Neoplasms and other space-occupying lesions within the spinal canal can be divided into two groups:

(1) those that arise within the substance of the spinal cord, either as a primary neural neoplasm or as a metastasis, and invade and destroy tracts and central gray structures (intramedullary) and (2) those arising outside the spinal cord (extramedullary), either from vertebral bodies and epidural tissues (extradural) or in the leptomeninges or roots (intradural) In a general hospital, the relative frequency of spinal tumors in these different locations is about 5 percent intramedullary, 40 percent intradural-extramedullary, and 55 percent extradural, the majority of the latter being metastatic cancers, as already mentioned This percentage of extradural lesions is higher than that encountered in more specialized neurosurgical services (eg, Elsberg s gures of 7, 64, and 29 percent, respectively), probably because the latter do not include as many patients with extradural lymphomas, metastatic carcinomas, etc, as are seen in general hospitals The most common primary extramedullary tumors are the neuro bromas and meningiomas (Fig 44-10), which together constitute about 55 percent of all intraspinal neoplasms They are more often intradural than extradural Neuro bromas have a predilection for the thoracic region, whereas meningiomas are more evenly distributed over the vertical extent of the cord The other primary extramedullary tumors are sarcomas, vascular tumors, chordomas, and epidermoid and similar tumors, in that order of frequency Primary intramedullary tumors of the spinal cord have the same cellular origins as those arising in the brain (Chap 31), although the proportions of particular cell types differ Ependymomas (some of which arise from the lum terminale; page 860)

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instance failures The standby site contains a physical standby database that is synchronized with the primary database by using Oracle Data Guard The Active Data Guard option enables the physical standby database to be open in a read-only state while the database is kept in sync with the primary database Active Data Guard enables you to offload read-only queries to the standby site and enhances the overall availability of the database by utilizing an otherwise idle standby site for reporting purposes The figure also depicts the use of Oracle database technologies such as Flashback, RMAN, and ASM for providing high availability during planned and unplanned downtime We ll next cover the Oracle high-availability features that address planned and unplanned downtime The intent is not to cover the complete set of MAA technologies, but only the topics that relate to the Exadata Database Machine and the common tasks that will be performed on the Machine The topics discussed in this section are listed here:

Figure 44-11 T1-weighted MRI of an intramedullary thoracic ependymoma, causing expansion of the cord and edema over several segments There is faint enhancement of the tumor with gadolinium

Figure 44-10 Gadolinium-enhanced MRI of intraspinal meningioma that caused incontinence and leg weakness, including spastic and accid elements (combined conus and cauda syndrome)

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make up 60 percent of the spinal cord cases (Fig 44-11) and astrocytomas about 25 percent The astrocytoma is the most common intramedullary tumor if one excludes tumors arising in the lum terminale Oligodendrogliomas are much less common The remainder (about 10 percent) consists of a diverse group of nongliomatous tumors: lipomas, epidermoids, dermoids, teratomas, hemangiomas, hemangioblastomas, and metastatic carcinomas The cavernous hemangioma may be a source of spontaneous hematomyelia As indicated further on, there is a frequent association between intramedullary tumors (both gliomatous and nongliomatous) and syringomyelia The basis of this relationship remains obscure Intramedullary growths invade as well as compress and distort fasciculi in the spinal cord white matter As the cord enlarges from the tumor growing within it or is compressed by a tumor from without, the free space around the cord is eventually consumed, and the CSF below the lesion becomes isolated or loculated from the remainder of the circulating uid above the lesion This is indicated by a Froin syndrome (xanthochromia and clotting of CSF) and an interruption of ow of contrast medium in the subarachnoid space (by myelogram) The most informative diagnostic procedure

This is a neurosis of sorts, which accounts for 1 to 2 percent of admissions to a neurologic service and a greater number of outpatient visits It usually has its onset in the teens or early twenties, almost exclusively in young women; a very few cases begin before puberty Once established, the diagnosis remains unchanged over many years but the symptoms recur intermittently, though with reduced frequency, throughout the adult years even to an advanced age No doubt there are cases of lesser severity in which symptoms occur only a few times or perhaps only once, just as there are mild forms of other diseases The patient may be seen for the rst time during middle life or later, and the earlier history may not at rst

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Some of the newer sound systems provide advanced speaker output capabilities, which allows for multichannel hi-fi to be played by your computer Hooking these systems up can sometimes require external connectors, splitters, and other devices Make sure they are all functioning and connected properly before diving into the audio card

High availability with Oracle Data Guard Using Oracle GoldenGate with Database Machine Database Machine patches and upgrades Exadata Storage Server high availability Preventing data corruption

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