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spinal cord compression; compressive myelopathy

Etiology: 1) epidural compression by metastatic tumor a) lung cancer b) breast cancer c) prostate cancer d) multiple myeloma e) renal cell carcinoma f) germ cell tumor 2) compression from local nodal involvement & tumor infiltration through intervertebral foramina - lymphoma, leukemia 3) trauma 4) epidural abscess 5) epidural hematoma Pathology: 1) thoracic compression (70%) 2) lumbar compression (20%) 3) cervical compression (10%) 4) involvement of multiple non-contiguous levels (10-40%) Clinical manifestations: 1) pain (90%) - localized spinal or radicular pain - pain may be aggravated by coughing, sneezing or straight-leg raising - cervical pain may radiate down arm - thoracic pain radiates around rib cage or abdominal wall - may be described as a compressing band bilateral around chest or abdomen - lumbar pain may radiate into the groin or down the leg 2) fever & focal pain & tenderness suggest epidural abscess 3) paresthesias 4) sensory loss, especially perineal 5) muscle weakness, motor deficits, paralysis - motor deficits at the time of diagnosis predicts neurologic outcome 6) abnormal reflexes, arreflexia, Babinski sign 7) autonomic manifestations a) urinary incontinence b) fecal incontinence 8) clinical syndromes of acute spinal cord compression [8] a) transverse myelopathy b) spinal shock c) central cord syndrome d) hemicord syndrome (Brown-Sequard syndrome) e) conus medullaris syndrome f) cauda equina syndrome 9) upper motor neuron signs - spasticity, hyperreflexia, extensor plantar response 10) occasionally lower motor neuron signs - atrophy, hyporeflexia Radiology: 1) magnetic resonance imaging (MRI) with gadolinium contrast of entire spine - > 1 site of spinal cord compression is common [3] 2) plain radiograph of little value 3) bone scan of little value [3] Differential diagnosis: - fever: epidural abscess - anticoagulation: epidural hematoma - cancer: metastases - trauma: vertebral fracture - elderly with chronic back &/or leg pain: spinal stenosis Management: 1) acute spinal cord compression is a medical emergency 2) establish diagnosis before neurologic deficits occur - avoid permanent disability - special case of epidural abscess 3) dexamethasone immediately a) initial: 10-100 mg IV b) then: 4 mg IV QID c) taper as indicated d) of no benefit if due to hematoma [3] e) avoid if due to infection [3] 4) surgery a) indications - surgical decompression - prior to radiation therapy for metastatic cancer [3,6]* - < 65 years, single area of compression, paraplegia < 48 hours, predicted survival > 6 months [3] - leukemia, lymphoma, multiple myeloma, germ cell tomors may be treated urgently with radiation therapy [3] - spine instability - tolerance to spinal cord irradiation - progressive neurologic decline despite radiation b) surgical decompression may have better outcomes [2] 5) radiation therapy to involved areas - leukemia, lymphoma, multiple myeloma, germ cell tomors - plasmacytoma, including spinal extradural solitary plasmacytoma - other radiosensitive tumors should have radiation therapy after surgery [3] 6) opiates for pain 7) chemotherapy for sensitive tumors a) lymphoma b) breast cancer 8) prognosis: - neurologic status is the most important predictor of prognosis in neoplastic spinal cord compression - ambulatory patients tend to remain ambulatory with treatment - nonambulatory patients generally remain nonambulatory [3] * except as per radiation therapy to involved areas

Related

cauda equina syndrome spinal stenosis

General

spinal cord injury (SCI)

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 681-682
  2. Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, Mohiuddin M, Young B. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005 Aug 20-26;366(9486):643-8. PMID: 16112300
  3. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Klimo P; Kestle JRW; Schmidt MH Treatment of Metastatic Spinal Epidural Disease: A Review of the Literature. http://www.medscape.com/viewarticle/465359
  5. Taylor JW, Schiff D. Metastatic epidural spinal cord compression. Semin Neurol. 2010 Jul;30(3):245-53. PMID: 20577931
  6. George R, Jeba J, Ramkumar G, Chacko AG, Leng M, Tharyan P. Interventions for the treatment of metastatic extradural spinal cord compression in adults. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006716 PMID: 18843728
  7. Tsutsumi S, Yasumoto Y, Ito M. Solitary spinal extradural plasmacytoma: a case report and literature review. Clin Neuroradiol. 2013 Mar;23(1):5-9. PMID: 22706517
  8. Ropper AE, Ropper AH. Acute Spinal Cord Compression. N Engl J Med 2017; 376:1358-1369. April 6, 2017 PMID: 28379788 http://www.nejm.org/doi/full/10.1056/NEJMra1516539
  9. George R, Jeba J, Ramkumar G, Chacko AG, Tharyan P. Interventions for the treatment of metastatic extradural spinal cord compression in adults. Cochrane Database Syst Rev. 2015 Sep 4;(9):CD006716. Review. PMID: 26337716
  10. Kelley BC, Arnold PM, Anderson KK. Spinal emergencies. J Neurosurg Sci. 2012 Jun;56(2):113-29. Review. PMID: 22617174