II. Epidemiology

  1. Epidural Spinal Cord Compression occurs in 5% of cancer patients

III. Pathophysiology

  1. Mechanism
    1. External compression from epidural lesions, typically metastases (90% of causes) or
    2. Vertebral body metastases may impinge on thecal sac
    3. Pathologic Fractures of spine with fragment retropulsion and cord compression
  2. Distribution
    1. Thoracic Spine is most common site of metastases (60-70%)
      1. Breast Cancer and Lung Cancer have predilection for Thoracic Spine
      2. Large blood supply
      3. Half the Vertebrae of entire spine
      4. Narrow spinal canal
      5. Most common site of Vertebral compression
    2. Lumbar Spine (25% of metastatic spine lesions)
      1. Prostate Cancer has predilection for Lumbar Spine
    3. Cervical Spine (15% of metastatic spine lesions)

IV. Causes: Benign Primary Spinal Tumors

V. Causes: Malignant Primary Spinal Tumors

  1. Sarcoma
  2. Multiple Myeloma (most common in adults)

VI. Causes: Metastatic Tumors of the Spine

  1. General
    1. Spine is third most common metastatic site
    2. More common than primary spine tumors by 25 fold
  2. Sources in Adults
    1. Breast Cancer (20%, most common cause of malignant Epidural Spinal Cord Compression)
    2. Lung Cancer (20%)
    3. Prostate Cancer (20%)
    4. Multiple Myeloma
    5. Renal Cell Cancer
    6. Non-Hodgkin's Lymphoma
    7. Thyroid Cancer
  3. Sources in Children
    1. Sarcoma
    2. Lymphoma
    3. Neuroblastoma

VII. Symptoms

  1. Back pain (80-95% of cases, new onset back pain is most common presenting symptom)
    1. Worse at rest, lying supine
    2. May awaken patient at night
    3. Precedes other symptoms by 2 months
    4. Midline focal tenderness to percussion
  2. Later changes
    1. Weakness (75%)
    2. Autonomic or sensory symptoms (50%)
    3. Urinary Incontinence

VIII. Signs: Neurologic Exam (Motor Exam)

  1. Symmetric motor weakness
    1. In Epidural Spinal Cord Compression, motor deficits are more common than sensory
    2. However sensory deficits are also present in 40-90% of cases
  2. Pain on Vertebral body compression
  3. Early changes
    1. Flaccidity
    2. Hyporeflexia
  4. Later changes
    1. Cauda Equina Syndrome (esp. bowel and Bladder changes)
    2. Spasticity
    3. Hyperreflexia

IX. Labs

X. Imaging

  1. Approach
    1. Image entire spine (multiple sites throughout the spine are present in at least one third of cases)
    2. Back pain with Myelopathy or radiculopathy
      1. Mild: MRI within 24 hours
      2. Severe or progressive: Emergent MRI now
        1. Also administer empiric Dexamethasone (below)
    3. Back pain without Myelopathy or radiculopathy
      1. Consider starting with plain film Spine XRay
      2. Spine XRay negative: Bone Scan or MRI
      3. Spine XRay positive: Obtain MRI
  2. Spine MRI with gadolinium contrast (first line test)
    1. Evaluates for cord compression
    2. Test Sensitivity: 93%
    3. Test Specificity: 97%
  3. CT with myelography
    1. Indicated in patients unable to undergo MRI
  4. Xray Spine
    1. May demonstrate solid tumors
  5. Bone Scan
    1. Consider in combination with XRay as alternative to MRI
  6. Post-Void Residual
    1. Bladder Ultrasound after voiding

XI. Management: Neurologic compromise (emergency)

  1. Precautions
    1. Permanent paralysis (Paraplegia) may occur even with delay of hours
  2. Indications (see complications below)
    1. Epidural Spinal Cord Compression
    2. Sudden Myelopathy
  3. Systemic Corticosteroids (Pretreatment)
    1. Indicated in all cases of neurologic involvement
      1. Reduces spinal cord edema
      2. Alleviates pain
    2. Protocol
      1. Start as soon as diagnosis is suspected
        1. Delay in diagnosis can result in Paraplegia
      2. Dexamethasone
        1. Protocol 1: 10 mg IV, followed by 4 mg orally every 6 hours
        2. Protocol 2: 6 mg IV every 6 hours
        3. Older, high dose regimens (up to 100 mg) are not typically used
          1. Heimdal (1992) J Neurooncol 12:141-4 [PubMed]
  4. Immediate Consultations
    1. Neurosurgery Consultation
    2. Radiation Oncology Referral
  5. Mass Reduction
    1. Radiation Therapy (Standard)
      1. Localized radiation up to 3000 Gy
    2. Surgery Indications
      1. Unsure diagnosis
      2. Unstable spine
      3. Severe, rapid, progressive neurologic deterioration
      4. Radiation Therapy not expected to be effective

XII. Complications

  1. Epidural Spinal Cord Compression
    1. Thoracic Spine (66%)
    2. Lumbosacral Spine (20%)
    3. Cervical Spine (14%)
  2. Acute Myelopathy Causes
    1. Irradiation
    2. Paraneoplastic necrotizing Myelitis
    3. Ruptured intervertebral disc
    4. Meningeal carcinomatosis

XIII. Prognosis

  1. Best prognosis is based on ambulation and neurologic status

XIV. References

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Related Studies

Ontology: Epidural Neoplasms (C0014536)

Definition (MSH) Neoplasms located in the space between the vertebral PERIOSTEUM and DURA MATER surrounding the SPINAL CORD. Tumors in this location are most often metastatic in origin and may cause neurologic deficits by mass effect on the spinal cord or nerve roots or by interfering with blood supply to the spinal cord.
Concepts Neoplastic Process (T191)
MSH D015174
English Epidural Neoplasms, Epidural Tumors, Neoplasms, Epidural, NEOPL EPIDURAL, EPIDURAL NEOPL, Epidural Neoplasms [Disease/Finding], epidural tumor, epidural tumors, Extradural neoplasm, Epidural tumor, Epidural tumour, Epidural Neoplasm, Epidural Tumor, Epidural Spinal Canal Neoplasm, Epidural Spinal Canal Tumors, Epidural Spinal Canal Tumor, Epidural Spinal Neoplasms, Epidural Spinal Tumors, Extradural Neoplasm, Extradural Spinal Canal Neoplasms, Extradural Spinal Canal Neoplasm, Extradural Spinal Canal Tumor, Extradural Spinal Neoplasms, Extradural Spinal Tumors, Extradural Tumor, Neoplasm of Epidural Spinal Canal, Neoplasm of Extradural Spinal Canal, Neoplasm of the Epidural Spinal Canal, Neoplasm of the Extradural Spinal Canal, Tumor of Epidural Spinal Canal, Tumor of Extradural Spinal Canal, Tumor of the Epidural Spinal Canal, Tumor of the Extradural Spinal Canal
French Tumeurs de l'espace épidural, Tumeur extra-durale, Tumeur épidurale, Tumeurs de l'espace extradural, Tumeurs de l'espace péridural, Tumeurs extradurales, Tumeurs épidurales
Swedish Epiduraltumörer
Czech epidurální nádory, Extradurální novotvar, Epidurální nádor
Finnish Epiduraaliset kasvaimet
Japanese 硬膜外腫瘍, コウマクガイシュヨウ, コウマクガイシンセイブツ, 硬膜外新生物
Italian Tumori epidurali, Tumore epidurale, Tumore extradurale, Neoplasie epidurali
Polish Nowotwory nadtwardówkowe
Norwegian Epiduralsvulster, Epiduraltumorer, Epidurale neoplasmer, Epidurale svulster, Epidurale tumorer
Dutch epidurale tumor, extraduraal neoplasma, Epidurale tumor, Epidurale tumoren, Tumor, epidurale, Tumoren, epidurale
German epiduraler Tumor, extradurale Neubildung, Epidurale Tumoren
Hungarian Epiduralis daganat, Epiduralis tumor, Extraduralis neoplasia
Portuguese Neoplasia extradural, Tumor epidural, Neoplasias Epidurais
Spanish Tumor epidural, Neoplasia extradural, Neoplasias Epidurales

Ontology: Spinal Cord Neoplasms (C0037930)

Definition (NCI) A primary or metastatic neoplasm affecting the spinal cord.
Definition (MSH) Benign and malignant neoplasms which occur within the substance of the spinal cord (intramedullary neoplasms) or in the space between the dura and spinal cord (intradural extramedullary neoplasms). The majority of intramedullary spinal tumors are primary CNS neoplasms including ASTROCYTOMA; EPENDYMOMA; and LIPOMA. Intramedullary neoplasms are often associated with SYRINGOMYELIA. The most frequent histologic types of intradural-extramedullary tumors are MENINGIOMA and NEUROFIBROMA.
Concepts Neoplastic Process (T191)
MSH D013120
SnomedCT 126962006
English Neoplasm, Spinal Cord, Neoplasms, Spinal Cord, spinal cord neoplasm, SPINAL CORD NEOPL, NEOPL SPINAL CORD, spinal cord tumor, spinal cord tumor (diagnosis), Spinal Cord Tumors, Tumor, Spinal Cord, Tumors, Spinal Cord, Spinal Cord Neoplasms, Spinal Cord Neoplasms [Disease/Finding], spinal tumour, spinal tumours, spinal cord tumors, spinal tumor, spinal tumors, Spinal cord neoplasm NOS, Spinal cord--Tumors, Spinal cord neoplasm, Spinal tumor, Spinal tumour, Tumor of spinal cord, Tumour of spinal cord, Neoplasm of spinal cord (disorder), Neoplasm of spinal cord, Spinal Cord Neoplasm, Spinal Cord Tumor, Neoplasm of Spinal Cord, Neoplasm of the Spinal Cord, Tumor of Spinal Cord, Tumor of the Spinal Cord
Italian Tumore del midollo spinale, Tumore del midollo spinale NAS, Neoplasie del midollo spinale
Dutch ruggenmergneoplasma NAO, ruggenmergneoplasma, Gezwel, ruggenmerg-, Gezwellen, ruggenmerg-, Ruggenmerggezwel, Ruggenmerggezwellen
French Tumeur de la moelle épinière SAI, Tumeur de la moelle épinière, Tumeurs de la moelle épinière, Tumeurs médullaires
German Neoplasie des Rueckenmarks NNB, Neubildung des Rueckenmarks, Neubildungen, Rückenmark-, Rückenmarkstumoren
Portuguese Neoplasia da medula espinal NE, Neoplasias da Medula Espinal, Neoplasias Intramedulares da Medula Espinhal, Neoplasias da Medula Espinhal, Neoplasias Intradurais-Extramedulares da Medula Espinhal, Neoplasia da medula espinal
Spanish Neoplasia de la médula espinal NEOM, neoplasia de la médula espinal (trastorno), neoplasia de la médula espinal, Neoplasia de la médula espinal, Neoplasias de la Médula Espinal
Japanese 脊髄新生物NOS, セキズイシンセイブツNOS, セキズイシンセイブツ, 脊髄新生物, 脊髄腫瘍
Swedish Ryggmärgstumörer
Finnish Selkäytimen kasvaimet
Czech Novotvar míchy, Novotvar míchy NOS, nádory míchy, tumory míchy, mícha - nádory, míšní nádory
Polish Nowotwory rdzenia kręgowego
Hungarian Gerincvelő neoplasia, Gerincvelő neoplasia k.m.n.
Norwegian Ryggmargskreft, Ryggmargsneoplasmer, Ryggmargssvulster, Ryggmargstumorer

Ontology: Spinal Neoplasms (C0037939)

Definition (NCI) A primary or metastatic neoplasm that occurs within the spinal canal including the spinal cord and surrounding paraspinal spaces.
Concepts Neoplastic Process (T191)
MSH D013125
English Neoplasm, Spinal, Neoplasms, Spinal, Spinal Neoplasm, SPINAL NEOPL, Spinal tumors, Spinal Neoplasms, Spinal Neoplasms [Disease/Finding], neoplasm spinal, spinal neoplasms, Intraspinal Neoplasms, Intraspinal Neoplasm, Intraspinal Tumor, Neoplasm of Spinal Canal and Spinal Cord, Neoplasm of the Spinal Canal and Spinal Cord, Neoplasms of Spinal Canal and Spinal Cord, Neoplasms of the Spinal Canal and Spinal Cord, Spinal Canal Tumors, Spinal Canal and Spinal Cord Neoplasm, Spinal Canal and Spinal Cord Tumor, Spinal Tumors, Tumor of Spinal Canal and Spinal Cord, Tumor of the Spinal Canal and Spinal Cord
Swedish Ryggradstumörer
Finnish Selkärangan kasvaimet
Polish Nowotwory kręgosłupa
Norwegian Svulster i ryggsøylen, Spinaltumor, Tumor i ryggsøylen, Spinale neoplasmer, Spinale tumores, Neoplasmer i ryggraden, Neoplasmer i ryggsøylen
Czech páteř - nádory, spinální nádory, nádory páteře
Spanish Tumores Vertebrales, Tumores Raquídeos, Neoplasias de la Columna Vertebral
French Tumeurs du rachis, Tumeurs rachidiennes, Tumeurs des vertèbres, Tumeurs vertébrales
German Neubildungen, Wirbelsäulen-, Wirbelsäulentumoren
Italian Neoplasie della colonna vertebrale
Dutch Spinale tumor, Tumor, wervelkolom-, Wervelkolomtumor, Wervelkolomtumoren
Portuguese Neoplasias da Coluna Vertebral

Ontology: Spinal cord compression by tumor infiltration (C1867611)

Concepts Finding (T033)
English Spinal cord compression by tumor infiltration