Orthopedics Book

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Tumors of the Spine

Aka: Tumors of the Spine, Spinal Neoplasm, Spine Metastatic Disease, Spine Metastases, Metastatic Spinal Tumor, Epidural Spinal Cord Compression, Spinal Cord Compression by Tumor Infiltration, Myelopathy due to Spinal Tumor
  1. Epidemiology
    1. Epidural Spinal Cord Compression occurs in 5% of cancer patients
  2. Causes: Benign Primary spinal tumors
    1. Osteoid Osteoma
    2. Eosinophilic Granuloma
    3. Aneurysmal bone cyst
    4. Osteoblastoma
  3. Causes: Malignant Primary spinal tumors
    1. Sarcoma
    2. Multiple Myeloma (most common in adults)
  4. 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
      1. Breast Cancer (most common cause of malignant Epidural Spinal Cord Compression)
      2. Multiple Myeloma
      3. Lung Cancer
      4. Renal Cancer
      5. Prostate Cancer
      6. Lymphoma
      7. Thyroid Cancer
  5. Symptoms
    1. Back pain (new onset back pain is most common presenting symptom)
      1. Worse at rest, lying supine
      2. May awaken patient at night
    2. Later changes
      1. Weakness (75%)
      2. Autonomic or sensory symptoms (50%)
      3. Urinary Incontinence
  6. Signs: Neurologic Exam (Motor Exam)
    1. Symmetric motor weakness
      1. In Epidural Spinal Cord Compression, motor deficits are more common than sensory
    2. Pain on Vertebral body compression
    3. Early changes
      1. Flaccidity
      2. Hyporeflexia
    4. Later changes
      1. Cauda Equina Syndrome
      2. Spasticity
      3. Hyperreflexia
  7. Labs
    1. Erythrocyte Sedimentation Rate > 50 mm/hour
  8. Imaging
    1. Protocol
      1. Back pain without myelopathy or radiculopathy
        1. Start with plain Spine XRay
        2. Spine XRay negative: Obtain Bone Scan
        3. Spine XRay positive: Obtain MRI
      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)
    2. Xray spine
      1. Will demonstrate solid tumor
    3. Spine MRI (first line test)
      1. Non-contrast study is preferred
      2. Evaluates for cord compression
    4. Other testing
      1. Spine Bone Scan
      2. Myelography (replaced by MRI)
  9. 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. Dosing
          1. Dexamethasone
            1. Protocol 1: 10 mg IV, followed by 4 mg q6 hours
            2. Protocol 2: 6 mg IV q6 hours
          2. High dose (up to 100 mg) is controversial
            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
  10. 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
  11. References
    1. Arce (2001) Am Fam Physician 64(4):631-8 [PubMed]
    2. Bilsky (1999) Oncologist 4:459-69 [PubMed]
    3. Higdon (2018) Am Fam Physician 97(11):741-8 [PubMed]
    4. Joines (2001) J Gen Intern Med 16:14-23 [PubMed]

Spinal cord compression by tumor infiltration (C1867611)

Concepts Finding (T033)
English Spinal cord compression by tumor infiltration
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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