Spinal Cord Neoplasms
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Neoplastic disease that involves the spine and results in spinal cord compression may be devastating.
Primary spinal cord tumors arise from the different elements of the central nervous system (CNS), including neurons, supporting glial cells, and meninges. Anatomically, neoplasms of the spinal cord may be classified according to the compartment of origin, either intramedullary (inside the cord) or extramedullary (outside the cord).
Additionally, cancers that metastasize to the vertebrae or surrounding tissues frequently cause spinal cord compression. Metastatic lesions are featured in this article, as they cause 85% of the cases of neoplastic spinal cord compression. The clinical presentation tends to be indistinguishable from that of primary cancers of the spine.
For the emergency physician, the cell origin of the tumor is less of a concern than the consequent syndromes of spinal cord dysfunction. These patients require rapid diagnosis and treatment to prevent permanent complications (see Presentation, Workup, and Treatment.
Metastatic spinal cord compression usually follows hematogenous dissemination of malignant cells to the vertebral bodies, with subsequent expansion into the epidural space. Spread into the epidural space may occur by means of tumor extension through the intervertebral foramina or hematogenous spread by way of the Batson venous plexus. Most frequently, metastatic seeding appears in the thoracic spine (accounting for about 70% of cases), with the lumbar spine being the next most involved site (20% of cases). The cervical spine is affected in approximately 10% of cases. Multiple spinal levels are affected in about 30% of patients. [1]
Systemic cancers with a tendency for spinal cord metastasis include the following:
Gastrointestinal and pelvic malignancies tend to affect the lumbosacral spine. Lung and breast cancers are more likely to affect the thoracic spine.
Metastases to the substance of the cord (intramedullary) are relatively rare. Signs and symptoms in such cases tend to resemble those of epidural compression; however, the associated motor weakness is more likely to be unilateral. Principles of treating intramedullary cancer are similar to those for epidural spinal cord compression.
Leptomeningeal metastases spread by means of diffuse or multifocal seeding of the meninges from systemic cancer (eg, lung or breast cancer, melanoma, lymphoma). Consequent signs and symptoms may be referable to the spine or spinal cord. Evidence of spinal compromise may include lower extremity weakness, paresthesias, reflex asymmetry, and spinal pain.
Most primary intramedullary spinal cord tumors are astrocytomas or ependymomas. [2] Intradural extramedullary tumors, including schwannomas, neurofibromas, and meningiomas, [2] that affect the paravertebral area may spread and compress the cord through expansion. Additionally, an enlarging cancerous lymph node may compress the cord.
Hemangiomas (benign tumors of the blood vessels) are usually discovered incidentally and usually do not produce symptoms. However, symptoms emerge if pathologic vertebral fractures or epidural extension occurs.
Nerve tracts most vulnerable to mechanical pressure include the corticospinal and spinocerebellar tracts and the posterior spinal columns. Additionally, neoplasms may compromise the vascular supply, causing edema or ischemia. Less frequently, tumors may induce cyst formation or cavitation within the spinal cord.
United States
Metastatic lesions that involve the spinal cord affect about 5-10% of patients with cancer. [3] Approximately 15% of all primary CNS lesions arise from the spinal cord, with an estimated incidence rate of 0.5-2.5 cases per 100,000 population.
International
The international incidence rate parallels that of the United States.
Most primary spinal cord cancers do not disseminate widely through the CNS or body. Consequent disability relates to the degree of cord impairment and anatomic level of cord injury.
Metastatic tumors that cause epidural cord compression and dysfunction are the most common causes of oncologic CNS injury. Mortality correlates with the prognosis of the primary cancer.
The severity of spinal cord compromise secondary to a tumor spans a wide range. Initially, symptoms may be limited to pain or minor sensory or motor disturbance. As the compression progresses, neurologic abnormalities become more pronounced, advancing to disability. Partial cord compression, such as Brown-Séquard syndrome, may evolve. In the advanced stage of compression, complete transverse sensory and motor paralysis with bowel and bladder incontinence occurs.
The disability of the patient at the initiation of therapy serves as the best predictor of ultimate disability in patients with epidural cord compression. Early detection of cord compression and early intervention is the goal.
A slight male predominance exists for primary spinal cord tumors. Symptomatic hemangiomas occur most frequently in teenaged girls and typically involve the thoracic spine.
The incidence of primary spinal cord tumors peaks in people aged 30-50 years. People older than 50 years are more likely to experience back pain secondary to a metastatic tumor. Certain CNS tumors, such as neuroblastoma, occur almost solely in pediatric patients.
Clinical syndromes produced by intramedullary tumors vary depending on the age of the individual. In children, gait disturbances prevail, with pain reported infrequently. Spinal cord neoplasms may manifest as scoliosis or torticollis in younger patients.
Pain is the most common early complaint of adult patients with spinal cord neoplasms, followed by the insidious progression of spinal cord dysfunction.
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Chamberlain MC, Tredway TL. Adult primary intradural spinal cord tumors: a review. Curr Neurol Neurosci Rep. 2011 Jun. 11(3):320-8. [Medline].
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Sodji Q, Kaminski J, Willey C, Kim N, Mourad W, Vender J, et al. Management of Metastatic Spinal Cord Compression. South Med J. 2017 Sep. 110 (9):586-593. [Medline].
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Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, et al. 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. [Medline]. [Full Text].
Spratt DE, Beeler WH, de Moraes FY, Rhines LD, Gemmete JJ, Chaudhary N, et al. An integrated multidisciplinary algorithm for the management of spinal metastases: an International Spine Oncology Consortium report. Lancet Oncol. 2017 Dec. 18 (12):e720-e730. [Medline].
Fehlings MG, Nater A, Tetreault L, Kopjar B, Arnold P, Dekutoski M, et al. Survival and Clinical Outcomes in Surgically Treated Patients With Metastatic Epidural Spinal Cord Compression: Results of the Prospective Multicenter AOSpine Study. J Clin Oncol. 2016 Jan 20. 34 (3):268-76. [Medline].
J Stephen Huff, MD, FACEP Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine
J Stephen Huff, MD, FACEP is a member of the following medical societies: American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Jeffrey L Arnold, MD, FACEP Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center
Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Physicians
Disclosure: Nothing to disclose.
Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Sanz Laniado Medical Center, Netanya, Israel
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Edmond A Hooker, II, MD, DrPH, FAAEM Associate Professor, Department of Health Services Administration, Xavier University, Cincinnati, Ohio; Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine
Edmond A Hooker, II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, Southern Medical Association
Disclosure: Nothing to disclose.
Spinal Cord Neoplasms
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