Metastatic spinal cord compression

Summary We reviewed all medical records concerning patients suffering from spinal cord or cauda equina compression (SCC) secondary to cancer, in the eastern part of Denmark, from 1979 through 1985.During the period the incidence of SCC in cancer patients went up from 4.4% to 6%. However, this increase was not significant.The series comprised 398 cases, with carcinoma of the prostate (19%), lung (18%), breast (14%) and kidney (10%) accounting for 61%. The symptoms were evaluated in accordance with the patients rating of pain, motor deficits, sphincter control and paraesthesia, whereas the clinical manifestations were classified on the basis of motor deficit and bladder dysfunction. During the period preceding the diagnosis of SCC, 83% of the patients suffered from back pain, 67% from deteriorating gait and 48% had retention of the urine. In 35% of the patients there was no sphincter disturbance and 10% had normal sensory function.The outcome of treatment was estimated by changes in motor deficits and sphincter function, and depended primarily on the patients condition at the time of the diagnosis. Of the patients who were able to walk before treatment, 79% remained ambulatory, wheras only 18% of the non-ambulatory patients regained walking ability. Patients treated by decompressive laminectomy followed by radiotherapy apparantly had a better response than patients treated with surgery or irradiation alone, but when the patients pre-treatment motor function was taken into account, no significant difference was observed.The study may call for a properly randomized trial with careful stratification of tumour biology, performance status and neurological deficits.     

Metastatic spinal cord compression — options for surgical treatment

Summary Fourty-three cases with metastatic spinal cord compression were reviewed post-operatively to clarify the usefulness of the procedures concerning restoration of neurological function, and pain relief. Only patients with pathological spinal instability and neurological sequelae were included. Posterior decompression and stabilization was performed in all but six patients. All but four patients (91%) reported decrease of pain symptoms. Amelioration of neurological function was achieved in 58%. Re-establishment of walking ability was obtained in 57%. Post-surgery life expectancy averaged 11 months. In patients with widespread metastatic disease and/or multi-level instability of the spine restriction to palliative dorsal procedures is sensible. Post-operative ancillary treatment is necessary.     

Metastatic spinal cord compression as the first sign of malignancy

Background and purpose — Metastatic spinal cord compression (MSCC) as the initial manifestation of malignancy (IMM) limits the time for diagnostic workup; most often, treatment is required before the final primary tumor diagnosis. We evaluated neurological outcome, complications, survival, and the manner of diagnosing the primary tumor in patients who were operated for MSCC as the IMM.

Patients and methods — Records of 69 consecutive patients (51 men) who underwent surgery for MSCC as the IMM were reviewed. The patients had no history of cancer when they presented with pain (n = 2) and/or neurological symptoms (n = 67).

Results — The primary tumor was identified in 59 patients. In 10 patients, no specific diagnosis could be established, and they were therefore defined as having cancer of unknown primary tumor (CUP). At the end of the study, 16 patients were still alive (median follow-up 2.5 years). The overall survival time was 20 months. Patients with CUP had the shortest survival (3.5 months) whereas patients with prostate cancer (6 years) and myeloma (5 years) had the longest survival. 20 of the 39 patients who were non-ambulatory preoperatively regained walking ability, and 29 of the 30 ambulatory patients preoperatively retained their walking ability 1 month postoperatively. 15 of the 69 patients suffered from a total of 20 complications within 1 month postoperatively.

Interpretation — Postoperative survival with MSCC as the IMM depends on the type of primary tumor. Surgery in these patients maintains and improves ambulatory function.     

Cervical spinal cord compression after thyroidectomy under general anesthesia

Cervical spinal cord injury is a rare but serious complication after general anesthesia. The risk factors include traumatic cervical injury, cervical spine instability, and difficult airway management. It has also occurred in the absence of cervical instability. Here we report a patient who had a history of intermittent neck pain without numbness. Preoperative radiologic examinations showed degenerative changes in the cervical spine. She developed progressive tingling and numbness in her limbs after thyroidectomy under general anesthesia. Magnetic resonance imaging showed a cervical disc protruding into the canal at C5–C6, which was considered to be induced by surgical positioning. She recovered after anterior cervical decompression and internal fixation surgery.     

Metastatic spinal cord compression as a result of the unknown primary tumour

Purpose

Patients presenting with metastatic spinal cord compression (MSCC) due to an unknown primary tumour (UPT) present an interesting problem with limited literature available to provide guidance on management. Our aim was twofold—first, to analyse all our patients with MSCC due to a UPT pre-operatively, to review their treatment and outcome; second, make comparisons with those patients who presented with MSCC due to a known primary tumour (KPT) during the same period.

Methods

All data was collected retrospectively from October 2004 to October 2009, then prospectively from October 2009 to October 2012 (8 years). We reviewed all patient records held on the database, including patient demographics, primary tumour, neurological outcome (Frankel grade), complications and survival.

Results

During the 8-year study period, out of the 382 patients who underwent emergency surgery for MSCC, 285 patients were included in whom complete information was available. Of these, 17 patients presented with MSCC due to a UPT (6 %; mean age 61 years, 5 M, 12 F). When compared to those with a known primary, the UPT group trended to a longer duration of symptoms prior to surgery (200 vs. 156 days, p = 0.86). They had a similar neurological outcome (88 % remained the same or improved post-operatively vs. 90 % in KPT group; p = 0.42), similar complication rate (23.5 vs. 33.6 %; p = 0.32) and survival (222 vs. 251 days, p = 0.42). The primary site in the UPT group was confirmed in 10/17 (58.8 %)—all 10 were adenocarcinoma [lung (6) and GI (4)].

Discussion

In our series, the incidence of MSCC due to an unknown primary was 6 %. They had similar overall outcome (neurology post-operatively, complications and survival) to those patients with MSCC from a known primary. Our experience would suggest that we need to treat these patients expeditiously with thorough evaluation and urgent treatment.     

Diagnosis and interdisciplinary therapy of spinal cord compression caused by spinal metastases]

Metastatic tumours of the bone system occur up to 60% in the spinal cord. The epidural spinal cord compression is also found by metastatic tumour, so patients with metastatic disease in this localisation carry a poor prognosis. From 1986 to 1988 35 patients with symptomatic spine metastasis are operated upon. 43% of these patients recover their capability of walking. 90% from the operated collective show a reduction of pain. The primary tumour is first found from cancer of the lung and second from the kidneys. The most common localisation of metastatic tumour is the thoracic spine. The ratio from male to female is 2:1. If the risk of operation and differential therapy is discussed, the decompression and tumour resection will be the first. The concept for postoperative mobilisation and therapy concludes the stabilisation of spinal cord with internal fixation. Treatment of metastatic tumours takes aim at the improvement of life quality.     

Metastatic testicular cancer presenting as spinal cord compression: report of two cases

BACKGROUND: Testicular cancers are heterogenous neoplasms often found in young adults. They tend to metastasize to the chest, retroperitoneum, or neck, but rarely to the long bones or skeleton. However, they can cause neurologic compromise and should be considered in young male patients who present with symptoms of a spine lesion and no known primary cancer. METHODS: Two patients presented with back pain and a rapid progression of lower extremity weakness. Both underwent radiographic workup and emergency surgery. Metastatic workup revealed testicular cancer and widespread metastases. RESULTS: Both patients improved neurologically after surgery, but neither regained the ability to ambulate independently. They both underwent chemotherapy. One patient is alive at 1 year follow-up; the other died 9 months after surgery of widespread metastases. CONCLUSIONS: Vertebral metastases from testicular tumors, although rare, should be considered in young men presenting with spinal cord compression. Work-up should include magnetic resonance imaging (MRI) of the spine and computed tomography (CT) of the chest, abdomen, and pelvis. Urgent intervention may be required, as these two cases show that loss of neurologic function can be rapid and permanent.     

Epidural spinal cord compression

Opinion statement Epidural spinal cord compression is a neurologic emergency requiring immediate attention. The therapy instituted depends on several factors, including the patient’s condition at the time of presentation, the nature of the underlying malignancy, the extent of systemic disease burden, and patient prognosis. The most essential aspect of treatment is the establishment of the diagnosis. If one suspects malignant cord compression an emergency, magnetic resonance imaging of the entire spinal axis is indicated. If magnetic resonance imaging is unavailable, post-myelographic computed tomography is an alternative. However, treatment should not be delayed until imaging is performed, particularly if neurologic deficits are present. Pain should be adequately addressed and opioids administered if necessary. Steroids should be given. If significant neurologic deficits are present, a high-dose corticosteroid bolus, followed by standing doses, should be given. However, if pain is the predominant symptom, steroids can be withheld pending immediate imaging or lower doses can be given without a bolus. Neurosurgical consultation should be obtained, and surgery should be considered if the patient’s condition permits. This is particularly true if spinal instability or significant kyphosis is present or compression is secondary to bony fragments. Other indications include patients with limited systemic disease burden in whom better survival is predicted and possibly those with radioresistant tumors. The type of surgery performed should be tailored to the distribution of disease within the spine and accessibility through anterior body cavities. Radiation therapy, an effective noninvasive treatment that can be delivered quickly and safely, is an appropriate option as well. This is particularly true in radio-responsive tumors, such as myeloma and lymphoma, in which surgery may be avoided entirely. Chemotherapy may play a role as adjuvant therapy in some tumors.     

Incidence in Catalonia of spinal cord compression due to spinal hematoma secondary to neuraxial anesthesia

OBJECTIVE: To study the incidence in Catalonia of spinal cord compression due to spinal hematoma secondary to neuraxial anesthesia. METHODS: The incidence of hematoma was based on published cases (MEDLINE, the Spanish Medical Index [Indice Medico Espa?ol], and Google) or cases reported at medical meetings or conferences by anesthesiologists from Catalan hospitals from 1996 to 2005, inclusive. The annual number of neuraxial anesthesias (spinal, epidural, and combined) was estimated based on the ANESCAT 2003 survey and the total number of anesthesias was calculated using the ANESCAT 2003 survey in conjunction with the surgical reports of Catalan hospitals. RESULTS: A total of 11 cases of spinal hematoma after neuraxial anesthesia (7 after spinal anesthesia and 4 after epidural anesthesia) were reported or published from 1996 to 2005, inclusive. A total of 194 154 neuraxial anesthesias were performed in 2003 (126 560 spinal anesthesias and 5926 combined spinal-epidural anesthesias) and it was estimated that somewhat over 1 700 000 neuraxial anesthesias were performed over the 10 years reviewed. The incidence (95% confidence interval [CI]) of hematoma was 0.6 (95% CI, 0.3-1.2) per 100 000 neuraxial anesthesias, 0.6 (95% CI, 0.3-1.3) per 100 000 spinal anesthesias, and 0.7 (95% CI, 0.2-1.9) per 100 000 epidural anesthesias. CONCLUSIONS: The incidence of spinal hematoma after neuraxial anesthesia is slightly more than 1 per 150 000 anesthesias-a similar finding to that of other epidemiological studies. The incidence is slightly higher in epidural anesthesia. These data imply a risk of approximately 1 spinal hematoma per year in Catalonia.     

Methylprednisolone in spinal cord compression

In acute nonsurvival studies, eight anesthetized lambs were subjected to cord compression at T13 by means of an epidural balloon distended to a pressure of 200 mm Hg for 40 minutes. Subsequent to withdrawal of the balloon, each animal received 30 mg/kg of methylprednisolone succinate in an intravenous bolus followed by a continuous infusion of 10 mg/kg/hr for the duration of the experiment. Spinal cord blood flow (SCBF) and spinal evoked potential (SEP) determinations were obtained sequentially prior to, during, and at 1/2, 1 1/2, and 2 1/2 hours following compression. In spite of the absence of ischemia following compression, SEPs failed to recover. Methylprednisolone had no apparent effect on blood flow or on the recovery of SEPs when compared with results in ten control animals that received saline alone.     

Malignant carcinoid causing spinal cord compression

Neurological complications of malignant carcinoid are infrequent. Only 11 cases of central nervous system metastasis are documented, and neurological symptoms may be the initial or only manifestation of this tumor. We describe the case of a 60-year-old man with no known primary tumor who presented with spinal cord compression by a thoracic epidural tumor. After laminectomy, the diagnosis of carcinoid was made by light and electron microscopic demonstration of neurosecretory granules in tumor cells. Urine 5-hydroxyindole acetic acid and plasma serotonin levels were subsequently found to be elevated. Carcinoid tumors should be considered in the differential diagnosis of lesions metastatic to the spinal cord and brain.     

Management of malignant spinal cord compression

Metastatic cord compression is one of the most serious complications of cancer. It is an emergency that requires rapid decision making involving several specialities, given the risk of permanent spinal cord injury. Patients may present with various clinical signs such as pain and neurological dysfunction with interventions aiming to improve both of these. Diagnosis is made through detailed history and examination followed by specific radiological investigations. The standard of care in most cases is rapid initiation of corticosteroids in combination with either surgical decompression in case of an operable candidate, followed by radiation therapy or radiotherapy alone. This process has recently been improved by the use of decision frameworks such as NOMS (neurologic, oncologic, mechanical, and systemic), to help clinicians’ direct treatment. This article represents an overview of the pathogenesis, investigations and management of metastatic cord compression. It references up-to-date national guidance and evidence-based protocols which should inform both surgical and nonsurgical clinicians.     

Solitary osteochondroma with spinal cord compression

Osteochondromas are unusual in the spine, and they are very rarely present with compression of the spinal cord. Two cases are reported with delineation of the tumor by metrizamide myelography and computed tomography.     

Vertebral histiocytosis-X causing spinal cord compression

An unusual case of spinal cord compression caused by histiocytosis-X of the vertebral body of T-7 was recently operated upon in our department; the case was diagnosed during the operation by means of the squash-smear cytologic technique. Characteristic cytologic features were the presence of sparse eosinophilic leukocytes containing mature, multilobed nucleai and sharp, rather coarse, cytoplasmic granules; abundant histiocytes with round to oval, sometimes indented nuclei and finely granular cytoplasm; and giant, multinucleated cells, as those seen in granulomatous lesions. These cytotypes were grouped to form a monotone, but highly characteristic pattern. We think the reported picture is diagnosic of the pathologic entity under discussion.     

Increased functional vulnerability to acute compression injury of a spinal cord segment under barbiturate anesthesia

Posttraumatic changes in polysynaptic reflex activity and axonal long-tract conduction were measured after transient compression of the L-7 spinal cord segment of cats, either made high spinal and unanesthetized or left intact under pentobarbital anesthesia. The severity of acute post-injury changes increased significantly in the anesthetized animals. Partial recovery and stabilization of functional deficits were observed in the spinal cat, but not in the anesthetized one. These findings suggest that, at least in the acute postinjury stage, pentobarbital anesthesia may enhance functional damages after experimental spinal cord compression.     

Primary spinal extradural hydatid cyst causing spinal cord compression

Primary spinal hydatid disease is rare and represents an uncommon but significant manifestation of hydatid disease. We report a case of primary intraspinal extradural hydatid cyst of the thoracic region causing spinal cord compression. The presenting symptoms were mostly atypical and the diagnosis was established preoperatively on the basis of magnetic resonance imaging. The patient underwent surgery resulting in complete recovery and is recurrence-free after 24 months follow-up.