Spinal Cord Metastases

By Schon Roberts MD PGY-3

61yo M with h/o of metastatic adenocarcinoma p/w numbness, tingling, and weakness in B/L UE and LE X 3 weeks. This has worsened in the past 3 days. He is now unable to walk or feed himself. He denies bowel/bladder incontinence, HA, fevers, chills, N/V/D, abdominal pain.  He denies any IVD. He was 3 weeks ago able to work full time as an electrician. He complains also of chronic neck and back pain.
Vital Signs are unremarkable.  Back is normal appearance. Pt has 4/5 strength in B/L UE and LE. He has rigidity of R arm with spasm. Decreased sensation B/L UE and LE R>L.  What is the best treatment option for this pt?

A. Discharge home. This is chronic back pain.
B. Refer patient to both pain management and a spinal surgeon to evaluate for disc herniation
C. Obtain consults from nuclear medicine, spinal surgery, and admit pt. Give steroids
D. Place pt in a TLSO brace and admit to the hospital
E. Start broad spectrum antibiotics: pt has an epidural abscess    

Answer
      C. Obtain consults from nuclear medicine, spinal surgery, and admit pt. Give steroids.
 
Pathophysiology

• Spinal Cord tumors can arise via a number of different sources including both intramedullary and extramedullary tumors.
• Primary tumors include neuron cell tumors, glial cell tumors, and meningeal tumors.
• Systemic cancers with a higher frequency for spinal cord metastasis include breast, prostate, renal, or lung neoplasms; lymphoma; sarcoma; and multiple myeloma. 
• Tumors place pressure and ultimately relate in neuropathy and cell death resulting in motor, sensory deficits, paralysis, bowel/bladder dysfunction. ​

Symptoms/Exam Findings

• Back Pain
• Radiculopathy
• Sensory loss
• Motor loss
• Bowel/Bladder incontinence
• Hyper/hyporeflexia
• Increased back pain with increase in vagal tone by valsalva, cough, etc.

Labs

• X-Ray
• CT Scan
• MRI

Diagnosis

• MRI showing tumor and cord compression.

Treatment

• Decadron
  • Studies show no difference between high dose Decadron (16 mg QDaily vs. 96 mg  QDaily)
• Radiation
• Surgical Laminectomy
  • Most recent evidence says that they are comparable with a 35% improvement either method.
  • 20-25% with major deterioration s/p surgery.

Clinical Pearls
·      Suspect spinal cord compression in a pt with H/O of CA and cauda equine symptoms.
·      Dx is made by MRI showing cord compression
·      Treatment should involve steroids.
·      Most recent data shows similar rates of relapse/improvement between radiation and surgery.
 
 
References
Sørensen S, Helweg-Larsen S, Mouridsen H, Hansen HH. Effect of high-dose dexamethasone in carcinomatous metastatic spinal cord compression treated with radiotherapy: a randomized trial. Eur J Cancer 1994; 30A:22.
Vecht CJ, Haaxma-Reiche H, van Putten WL, et al. Initial bolus of conventional versus high-dose dexamethasone in metastatic spinal cord compression. Neurology 1989; 39:1255.
 Graham PH, Capp A, Delaney G, et al. A pilot randomized comparison of dexamethasone 96 mg vs. 16 mg per day for malignant spinal-cord compression treated by radiotherapy: TROG 01.05 Superdex study. Clin Oncol (R Coll Radiol) 2006; 18:70.
 Findlay GF. Adverse effects of the management of malignant spinal cord compression. J Neurol Neurosurg Psychiatry 1984; 47:761.
 Young RF, Post EM, King GA. Treatment of spinal epidural metastases. Randomized prospective comparison of laminectomy and radiotherapy. J Neurosurg 1980; 53:741.