Spinal Cord Neoplasms Clinical Presentation

Early symptoms of spinal cord neoplasms are often nonspecific and include local pain or stiffness.

A history of malignancy may provide the pivotal clue in establishing the diagnosis.

Gradually worsening back pain is the classic initial feature of spinal cord neoplastic disease in about 90% of adult patients. Pain often precedes other symptoms associated with spinal cord compression by 2-4 months. Discomfort may be radicular, localized to the back, or both. Radicular pain suggests nerve root impingement and may be exacerbated with movement or straining.

Once symptoms other than pain appear, symptom progression may be rapid.

Pain from vertebral metastasis may worsen with a recumbent position in contrast to back pain from degenerative joint disease, which may improve with a recumbent position.

Sensory or motor symptoms that may be referred to the cord include limb paresthesias and weakness.

Emergence of leg weakness, paresthesias in the lower extremities, and/or bowel or bladder dysfunction in patients with a history of cancer should evoke immediate concern for cord compression.

Paraplegia and bowel or bladder disturbances (eg, constipation, urinary hesitancy, retention, incontinence) are usually late findings except in conus medullaris syndrome, in which sphincter dysfunction and saddle anesthesia may emerge early in the course.

Findings on physical examination correspond to the location of the tumor, degree of cord impingement, and duration.

• Spasticity, hyperreflexia, and loss of pinprick, temperature, position, and vibratory sensation may occur early.
• Percussion tenderness over the affected spinal region may be present.
• Deep-tendon reflexes may be initially hypoactive or absent. The Babinski sign (upward movement of the toe in response to plantar stimulation) may be absent early in the course of compression.
• Pain that progresses down the asymptomatic (or less symptomatic) limb caused by straight-leg raising may suggest cord compression.
• Valsalva maneuvers, such as coughing, sneezing, or straining, may exacerbate radicular back pain from cord compression.
• Late signs include demonstrable weakness, clear sensory loss, bilateral Babinski signs, and decreased anal sphincter tone and bulbocavernosus reflex. As spinal cord compromise advances, hyperreflexia and Babinski reflexes are typically present. Lax rectal sphincter tone is a late sign of spinal cord dysfunction.
• Almost one half of patients with a tumor and subsequent spinal cord compression have some paresis, with as many as 15% of patients being paraplegic at the time of diagnosis.
• Coexisting emergence of lower extremity weakness and sensory loss may cause ataxia or a gait disturbance.^[4]
• The Lhermitte sign (ie, sudden, electric shock-like pain with neck flexion) indicates meningeal irritation.
• Nuchal rigidity occurs in about 10% of patients with leptomeningeal metastasis.
• Partial cord disorders, such as Brown-Séquard syndrome (contralateral motor and sensory deficits), arise from lateral spinal cord compression.
• Lesions of the cauda equina and the termination of the spinal cord may cause a combination of upper motor neuron and lower motor neuron signs.
• Tumors in the region of the foramen magnum may produce quadriparesis and simulate other causes of diffuse weakness.
• If a cervical intramedullary tumor or syrinx (cavity) is present, the unusual clinical picture of isolated sensory loss may be present in the upper extremities.