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Spinal Cord Neoplasms Clinical Presentation

  • Author: J Stephen Huff, MD, FACEP; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Feb 09, 2015
 

History

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 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.

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Physical

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.
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Contributor Information and Disclosures
Author

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.

Specialty Editor Board

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.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

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.

References
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  2. 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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  4. Dugas AF, Lucas JM, Edlow JA. Diagnosis of spinal cord compression in nontrauma patients in the emergency department. Acad Emerg Med. 2011 Jul. 18(7):719-25. [Medline].

  5. Plank C, Koller A, Mueller-Mang C, Bammer R, Thurnher MM. Diffusion-weighted MR imaging (DWI) in the evaluation of epidural spinal lesions. Neuroradiology. 2007 Dec. 49(12):977-85. [Medline].

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  7. Regine WF, Tibbs PA, Young A. Metastatic spinal cord compression: a randomized trial of direct decompressive surgical resection plus radiotherapy vs radiotherapy alone. Int J Radiat Oncol Biol Phys. 2003. 57 (suppl 2):5125.

  8. Piepenbrink JC, Cullen JI Jr, Stafford TJ. The use of video in anesthesia record keeping. Biomed Instrum Technol. 1990 Jan-Feb. 24(1):19-24. [Medline].

  9. Cole JS, Patchell RA. Metastatic epidural spinal cord compression. Lancet Neurol. 2008 May. 7(5):459-66. [Medline].

  10. Engelhard HH, Villano JL, Porter KR, et al. Clinical presentation, histology, and treatment in 430 patients with primary tumors of the spinal cord, spinal meninges, or cauda equina. J Neurosurg Spine. 2010 Jul. 13(1):67-77. [Medline].

  11. Sansur CA, Pouratian N, Dumont AS, Schiff D, Shaffrey CI, Shaffrey ME. Part II: spinal-cord neoplasms--primary tumours of the bony spine and adjacent soft tissues. Lancet Oncol. 2007 Feb. 8(2):137-47. [Medline].

  12. Schiff D. Spinal cord compression. Neurol Clin. 2003 Feb. 21(1):67-86, viii. [Medline].

  13. Schiff D, O'Neill BP. Intramedullary spinal cord metastases: clinical features and treatment outcome. Neurology. 1996 Oct. 47(4):906-12. [Medline].

  14. Schiff D, O'Neill BP, Suman VJ. Spinal epidural metastasis as the initial manifestation of malignancy: clinical features and diagnostic approach. Neurology. 1997 Aug. 49(2):452-6. [Medline].

  15. Traul DE, Shaffrey ME, Schiff D. Part I: spinal-cord neoplasms-intradural neoplasms. Lancet Oncol. 2007 Jan. 8(1):35-45. [Medline].

 
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Patient with metastatic breast cancer; plain radiograph shows L4 vertebral collapse.
MRI of plain film above showing intrusion of tumor and vertebral collapse into spinal canal.
Patient with renal cell carcinoma; MR shows collapse of a thoracic vertebra with spinal cord impingement.
Axial MR of patient in Media File 3 above with vertebral destruction and spinal cord impingement.
 
 
 
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