eMedicine Specialties > Emergency Medicine > Hematology & Oncology

Neoplasms, Spinal Cord: Differential Diagnoses & Workup

Author: J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
Contributor Information and Disclosures

Updated: Jul 1, 2009

Differential Diagnoses

Amyotrophic Lateral Sclerosis
Lumbar (Intervertebral) Disk Disorders
Back Pain, Mechanical
Neoplasms, Brain
Brown-Sequard Syndrome
Spinal Cord Infections
Cauda Equina Syndrome
Spinal Cord Injuries
Epidural and Subdural Infections
Epidural Hematoma

Other Problems to Be Considered

Abscess
Hematoma
Syrinx
Radiation myelopathy
Chemotherapy myelopathy
Paraneoplastic myelopathy
Neoplastic meningitis
Spinal arachnoiditis
Transverse myelitis
Central disk herniation
Spondylitic myelopathy
Disk-space infections
Diskitis

Workup

Laboratory Studies

  • Laboratory studies are not generally helpful in establishing the diagnosis of spinal cord neoplasm.
  • Marked elevation of the erythrocyte sedimentation rate suggests infection or inflammation.
  • Patients with a suspected spinal cord neoplasm are at risk for additional oncologic insults. Routine blood workup typically includes analysis of the following: CBC; prothrombin time; activated partial thromboplastin time; and metabolic profile, including calcium level and liver function.

Imaging Studies

  • MRI
    • MRI of the affected area provides the best definition of spinal lesions and is the procedure of choice.
    • With MRI, the entire spine may be visualized rapidly (sagittal images), and images may be obtained in multiple planes for best definition of the lesion, vertebrae, epidural space, and spinal cord. Roughly one third of people with spinal epidural metastases have multiple spinal metastases.
    • MRI can usually be used to differentiate a collapsed vertebra secondary to osteoporosis or trauma from malignant disease.


MRI of plain film above showing intrusion of tumo...

MRI of plain film above showing intrusion of tumor and vertebral collapse into spinal canal.

[ CLOSE WINDOW ]
MRI of plain film above showing intrusion of tumo...

MRI of plain film above showing intrusion of tumor and vertebral collapse into spinal canal.

    • The intervertebral space is usually not involved in tumors of the spine. When the disk space is obliterated, infection is more likely.
    • Diffusion-weighted MR imaging may be useful in evaluation of epidural neoplastic lesions.3
    • If MRI cannot be performed, consult a qualified radiologist or oncologist about other imaging options (eg, intrathecal contrast-enhanced myelography, CT scan, nuclear medicine bone scanning).
  • Plain radiography
    • Plain radiographs may reveal bony destruction (osteolytic or osteoblastic lesions), vertebral collapse or subluxation, or calcification (associated with a meningioma). Roughly 50% of the bone must be destroyed to be visible on plain films.


Patient with metastatic breast cancer; plain radi...

Patient with metastatic breast cancer; plain radiograph shows L4 vertebral collapse.

[ CLOSE WINDOW ]
Patient with metastatic breast cancer; plain radi...

Patient with metastatic breast cancer; plain radiograph shows L4 vertebral collapse.

    • Conventional radiographs do not provide information about spinal cord structure or compression.
    • Changes are demonstrated on plain films in about 80% of patients with spinal cord tumors. Conversely, findings on plain films are falsely negative in about 20% of cases.
  • Nuclear medicine: Most tumors (excluding myeloma) exhibit increased activity on nuclear medicine scans.

Procedures

  • Lumbar puncture
    • Be cautious when considering a lumbar puncture; the presence of a spinal cord tumor is a relative contraindication to the performance of a lumbar puncture.
    • Removal of cerebrospinal fluid in the presence of a tumor may worsen cord compression.
    • In leptomeningeal metastasis, examination findings of the spinal fluid are almost always abnormal and reveal elevated protein levels and positive cytologic results.
  • Post-void residual urine volume: Have the patient urinate and check the urinary residual volume by catheterization when bladder impairment is a concern. Volumes greater than 200 mL may suggest a neurogenic bladder.

More on Neoplasms, Spinal Cord

Overview: Neoplasms, Spinal Cord
Differential Diagnoses & Workup: Neoplasms, Spinal Cord
Treatment & Medication: Neoplasms, Spinal Cord
Follow-up: Neoplasms, Spinal Cord
Multimedia: Neoplasms, Spinal Cord
References
[ CLOSE WINDOW ]

References

  1. Spinazze S, Caraceni A, Schrijvers D. Epidural spinal cord compression. Crit Rev Oncol Hematol. Dec 2005;56(3):397-406. [Medline].

  2. Prasad D, Schiff D. Malignant spinal-cord compression. Lancet Oncol. Jan 2005;6(1):15-24. [Medline].

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

  4. 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.

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

  6. Gilbert MR, Minhas TA. Epidural spinal cord compression and neoplastic meningitis. In: Johnson RT, ed. Current Therapy in Neurologic Disease. 1997:253-9.

  7. Newton HB, Shah SML. Neurological syndromes and symptoms in the cancer patient: differential diagnosis, assessment protocols, and targeted clinical interventions. Emerg Med Rep. 1997;18:149-58.

  8. Patten J. The spinal cord in relation to the vertebral column. In: Neurologic Differential Diagnosis. 1996:247-81.

  9. 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. Feb 2007;8(2):137-47. [Medline].

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

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

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

  13. Schmidt RD, Markovchick V. Nontraumatic spinal cord compression. J Emerg Med. Mar-Apr 1992;10(2):189-99. [Medline].

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

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

spinal cord neoplasm, spinal cord tumor, neoplastic disease, spinal cord compression, primary spinal cord tumors, metastatic lesions, spinal cord dysfunction, spinal cord metastasis, epidural spinal cord compression, partial cord compression, Brown-Sequard syndrome, hemangiomas, scoliosis, torticollis, vertebral metastasis, leptomeningeal metastasis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edmond A Hooker II, MD, DrPH, FAAEM, Assistant Professor, Department of Health Services Administration, Xavier University; Associate Clinical Professor, Department of Emergency Medicine, University of Louisville; Assistant Clinical Professor, Department of Emergency Medicine, Wright State University
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, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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 and American College of Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
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, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.