eMedicine Specialties > Emergency Medicine > Hematology & Oncology

Neoplasms, Spinal Cord

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

Introduction

Background

Neoplastic disease that involves the spine with spinal cord compression may be devastating if unrecognized.

Primary spinal cord tumors arise from the different elements of the CNS, including neurons, supporting glial cells, and meninges. Anatomically, neoplasms of the spinal cord may be classified according to the compartment of origin, either intramedullary (inside the cord) or extramedullary (outside the cord). Additionally, cancers that metastasize to the vertebrae or surrounding tissues frequently cause spinal cord compression.

Metastatic lesions are featured in this discussion since they cause 85% of the cases of neoplastic spinal cord compression. The clinical presentation tends to be indistinguishable from that of primary cancers of the spine.

For the emergency physician, the cell origin of the tumor is less of a concern than the consequent syndromes of spinal cord dysfunction.

Pathophysiology

Neoplastic spinal cord compression usually follows hematogenous dissemination of malignant cells to the vertebral bodies, with subsequent expansion into the epidural space. Spread into the epidural space may occur by means of tumor extension through the intervertebral foramina or hematogenous spread by way of the Batson venous plexus. Most frequently, metastatic seeding appears in the thoracic spine (accounting for about 70% of cases), with the lumbar spine being the next most involved site (20% of cases). The cervical spine is affected in approximately 10% of cases. Multiple spinal levels are affected in about 30% of patients.¹

Systemic cancers with a tendency for spinal cord metastasis include the following: breast, prostate, renal, or lung neoplasms; lymphoma; sarcoma; and multiple myeloma. Gastrointestinal and pelvic malignancies tend to affect the lumbosacral spine; lung and breast cancers are more likely to affect the thoracic spine.

Metastases to the substance of the cord (intramedullary) are relatively rare. Signs and symptoms tend to simulate those of epidural compression; however, the associated motor weakness is more likely to be unilateral. Principles of treating intramedullary cancer are similar to those for epidural spinal cord compression.

Leptomeningeal metastases spread by means of diffuse or multifocal seeding of the meninges from systemic cancer (eg, lung or breast cancer, melanoma, lymphoma). Consequent signs and symptoms may be referable to the spine or spinal cord. Evidence of spinal compromise may include lower extremity weakness, paresthesias, reflex asymmetry, and spinal pain.

Most primary spinal cord tumors are astrocytomas or ependymomas. Primary tumors that affect the paravertebral area may spread and compress the cord through expansion, particularly in an intervertebral foramen. Additionally, an enlarging cancerous lymph node may compress the cord.

Hemangiomas (benign tumors of the blood vessels) are usually discovered incidentally and usually do not produce symptoms. However, symptoms emerge if pathologic vertebral fractures or epidural extension occurs.

Nerve tracts most vulnerable to mechanical pressure include the corticospinal and spinocerebellar tracts and the posterior spinal columns. Additionally, neoplasms may compromise the vascular supply, causing edema or ischemia. Less frequently, tumors may induce cyst formation or cavitation.

Frequency

United States

Metastatic lesions that involve the spinal cord affect about 5-10% of patients with cancer.² Approximately 15% of all primary CNS lesions arise from the spinal cord, with an estimated incidence rate of 0.5-2.5 cases per 100,000 population.

International

The international incidence rate parallels that of the United States.

Mortality/Morbidity

Most primary spinal cord cancers do not disseminate widely through the CNS or body. Consequent disability relates to the degree of cord impairment and anatomic level of cord injury.

• Metastatic tumors that cause epidural cord compression and dysfunction are the most common causes of oncologic CNS injury. Mortality correlates with the prognosis of the primary cancer.
• The severity of spinal cord compromise secondary to a tumor spans a wide range. Initially, symptoms may be limited to pain or minor sensory or motor disturbance. As the compression progresses, neurologic abnormalities become more pronounced, advancing to disability. Partial cord compression, such as Brown-Séquard syndrome, may evolve. In the advanced stage of compression, complete transverse sensory and motor paralysis with bowel and bladder incontinence occurs.
• The disability of the patient at the initiation of therapy serves as the best predictor of ultimate disability in patients with epidural cord compression. Early detection of cord compression and early intervention is the goal.

Sex

• A slight male predominance exists for primary spinal cord tumors.
• Symptomatic hemangiomas occur most frequently in the thoracic region of teenaged girls.

Age

People older than 50 years are more likely to experience back pain secondary to a metastatic tumor. The incidence of primary spinal cord tumors peaks in people aged 30-50 years.

• Certain CNS tumors, such as neuroblastoma, occur almost solely in pediatric patients.
• Clinical syndromes produced by intramedullary tumors vary depending on the age of the individual. In children, gait disturbances prevail, with pain reported infrequently. Spinal cord neoplasms may manifest as scoliosis or torticollis in younger patients.
• Pain is the most common early complaint of adult patients with spinal cord neoplasms, followed by the insidious progression of spinal cord dysfunction.

Clinical

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 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.

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.
• 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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