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Chapter 46: Oncologic Emergencies

Mauricio Burotto Pichun; Tito Fojo

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SPINAL CORD COMPRESSION (SCC)

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Etiology

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Etiology
Lifetime incidence of SCC in cancer patients:1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36 1–6%
Median overall survival of patients with SCC: 3–16 months
SCC as the initial manifestation of cancer: 20–30% of all cases of SCC
SCC as the initial manifestation of cancer:

Lung cancer

Cancer of unknown primary

Non-Hodgkin lymphoma

Multiple myeloma

SCC distribution along spine:

    Thoracic spine:

    Lumbar spine:

    Cervical spine:

60–80%

15–30%

4–13%
Sites of Involvement Percentage of SCC Histology (% Among All Cases)
Extradural metastases:✫ 90–95

Prostate cancer (15–20%)

Breast cancer (15–20%)

Lung cancer (15–20%)

Non-Hodgkin lymphoma (5–10%)

Multiple myeloma (5–10%)

Renal cancer (5–10%)
Intradural masses: 5–10

Meningioma

Nerve sheath tumors

Large leptomeningeal metastases
Transforaminal progression of paravertebral tumor: Uncommon

Lymphomas

Neuroblastomas
Primary hematogenous seeding to epidural space: Rare  

✫The most common mechanisms are:

  • Direct extension into the epidural space of a hematogenous metastasis to a vertebral body

  • Pathologic fracture of a vertebral body infiltrated by a metastatic deposit resulting in cord injury by a bone fragment or spinal instability

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Work-up

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Work-up

  • Spinal cord compression has been associated with most cancers. Consequently, any patient with cancer and new back pain or a change in character of preexisting back pain should receive appropriate evaluation

  • Differential diagnosis of SCC:

    1. Epidural abscess

    2. Subdural abscess

    3. Hematoma

    4. Herniated disc

    5. Leptomeningeal disease

    6. Hypertrophic arthritic changes

    7. Radiation myelopathy

    8. Myelopathy secondary to intrathecal chemotherapy

  • Suspected spinal cord compression requires immediate imaging studies and consultation with a radiation oncologist and a neurosurgeon

  • Because multiple spinal epidural metastasis are found in one-third of patients it is recommended that the entire spinal cord be imaged, or at least the thoracic and lumbar spine in addition to the symptomatic region

Symptoms
Back pain 95%
Weakness 60–85%
Sensory deficits 40–90%
Autonomic dysfunction 50%
Ataxia 5%
Imaging Studies
Gadolinium-enhanced MRI

  • The standard for diagnosis of spinal cord compression

  • Sensitivity: 93%; specificity: 97%; overall diagnostic accuracy: 95%
CT scan

  • Useful for assessing the degree of bone destruction and whether bone or tumor is causing spinal cord compression
Myelography

  • Myelography and postmyelogram CT is used for patients in whom MRI is contraindicated (such as patients with pacemakers, mechanical valves, and other metal implants)

  • Myelography is contraindicated in the presence of brain masses, thrombocytopenia, or coagulopathy, and has a small risk of worsening the neurologic deficit from pressure shifts in the event of complete spinal subarachnoid block

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Treatment Strategies

  1. Supportive care

    • Pain frequently is ...

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