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Chapter 46: Oncologic Emergencies

Mauricio Burotto Pichun; Tito Fojo

SPINAL CORD COMPRESSION (SCC)

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

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

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

Treatment Strategies