1. SPINAL CORD COMPRESSION

2. SPINAL CORD COMPRESSION
Oncologic emergency
Occurs in 5% of patients in autopsy series
In 20% of patients with neoplastic involvement of the vertebral column
Usually occurs in the setting of disseminated cancer
May be the initial manifestation of malignant disease or the sole site of disease recurrence
Requires emergency diagnostic procedures and treatment to prevent irrevercible neurologic injury.

3. TUMOR TYPES that may cause compression
Breast 21%
Lung 17%
Lymphoma 9%
Prostate 7%
Sarcoma
Myeloma %
Kidney
Other %

4. PATHOPHYSIOLOGY
Vertebral body – most commonly involved (-> pedicules ->posterior lamina)
->> collapse of the vertebral body or erosion of cortical bone and tumor invasion into the extradural space
Far less commonly – tumor extension from a paravertebral mass through the intervertebral foramina into the spinal canal
Intramedullary metastases – extremely rare
Pathologic consequences: from reversible vasogenic edema to irreversible necrosis
The part of he vertebra most commonly involved is the vertebral body, followed by the pedicules and posterior lamina.
Metastasis to bone often results in eventual collapse of the vertebral body or erosion of cortical bone and tumor invasion into the extradural space. Far less commonly tumor may extend from…
Pathologic consequences may vary from…

5. LOCATION 70% - thoracic 20% - lumbar 10% - cervical
9-30% - multiple sites!
70% of cord compressions are thoracic in origin, 20% are lumbar, 10% are cervical and 9-30% are multiple.

6. CLINICAL MANIFESTATION
back pain-initial symptom in 70-95% of adults and 80% of children
almost always precedes diagnosis by several days to many months
local or radicular
*local - in almost all cases; close to the site
of compression; usually constant, dull, aching, worse
when the patient is supine; exacerbated by movement,
sneezing or neck flexion
*radicular – often intermittent and shooting; in the cervical or
lumbar lesion may involve the shoulder or limb
* spinal percussion enables to establish the level of lesion
*the opposite to degenerative joint disease or herniated disc

7. CLINICAL MANIFESTATION
Weakness – in approximately 80% of patients
Usually follows pain by week or months
Most evident when affects proximal muscles of the lower extremity (difficulty in climbing stairs or rising from chair)
May evolve to paraplegia within hours or days
High cervical cord lesions are potentially fatal – may produce paralysis of respiratory muscles and the diaphragm
* Neurologic deficits tend to manifest in the lower extremities – preponderance of thoracic and lumbar spine lesions

8. CLINICAL MANIFESTATION
Sensory disability (sensory loss, paresthesia)
*patients generally demonstrate more motor
than sensory disability (most common anterior
compression)
Autonomic dysfunction (urinary frequency, urgency, urinary retention, constipation, impotence) – occurs late, associated with a poor prognosis
Because the vertebral body is usually involved, anterior compression of spinal cord is most common and patients generally demonstrate more motor disability than sensory disability.

9. DIAGNOSTIC PROCEDURES
Plain radiographs
- destruction of the cortical bone of the
pedicles
- collapse of the vertebral body
- erosion of lamina
- identification of a paravertebral soft
tissue mass
Detect bony abnormalities in 72% of patients with epidural cord compression
May be normal in 60% of patients with compression by lymphoma or pediatric malignancies!
! In these cases, posterior or posterolateral compression results from paraspinous soft tissue mass invading the vertebral foramen – these lesiones are detected more reliably with CT or MRI

10. DIAGNOSTIC PROCEDURES
Myelography – historical method
- provides only indirect evidence of
extradural disease
- impaired flow of contrast medium injected into the
subarachnoid space by lumbar puncture due to
extradural tumor manifests as a block on plain
radiographs
- does not detect multiple sites of lesions

11. DIAGNOSTIC PROCEDURES
MRI
- imaging modality of choice!
- assesses full length of the spinal cord (multiple
sites of compression)
- better in delineation of paraspinous soft tissues
- detects vertebral foramina invasion
- safer, more convenient, better tolerated
- use of contrast (gadolinium) demonstrates intramedullary
metastases, leptomeningeal involvement, paravertebral masses
Provided that it is available and there are no contraindications for it.
- extremely useful in planning radiotherapy or surgery

12. TREATMENT
* Patients diagnosed with spinal cord compression should be treated emergently!
* Treatment decision depends on:
- patient’s expected survival
- location and mechanism of compression
- rapidity of neurologic progression
- tumor histology
- extent of spinal involvement
- previous treatment method (rth)
Corticosteroids
Radiotherapy
Surgery
Chemotherapy

13. TREATMENT Goals of treatment:
preservation or recovery of neurologic function
palliation of pain
prevention of local recurrence
preservation of spinal stability

14. TREATMENT Corticosteroids (dexamethasone)
- improve the initial rate of neurologic recovery
- lead to stabilization of neurologic deficits
before the start of definitive treatment
- administered throughout an entire course of
radiotherapy
- initial dose of mg intravenously followed
by oral daily dose of 4-24mg every 6 hours
When the diagnosis of epidural compression has been made, dexamethasone should be administered.

15. TREATMENT Radiotherapy
- definitive treatment for most patients (except of patients with compression from retropulsed bone, spinal instability, patients without a clinical or pathologic diagnosis of cancer – considered for surgery; children with chemosensitive tumors)
- reduces pain in 70% of patients
- improves motor function in 45-60% of patients
Children with chemosensitive tumors should be considered for initial chemotherapy.
Immidiate surgical decompression should be cosidered for patients with neurologic progression during radiotherapy.
Patients previously treated with rth?

16. TREATMENT
Surgery
- laminectomy – for posterior or posterolateral tumors
- vertebral body resection – for anterior tumors
- spinal stabilization

17. TREATMENT Chemotherapy
- pediatric patients with chemoresponsive tumors
- adjuvant treatment in adults with
chemosensitive tumors
- initial or recurrent cord compression by a
chemosensitive tumor in a site of previous
radiation or surgery

18. CONCLUSIONS
* As the median age of the population increases and cancer survival is prolonged by more effective treatment, spinal cord compression will remain an important oncologic problem.
* Early intervention is essential for successful treatment.