Malignant spinal cord compression (MSCC) is caused by metastatic or direct tumor spread into the epidural space.
Tumors affecting the spinal column are often classified by their location as extradural, intradural extramedullary, or intradural intramedullary. Metastatic extradural (epidural) tumors are the most common type of spine tumor.
Acute spinal cord compression is a medical emergency. Urgent diagnosis and treatment is essential to prevent irreversible spinal cord injury and disability.
Diagnosis of MSCC is by magnetic resonance imaging (MRI) of the whole spine, preferably with gadolinium enhancement. Computed tomography myelography can be used if MRI is contraindicated or unavailable.
Treatment usually involves corticosteroids initially, followed by radiation therapy with or without surgery as appropriate to the patient's circumstances.
Prognosis is more favorable for previously ambulatory patients and for patients who have been immobile for less than 24 hours.
Malignant spinal cord compression (MSCC) is caused by a tumor pressing on the spinal cord or cauda equina. Spinal tumors can be primary, or secondary to metastatic disease (e.g., of breast, prostate, or lung cancer). Presenting symptoms of MSCC include back and/or neck pain (which is usually the first symptom), limb weakness, sensory symptoms such as loss of sensation, and bladder and/or bowel dysfunction. Tumors affecting the spinal column can be classified by their location as extradural, intradural extramedullary, or intradural intramedullary. All tumor types will be mentioned but the focus of this topic is on metastatic epidural disease causing cord compression.
History and exam
Key diagnostic factors
- known cancer diagnosis
- ≥40 years of age
- back pain
- weakness or paralysis
- numbness or paresthesias
- sensory loss
- hyperreflexia and Babinski or associated reflexes
- bladder or bowel dysfunction
Other diagnostic factors
- cauda equina syndrome
- Brown-Sequard syndrome
- tumor type and metastases
- immune system disorders
- radiation exposure
- genotype features
1st investigations to order
- gadolinium-enhanced MRI spine
- MRI spine
- CT myelography
Investigations to consider
- CT spine
- bone scintigraphy
- positron emission tomography (PET)
- tumor biopsy and histopathology
- serum calcium
- serum alkaline phosphatase
- cancer-specific laboratory testing
- cancer stem cell markers
- Spinal epidural abscess
- Osteoporotic spinal compression fracture
- Intervertebral disk herniation/compression
- ACR appropriateness criteria: management of vertebral compression fractures
- NCCN clinical practice guidelines in oncology: central nervous system cancers
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