Spinal Tumors, Primary & Metastatic

Essentials of Diagnosis

• Pain, especially with extradural lesions

• Weakness, sensory disturbances, and reflex changes below the level of the lesion

• Bladder, bowel, and sexual dysfunction may occur

General Considerations

• Approximately 10% of spinal tumors are intramedullary

• Ependymoma is the most common type of intramedullary tumor; the remainder are other types of glioma

• Extramedullary tumors may be extradural or intradural in location

• Among the primary extramedullary tumors, neurofibromas and meningiomas are relatively common and benign and may be intradural or extradural

• Carcinomatous metastases, lymphomatous or leukemic deposits, and myeloma are usually extradural

• Common primary sites for metastases

  • Prostate

  • Breast

  • Lung

  • Kidney

Symptoms and Signs

• Tumors may lead to spinal cord dysfunction by

  • Direct compression

  • Ischemia secondary to arterial or venous obstruction

  • Invasive infiltration in the case of intramedullary lesions

• Symptoms usually develop insidiously

• Pain with extradural lesions

  • Characteristically aggravated by coughing or straining

  • May be radicular, localized to the back or felt diffusely in an extremity

  • May be accompanied by motor deficits, paresthesias, or numbness, especially in the legs

  • Often precedes specific neurologic symptoms in epidural metastases

• Sphincter disturbances may occur

• Localized spinal tenderness

• Segmental lower motor neuron deficit or dermatomal sensory changes (or both) may be found at the level of the lesion

• An upper motor neuron deficit and sensory disturbance are found below it

Differential Diagnosis

• Primary tumor, eg, ependymoma, meningioma, neurofibroma

• Lymphoma, leukemia, plasma cell myeloma

• Metastases, eg, cancer of the prostate, breast, lung, kidney

• Cervical or lumbar disk disease

• Multiple sclerosis

• Tuberculosis (Pott disease)

Laboratory Tests

• Cerebrospinal fluid

  • Is often xanthochromic

  • Contains a greatly increased protein concentration

  • Has normal cell content and glucose concentration

Imaging Studies

• MRI with contrast or CT myelography

  • Used to identify and localize the lesion

  • Combination of known tumor elsewhere in the body, back pain, and either abnormal plain films of the spine or neurologic signs of cord compression is indication to perform studies urgently

Medications

• Dexamethasone in high dosage (eg, 10–96 mg once intravenously, followed by 4–25 mg four times daily for 3 days orally or intravenously, followed by rapid tapering of the dosage, depending on initial dose and response) to reduce cord swelling and relieve pain

Surgery

• Intramedullary tumors are treated by decompression and surgical excision (when feasible) and by radiation

  • Prognosis depends on the cause and severity of cord compression before it is relieved

• Surgical decompression for epidural metastases is reserved for

  • Tumors that are unresponsive to irradiation or have previously been irradiated

  • Patients with spinal instability

  • Patients in whom there is some uncertainty about diagnosis

Prognosis

• Long-term outlook is poor, but treatment may at least delay the onset of major disability

When to Admit

• All patients