Spinal Cord Compression, Malignant

Key Features

• Complication of metastatic solid tumor, lymphoma, or plasma cell myeloma

• Back pain is most common presenting symptom

• Prompt diagnosis is essential because once a severe neurologic deficit develops, it is often irreversible

• Emergent treatment may prevent or potentially reverse paresis and urinary and bowel incontinence

Clinical Findings

• Back pain (in > 80%) aggravated by lying down, weight bearing, sneezing, coughing

• Progressive weakness of the lower extremities

• Sensory loss (usually in the lower extremities)

• Late findings: bowel and bladder dysfunction progressing to incontinence

Diagnosis

• MRI with and without contrast

• Bone radiographs are neither sensitive nor specific for evaluating the cancer patient with back pain

• Whole-body PET-CT with ¹⁸F-2-deoxyglucose may be useful as a screening procedure if back pain symptoms are nonspecific

Treatment

• Dexamethasone (10 mg intravenously followed by 4–6 mg intravenously or orally every 6 hours) should be given immediately to patients with a known cancer diagnosis and epidural impingement of the spinal cord

• Emergent surgery should be performed in patients without a known diagnosis of cancer to

  • Relieve impingement

  • Obtain a pathologic specimen

• Preoperative corticosteroids should not be given since they compromise the pathology results

• Surgical decompression followed by radiation therapy is indicated for patients with a single area of compression due to solid tumors

• Fractionated radiation therapy is the preferred treatment option if multiple vertebral body levels are involved with cancer

• Corticosteroids are generally tapered toward the end of radiation therapy