Spinal Cord Compression and tumors
Q1. How does spinal cord compression manifest?
- Spinal cord compression causes spastic weakness and increased deep tendon reflexes.
- Sphincter dysfunction occurs resulting in incontinence then retention.
Q2. What are the sites where tumor can be located in spinal cord? How do you distinguish them?
- Extramedullary (neurofibromas and meningiomas) – pain at the level of the lesion, postural and discriminatory sensory loss with spastic weakness and increased deep tendon reflexes (upper motor neuron signs)
- Intramedullary (ependymomas and astrocytomas) – weakness and atrophy of muscles with loss of deep tendon reflexes (lower motor neuron signs), also pain, decreased temperature sensation, and sparing of position sense (posterior columns). Also, bladder symptoms are present.
Q3. What are the common causes for spinal cord compression?
- malignant extradural tumors (including prostate, thyroid, breast, lung, kidney, and myeloma)
- intradural extramedullary tumors (including neurofibromas, meningiomas)
- intramedullary tumors (ependymomas, astrocytomas)
- angiomas
- spinal infection
- disc rupture / degenerative diseases of the spine
Q4. What are the available imaging procedures for evaluation of spinal cord compression and their utility?
- MRI is the best imaging technique to evaluate patients with spinal cord compression.
- X-rays reveal bony architecture, but reveal very little about surrounding soft tissue.
- Radioactive isotope scanning is particularly useful in identifying metastases, and also useful for detecting inflammatory processes.
- Radioactive isotope scanning can detect changes before they are detectable on x-ray.
- CT is more useful in visualizing pathology of the bone.
- Spinal angiography may help with vascular pathology, such as arterio-venous malformations. Treatment with embolization may be provided at the time of visualization.
- Myelography has been replaced by MRI.
Q5. What is the initial procedure for evaluation of spinal cord compression and why? What is the urgency for evaluation of spinal cord compression?
- MRI because it is the best imaging modality and there is an urgent need to determine if there is spinal cord compression as soon as possible, otherwise the patient will could become permanently paralyzed.
Case 1:
A 73 yr/o male with a history of cancer kidney presents to the ER with weakness of his left lower extremity, and incontinence early today. He also complains of severe lower back pain. On exam, the patient is found to have increased deep tendon reflexes and spastic paralysis.
Which imaging procedure will you order?
Emergency MRI of spine
What is your concern?
Spinal cord compression from metastatic disease.
Case 2:
A 68 year olld male presents with shooting pain along the back of right leg. He has been having back ache for the past 6 months.
Which imaging procedure will you order?
MRI of spine