Mets spinal cord disease ED diagnostic approarch

Ahmed Alhubaishi

overview Introduction and background Statistics Clinical history Physical examination Investigations Treatment pitfalls

introduction Epidural spinal cord compression is :

true medical emergency that cannot be missed. Over 90% of cases are due to spinal epidural

metastases primary risk factor for spinal epidural metastases

is a history of malignancy

Metastatic disease is 25 times more common than primary tumors Approximately 5-10% of cancer patients will have

spinal metastases Breast, lung, and prostate cancers are most

common Where does epidural compression occur?

15% cervical 68% thoracic 19% lumbar

Although prostate, breast, and lung cancer most commonly cause bony metastases, it is important to realize that any systemic malignancy can metastasize to the spine. Lymphoma, renal Lymphoma, renal cell cancer, gastrointestinal malignancies, and cell cancer, gastrointestinal malignancies, and multiple myelomamultiple myeloma are frequently overlooked, yet account for a significant percentage of cases

As many as 5% of all cancer patients will develop metastases to the spine and spinal cord at some point in the course of their disease

Posner JB. Back pain and epidural spinal cord compression.Med Clin N Am 1987

Epidural spinal cord compression may be the first clinical manifestation of malignancy. Patient outcomes have been shown to be related to early diagnosis and rapid institution of therapy

Kim RY, Spencer SA, Meridith RF, et al. Extradural spinal cord compression: analysis of factors determining functional progress, prospective study. Radiology 1990

How does spinal cord mets cause symptoms?

Compression, invasion or destruction of spinal tracts

Symptoms will depend on location and growth of the tumour

Jama ,760-765:1992

Historical Clues Worrisome for Compression Pain Neck pain or arm pain (cervical radiculopathy) Low back pain or sciatica (lumbar

radiculopathy) Neuro complaints without pain (concerning for

spinal cord) Motor complaints Unilateral weakness (suggests radiculopathy) Bilateral weakness or spasticity (concerning

for spinal cord)

Sensory complaints Dermatomal sensory loss / paresthesias

(suggests radiculopathy) Multiple dermatomes (concerning for spinal

cord) Autonomic manifestations (Always

concerning for central cause) Impotence or priapism Bowel constipation or incontinence Urinary frequency, urgency, retention, or

incontinence

Suspicion for serious pathology

begins with an assessment of

patient risk factors for disease.

Suspicion for serious pathology

begins with an assessment of

patient risk factors for disease.

RED FLAGS

H/O CANCER AGE > 50 BACK PAIN ESPECIALLY AT NIGHT OR WITH

Unexplained wt loss Pain unreleived by bedrest [ sen > 90% but very

non specific] NIGHT SWEAT FEVER

SYMPTOMS MORE THAN 4-6 WKs with failure of conservative Rx

NEUROLOGICAL DEFICIT: motor, sensory Lancet 373: 463-472, 2009

Physical Exam Findings that Suggest Compression Pain on Exam

Elicited with Spurling’s test (cervical radiculopathy) Elicited with straight leg raise (lumbar radiculopathy)

Motor Findings Unilateral weakness or reflex change (suggests

radiculopathy) Spasticity or bilateral weakness (concerning for spinal

cord) Positive Babinski’s reflex (concerning for spinal cord) Bilateral reflex abnormalities (concerning for spinal

cord)

Sensory Findings Dermatomal sensory loss (suggests radiculopathy) Sharp demarcation of sensory (suggests

radiculopathy) Multiple dermatomes (concerning for spinal cord)

Autonomic Findings (Always concerning for central cause) Priapism, urinary retention, or decreased rectal

tone Horner’s syndrome (miosis, ptosis, anhidrosis)

Motor Exam Muscles Test all major joints flex and

extend Evaluate muscle tone, bulk, and tenderness Determination of symmetry is very important Upper Motor Neuron Spastic paralysis Hyperreflexia Hypertonicity Babinski reflex Lower Motor Neuron Flaccid paralysis Hyporeflexia Hypotonicity Muscle atrophy

Sensory Exam Pain: Spinothalamic tract - anterior cord

(also temperature) - cross immediately Light touch: Posterior columns -

posterior cord (also vibration) - cross in brain stem Determine: Right versus left Dermatome distributions Proximal versus distal Reflexes C5-C6 Biceps C5-C6 Brachioradialis C7-C8 Triceps L3-L4 Patellar S1-S2 Ankle Cerebellum Finger to nose Heel to shin Rapid alternating movements Romberg’s test Gait Involves multiple sensory and motor systems Vision Proprioception Lower motor neurons Upper motor neurons Basal ganglia Cerebellum Cortex

clinical It is imperative to perform a complete

neurologic examination including, when indicated, a rectal examination and post-void residual measurement

In cases of spinal cord compression, motor deficits are the most common neurologic finding and are present in up to 85% of patients

ED assesment attention to the motor examination of the lower

extremities Appropriate examination should include an assessment

of : hip flexion and extension leg flexion and extension ankle dorsiflexion and inversion great toe dorsiflexion

In cases of thoracic spinal cord compression, the iliopsoas muscles are preferentially affected, producing weakness of the proximal lower extremities when testing hip flexion

Prasad D, Schiff D. Malignant spinal-cord compression. Lancet Oncol 2005

ED assessment Sensory abnormalities occur slightly less

often than motor deficits, whereas bowel and/or bladder dysfunction is a late finding in patients with epidural spinal cord compression

Indications for rectal exam: fecal retention or incontinence and/or saddle

anesthesia severe pain and/or the presence of any neurologic

deficit

Prasad D, Schiff D. Malignant spinal-cord compression. Lancet Oncol 2005

patients with suspected spinal cord

compression should have a post-void residual measurement. A post-void residual greater than 100–200 ml is indicative of acute urinary retention.[90% sensitivity and 95% specificity for cauda equina syndrome ]

Small SA, Perron AD, Brady WJ. Orthopedic pitfalls: cauda equina syndrome. Am J Emerg Med 2005

Physical examination may be less useful than history

Neurologic deficit will depends on the tumour location

Look for primary cancer when suspected [ prostate, lung,breast]

Emerg med clin NA,17:1999

Investigation approach plain films may be falsely negative in up to

17% of patients with cord compression Pooled sensitivity of plain radiographs for

spinal metastases is just 60% Bone scanning, computed tomography, and

positron-emission tomography not superior to MRI [MRI diagnostic accuracy is 95%]

For patients suspected of cord compression due to metastatic disease, MRI of the entire spine is recommended, as compression can occur at multiple levels

Should we go straight to MRI when cancer suspected? Plain film X-rays are recommended first MRI is not cost effective for back pain with no history

of cancer Emergent MRI for abnormal X-rays or neurologic

findings When performing MRI, do the entire spine

10% with metastases will have other distant lesions Limiting to symptomatic site may have worse

outcome

Emerg med clin NA 1999 Jama 2003

Treatment approach multi-disciplinary approach If Dx suspected: consult neurosurgery,

orthopedic surgery, and radiation oncology. ED: supportive care i.e Parenteral pain

medications and dexamethasone (10 mg followed by 6 mg every 4 h) should be administered to patients with suspected spinal cord compression.

Recent RCT: in the case of cord compression due to metastatic disease, patients who received corticosteroids were more likely to be ambulatory at long-term follow up

Dexamethasone is the corticosteroid of choice given its low cost and relatively low mineralocorticoid activity . Currently, there is no concensus on the optimal dose

Schiff D. Spinal cord compression. Neurol Clin N Am 2003

Acute compressive myelopathy is oncologic emergency Treat immediately with dexamethasone (10 - 100 mg IV) Steroids will decrease swelling and vasogenic edema Admission for radiation and possible surgical intervention

Neurologic status at presentation is important Inability to walk is a very poor prognostic sign as only 5 -

30 % of patients will regain ambulatory status 60 - 90% of patients ambulatory at diagnosis will still

walk Jama 2003

J emerg med 1992

pitfalls “Classic” presentations are the exception

rather than the rule in back pain emergencies and they often present with symptoms mimicking other disease

Risk factors assessment is crucial to help identify patients requiring emergent imaging

Patients with back pain require a careful neurological examination to identify those requiring emergent treatment.

pitfalls Plain films of the back are almost never

indicated for nontraumatic back pain MRI is currently the only test that can exclude

spinal cord compression Steroids are indicated for patients with spinal

cord compression Patients with motor deficits should have

urgent appropriate referral

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