EPIDURAL SPINAL

CORD COMPRESSION
DR. ABDELKAREEM WEDAA
ELTOHAMY
INTRODUCTION
Epidural spinal cord compression is a neuro-oncologic
emergency
The  .
Any cancer patient with back pain should receive a prompt and
thorough evaluation, and those with neurologic dysfunction
localizing to the spinal cord or cauda equina require emergency
evaluation and treatment.
PATHOGENESIS

 INCIDENCE
 DISTRIBUTION
 RESPONSIBLE TUMORS
 MECHANISMS
 PATHOGENESIS
 1. Incidence:
About 5% of patients with cancer develop clinical evidence of
spinal cord compression.
 2. Distribution:
About 10% of epidural metastases occur in the cervical spine,
70% in the thoracic spine, and
20% in the lumbosacral spine.
About 10% to 40% of patients have multifocal epidural tumor.
 PATHOGENESIS
3. Responsible tumors:
Any tumor can cause spinal cord compression,

 lung cancer accounts for 15% of cases;

 breast, 10%
 prostate, 10%
 carcinoma of unknown primary site, 10%
 lymphoma, 10%
 myeloma 10%
 PATHOGENESIS
4. Mechanisms:
A tumor reaches the epidural space by either
(1) direct extension from a metastasis to the vertebral body growing into
the epidural space or
(2) tumor such as lymphoma can grow into the spinal canal through the
intervertebral foramina without destroying bone.
Secondary vascular compromise may cause venous infarction resulting in
the sudden, irreversible deterioration seen in some patients.
Direct metastasis to the spinal cord parenchyma is a rare cause of spinal
cord dysfunction in cancer patients
DIAGNOSIS

 NATURAL HISTORY
 CLINICAL PRESENTATION
 EVALUATION
 DIFFERENTIAL DIAGNOSIS
 DIAGNOSIS
 1. Natural history.
The progression of disease from the spinal column to the epidural space with neural
encroachment is manifested clinically as local back pain followed by radicular symptoms
and eventually myelopathy.
a. The initial stage of localized pain can last for several weeks or, in tumors such as
breast or prostate cancer and lymphoma, for several months.
b. Radicular symptoms, such as pain radiating in a root distribution, heralds further
tumor progression but is still a relatively early symptom.
c. Once paraparesis or ascending numbness of the legs occurs, the progression may be
extremely rapid and a complete myelopathy may develop within hours.
 DIAGNOSIS
2. Clinical presentation
depends on the level of spinal involvement.

a. Back pain
the initial symptom in >95% of patients with spinal cord compression caused by
malignancy. The pain is dull, aching, and often localized to the upper back; it typically
worsens with recumbency, unlike back pain from spinal degenerative disease.
Tenderness over the appropriate spinal level may be readily elicited.
 DIAGNOSIS
2. Clinical presentation
b. Radiculopathy
usually manifested by pain in a dermatomal distribution but can also include
sensory or motor loss in the distribution of the involved roots.
Cervical and lumbar diseases usually cause unilateral radiculopathy,
thoracic disease causes bilateral radiculopathy, resulting in a band-like
distribution of pain around the torso.
The pain from thoracic radiculopathies can sometimes be similar to pain from
pleurisy, cholecystitis, or pancreatitis.
The pain from cervical or lumbar radiculopathies can simulate disk herniation.
 DIAGNOSIS
2. Clinical presentation
c. Myelopathy
can occur rapidly,
the signs include bilateral leg weakness and numbness and loss of bowel and bladder
function depending on the level of spinal involvement.
Associated neurologic findings include hyperactive deep tendon reflexes, Babinski
responses, and decreased anal sphincter tone.
Disease at the level of the cauda equina usually causes urinary retention and saddle
anesthesia.
Unusual presentations of spinal cord compression include ataxia without motor, sensory, or
autonomic dysfunction.
Metastasis to the spinal cord parenchyma can cause a myelopathy without back pain.
 DIAGNOSIS
 3. Evaluation
Because the prognosis worsens when myelopathy develops, the diagnosis of epidural
metastasis should be established before the onset of spinal cord injury.
a. MRI
the procedure of choice for evaluating patients with suspected cord compression.
defines the degree of neural impingement and the extent of bone involvement
noninvasive and accurately detects other entities in the differential diagnosis of
myelopathy.
the entire spine can be imaged, which is essential in any patient with an epidural
metastasis.
Contrast will identify leptomeningeal metastasis or a spinal cord metastasis if they are
diagnostic considerations
 DIAGNOSIS
 3. Evaluation
 b. CT myelography
can be used if the patient cannot undergo an MRI.
If myelography shows a complete block, contrast material needs to be administered at
both the lumbar and the high cervical levels to establish the extent of disease.
If myelography is performed, CSF should always be sent for routine studies and
cytologic examination.
Myelography is contraindicated in patients with coagulopathy and may worsen a
neurologic deficit below the level of a complete spinal block.
 DIAGNOSIS
 4. Differential diagnosis:
 a. Structural lesions.
 Epidural hematoma (may occur spontaneously or after invasive procedures, especially
in patients with a coagulopathy),
 Epidural abscess,
 Herniated disk, or
 Osteoporotic vertebral collapse.
 b. Nonstructural lesions:
 Paraneoplastic syndromes
 Radiation myelopathy
 Guillain-Barré syndrome
 DIAGNOSIS
 4. Differential diagnosis:
 c. Back pain
in the absence of neurologic findings in patients with normal imaging
studies of the spine, back pain may be caused by leptomeningeal,
lumbosacral, or brachial plexus or retroperitoneal metastases, which can
be diagnosed by enhanced MRI, CSF studies, or body MRI or CT scans.
MANAGEMENT

 1. Dexamethasone
 2. Radiotherapy ( RT )
 3. Surgery
 4. Chemotherapy
 MANAGEMENT
 1. Dexamethasone
 Useful for alleviating neurologic symptoms and helps to control pain
associated with epidural cord compression.
 Treatment should begin immediately, even before diagnostic studies are
performed, unless the patient has lymphoma in which case
corticosteroids can cause tumor regression and a false-negative finding
on MRI.
 Dosing depends on the degree of neurologic involvement. For
radiculopathy only, doses are usually 10 mg IV followed by 4 to 8 mg IV
or PO twice a day.
 MANAGEMENT
2. Radiotherapy ( RT )
 Effective for spinal cord compression.
 It retards tumor growth and also alleviates pain.
 RT is especially useful for tumors that are sensitive to radiation (e.g.,
lymphoma, breast), early and slowly progressive lesions, and metastases
below the conus medullaris.
 The usual dose is 3,000 cGy divided in 10 fractions, but recent data
suggest a shorter course with 2,000 cGy divided in 5 fractions is equally
effective
 MANAGEMENT
3. Surgery
 surgery followed by RT is superior to RT alone, giving significantly longer survival
and better neurologic outcome, including restoration of ambulation in paraplegic
patients.
 specific indications for surgery include the following:
 a. Need for a pathologic diagnosis.
 b. Progression of neurologic abnormalities during RT; surgery rarely restores lost
neurologic function in this situation.
 c. Recurrent spinal cord compression in a previously irradiated area.
 d. Spinal instability.
 MANAGEMENT
 4. Chemotherapy
used in highly responsive tumors, such as lymphoma or germ cell tumors,
if neurologic involvement is limited.
 PROGNOSIS
 The outcome is greatly improved if treatment is initiated before spinal cord
symptoms appear.
 In general, if the patient is walking at diagnosis, he or she will remain ambulatory
after treatment, but if the patient is not walking at diagnosis, restoration of
ambulation is less likely.
 Other prognostic factors include the level of spinal cord involvement and the rate of
neurologic progression.
 Patients with breast cancer and lymphoma tend to do better because their tumors
respond to therapy.
 Patients with lung or prostate cancer that is refractory to treatment, and who have
cord compression that has progressed rapidly, tend to do poorly.
THANK YOU