Malignant spinal neoplasms
Malignant spinal neoplasms: Excerpt from Professional Guide to Diseases (Eighth Edition)
Malignant spinal neoplasms may be any one of many tumor types similar to intracranial tumors; they involve the cord or its roots and, if untreated, can eventually cause paralysis. As primary tumors, they originate in the meningeal coverings, the parenchyma of the cord or its roots, the intraspinal vasculature, or the vertebrae. They can also occur as metastatic foci from primary tumors.
Causes and incidence
Primary tumors of the spinal cord may be extramedullary (occurring outside the spinal cord) or intramedullary (occurring within the cord itself). Extramedullary tumors may be intradural (meningiomas and schwannomas), which account for 60% of all primary malignant spinal cord neoplasms, or extradural (metastatic tumors from breasts, lungs, prostate, leukemia, or lymphomas), which account for 25% of these malignant neoplasms.
Intramedullary tumors, or gliomas (astrocytomas or ependymomas), are comparatively rare, accounting for only about 10%. In children, they're low-grade astrocytomas.
Spinal cord tumors are rare compared with intracranial tumors (ratio of 1:4). They occur equally in men and women, with the exception of meningiomas, which occur mostly in women. Spinal cord tumors can occur anywhere along the length of the cord or its roots.
Signs and symptoms
Extramedullary tumors produce symptoms by pressing on nerve roots, the spinal cord, and spinal vessels; intramedullary tumors, by destroying the parenchyma and compressing adjacent areas. Because intramedullary tumors may extend over several spinal cord segments, their symptoms are more variable than those of extramedullary tumors.
The following clinical effects are likely with all malignant spinal cord neoplasms:
❑Pain — Most severe directly over the tumor, radiates around the trunk or down the limb on the affected side and is unrelieved by bed rest. It may worsen when lying down or with straining, coughing, or sneezing. Pain can be diffuse, occurring over all extremities. Generally, it progressively worsens and isn't relieved by medication.
❑ Motor symptoms — Asymmetric spastic muscle weakness, decreased muscle tone, exaggerated reflexes, and a positive Babinski's sign. If the tumor is at the level of the cauda equina, muscle flaccidity, muscle wasting, weakness, and progressive diminution in tendon reflexes are characteristic.
❑ Sensory deficits — Contralateral loss of pain, temperature, and touch sensation (Brown-Séquard's syndrome). These losses are less obvious to the patient than functional motor changes. Caudal lesions invariably produce paresthesias in the nerve distribution pathway of the involved roots.
❑Bowel and bladder symptoms — Urine retention is an inevitable late sign with cord compression. Early signs include incomplete emptying or difficulty with the urine stream, which is usually unnoticed or ignored. Cauda equina tumors cause bladder and bowel incontinence due to flaccid paralysis.
Diagnosis
❑Spinal and lumbosacral magnetic resonance imaging confirm spinal tumor.
❑ X-rays show distortions of the intervertebral foramina; changes in the vertebrae or collapsed areas in the vertebral body; and localized enlargement of the spinal canal, indicating an adjacent block.
❑ Myelography identifies the level of the lesion by outlining it if the tumor is causing partial obstruction; it shows anatomic relationship to the cord and the dura. If obstruction is complete, the injected dye can't flow past the tumor. (This study is dangerous if cord compression is nearly complete because withdrawal or escape of cerebrospinal fluid (CSF) will allow the tumor to exert greater pressure against the cord.)
❑ Radioisotope bone scan demonstrates metastatic invasion of the vertebrae by showing a characteristic increase in osteoblastic activity.
❑ Computed tomography scan shows cord compression and tumor location.
❑ Frozen section biopsy at surgery identifies the tissue type.
❑ Lumbar puncture may be normal, abnormal, or nonspecific. It may show clear yellow CSF as a result of increased protein levels if the flow is completely blocked. If the flow is partially blocked, protein levels rise, but the fluid is only slightly yellow in proportion to the CSF protein level. Cytology of the CSF may show malignant cells of metastatic carcinoma.
Treatment
Treatment of spinal cord tumors generally includes decompression or radiation. Laminectomy is indicated for primary tumors that produce spinal cord or cauda equina compression; it isn't usually indicated for metastatic tumors. If the tumor is slowly progressive or if it's treated before the cord degenerates from compression, symptoms are likely to disappear, and complete restoration of function is possible. In a patient with metastatic carcinoma or lymphoma who suddenly experiences complete transverse myelitis with spinal shock, functional improvement is unlikely, even with treatment, and his outlook is ominous. If the patient has incomplete paraplegia of rapid onset, emergency surgical decompression may save cord function. Steroid therapy with dexamethasone minimizes cord edema and temporarily relieves symptoms until surgery can be performed. Partial removal of intramedullary gliomas, followed by radiation, may alleviate symptoms for a short time. Metastatic extradural tumors can be controlled with radiation, analgesics and, in the case of hormone-mediated tumors (breast and prostate), appropriate hormone therapy. Transcutaneous electrical nerve stimulation (TENS) may control radicular pain from spinal cord tumors and is a useful alternative to opioid analgesics. In TENS, an electrical charge is applied to the skin to stimulate large-diameter nerve fibers and thereby inhibit transmission of pain impulses through small-diameter nerve fibers. Chemotherapy generally hasn't proven effective against most spinal tumors, but may be recommended in some cases.
Special considerations
The care plan for patients with spinal cord tumors should emphasize emotional support and skilled intervention during acute and chronic phases, early recognition of recurrence, prevention and treatment of complications, and maintenance of quality of life.
❑On your first contact with the patient, perform a complete neurologic evaluation to obtain baseline data for planning future care and evaluating changes in his clinical status.
❑Care of the patient with a spinal cord tumor is basically the same as that for the patient with spinal cord injury and requires psychologic support, rehabilitation (including bowel and bladder retraining), and prevention of infection and skin breakdown. After laminectomy, care includes checking neurologic status frequently, changing position by logrolling, administering analgesics, monitoring frequently for infection, and aiding in early walking. Physical therapy may be needed to improve muscle strength and to improve the ability to function independently when permanent neurologic losses occur.
❑Help the patient and his family to understand and cope with the diagnosis, treatment, potential disabilities, and necessary changes in lifestyle.
❑Take safety precautions for the patient with impaired sensation and motor deficits. Use side rails if the patient is bedridden; if he isn't, encourage him to wear flat shoes, and remove scatter rugs and clutter to prevent falls.
❑Encourage the patient to be independent in performing daily activities. Avoid aggravating pain by moving the patient slowly and by making sure his body is well aligned when giving personal care. Advise him to use TENS to block radicular pain.
❑Administer steroids and antacids, as ordered, for cord edema after radiation therapy. Monitor for sensory or motor dysfunction, which indicates the need for more steroids.
❑Enforce bed rest for the patient with vertebral body involvement until the physician says he can safely walk because body weight alone can cause cord collapse and cord laceration from bone fragments.
❑Logroll and position the patient on his side every 2 hours to prevent pressure ulcers and other complications of immobility.
❑If the patient is to wear a back brace, make sure he wears it whenever he gets out of bed.
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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