Spinal neoplasms

A spinal neoplasm is any one of many tumor types that are similar to intracranial tumors and involve the spinal cord or its roots. If untreated, they can eventually cause paralysis.

Primary spinal neoplasms 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

Primary spinal cord tumors may be extramedullary (occurring outside the spinal cord) or intramedullary (occurring within the cord itself). Extra-medullary tumors may be intradural (meningiomas and schwannomas), which account for 60% of all primary spinal cord neoplasms, or extradural (metastatic tumors from breasts, lungs, prostate, leukemia, or lymphomas), which account for 25% of these neoplasms.

Intramedullary tumors, or gliomas (astrocytomas or ependymomas), are comparatively rare, accounting for only about 10% of tumors. In children, they’re low-grade astrocytomas.

Spinal cord tumors are rare compared with intracranial tumors (ratio of 1:4). They occur with equal frequency in men and women, with the exception of meningiomas, which occur most often 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; intra-medullary 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 spinal cord neoplasms:

❑ Pain is most severe directly over the tumor, radiates around the trunk or down the limb on the affected side, and is unrelieved by bed rest.

❑ Motor signs and symptoms include asymmetrical 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 include 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 paresthesia in the nerve distribution pathway of the involved roots.

❑ Bladder symptoms vary according to the stage of the tumor. Early signs include incomplete emptying or difficulty with the urine stream, which is usually unnoticed or ignored. Urine retention is an inevitable late sign with cord compression. Cauda equina tumors cause bladder and bowel incontinence from flaccid paralysis.

❑ Constipation can also occur.

Diagnosis

❑ Spinal computed tomography scan or magnetic resonance imaging shows the location and size of the tumor, or evidence of compression.

❑ Spinal tap shows clear yellow cerebrospinal fluid (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. A CSF smear may show malignant cells of metastatic carcinoma.

❑ X-rays show distortions of the intervertebral foramina, changes in the vertebrae, 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 the anatomic relationship of the tumor to the cord and the dura. If the obstruction is complete, the injected dye can’t flow past the tumor.

Note: This study is dangerous if cord compression is nearly complete because withdrawal or escape of CSF will actually 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.

❑ Frozen section biopsy at surgery identifies the tissue type.

Treatment

Spinal cord tumors usually require decompression or radiation. Laminectomy is indicated for primary tumors that produce spinal cord or cauda equina compression; it’s not 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 the outlook is ominous.

If the patient has incomplete paraplegia of rapid onset, emergency surgical decompression may save cord function. Steroid therapy minimizes cord edema 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 narcotic 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.

Special considerations

❑ 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.

❑ Provide psychological support. Help the patient and his family to understand and cope with the diagnosis, treatment, potential disabilities, and necessary changes in lifestyle. Suggest appropriate support groups or organizations such as the American Cancer Society.

❑ After laminectomy, check neurologic status frequently and watch for signs of infection. Administer analgesics, and aid the patient in early walking.

❑ 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.

❑ Make sure the patient receives appropriate rehabilitation, including bowel and bladder retraining.

❑ Administer steroids and antacids 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 he can safely walk; 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: Handbook of Diseases
• Author(s): Springhouse
• Year of Publication: 2003
• Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright Details: Handbook of Diseases, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Handbook of Diseases Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 1-58255-266-5

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