Incidence 5-15% of patients with cancer have spinal metastasis( spread to the spine) In autopsy studies 70% of cancer patients have spinal metastasis Risk of getting a primary spinal cord tumour is 1 in 140 for men and 1 in 180 for women.
Tumours in the Vertebra Spinal Metastases( commonest) Multiple Myeloma Lymphoma Osteoid Osteoma( 10-25 yrs) Osteoblastome( 20-30 yrs) Eosinophilic Granuloma Haemangioma Aneurysmal Bone Cysts Sarcoma Chordoma
Symptoms of early cord compression Heaviness in legs and arms Altered sensation ‘Water running down legs’ Loss of co-ordination when walking Weakness Changes in bladder function
3 types of pain in these cases Biological- from the inflammation around the tumour- described as a deep ache and is worse at night, eased on getting up and moving around. Radicular-from pressure on a nerve root Mechanical- from bony destruction- worse on loading the spine- eg lifting, bending, sitting. CAN MIMIC DEGENERATIVE SPINAL PAIN SO HIGH INDEX OF SUSPICION NEEDED.
Symptoms of hpercalcemia Thirst Confusion Loss of apetite Nausea Tiredness Constipation
Investigations MRI is the investigation of choice- order brain and whole spine MRI with contrast if a tumour or cord compression is suspected Bone scan to check for skeletal spread Chest X-ray CT scan chest and abdomen– to look for a primary once a spinal tumour is diagnosed Biopsy
Blood tests FBC, ESR, CRP, U&E Serum Electrophoresis- Myeloma Bone Chemistry-look for elevated Alkaline phosphatase in bone destruction, elevated calcium levels Thyroid levels PSA – for prostate CEA Antigen
Treatment Options Dexamethasone- to reduce cord oedema Spinal cord tumours- usually need surgery Spinal Metastasis: Surgical decompression and stabilization if causing cord compression, radiotherapy with our without vertebroplasty if not. Chemotherapy in some cases as indicated.
T5 Metastatic Tumour Patient in 60’s. Sneezing episode Got Mid-thoracic pain Also reports some heaviness in legs No loss of appetite or weight loss O/E- Myelopathic gait, sensory level T6, tender D5/6 Walks like a drunk. Going off legs. No known primary 20% of patients with tumors present with no known primary.
Treatment. T5 Trans-pedicular vertebrectomy +Bone Cement into Vertebra Pain and cord compression symptoms resolved
Vertebroplasty for a spinal tumour Dec 02 – Lifts heavy weight LBP Since then Getting Worse Night Sweats x 6 weeks ESR=73 Biopsy and Vertebroplasty - L2 Non-Hodgkins Lymphoma- now in remission after Chemotherapy
Neurofibroma causing Radicular Pain Patient in 50’s.. Left buttock, and leg pain for 12 months. No postural relief. Widespread Neurofibromatosis. With Gadolinium
Intra-medullary Tumor- Schwannoma. Treated successfully by excision surgery Post-GAD IMAGES. Patient in 40’s 6month history of abdominal pain Had hernia repair- no better Hyper-sensitive to touch in abdomen T6-10 distribution. BILATERAL POSITIVE HOFFMAN REFLEX