Malignant spinal cord compression

Background

• Suspect in patient w/ known cancer (esp lung, breast, prostate) + back pain
• Occurs in thoracic location in 70% of patients

Clinical Features

• Back pain (90% of patients)
  • Progressive and worse when supine
• Motor weakness (proximal legs)
• Sensory changes and bladder or bowel dysfunction (late findings)

Diagnosis

• MRI: modality of choice
• CT myelography: use if MRI unavailable
• Metastatic Bone Cancers
  • BTL w/ Pickles and Relish: Breast, Thyroid, Lung, Prostate, Renal

Differential Diagnosis

Oncologic Emergencies

Related to Local Tumor Effects

• Malignant airway obstruction
• Bone metastases and pathologic fractures
• Malignant spinal cord compression
• Malignant Pericardial Effusion and Tamponade
• Superior vena cava syndrome

Related to Biochemical Derangement

• Hypercalcemia of malignancy
• Hyponatremia due to SIADH
• Adrenal insufficiency
• Tumor lysis syndrome
• Carcinoid syndrome

Related to Hematologic Derangement

• Neutropenic fever
  • Neutropenic enterocolitis (typhlitis)
• Leukostasis and hyperleukocytosis
• Hyperviscosity syndrome
• Thromboembolism

Related to Therapy

• Chemotherapy-induced nausea and vomiting
• Cytokine release syndrome
• Chemotherapeutic drug extravasation
• Differentiation syndrome (retinoic acid syndrome) in APML
• Stem cell transplant complications
• Catheter-related complications
  • Tunnel infection
  • Exit site infection
  • CVC obstruction (intraluminal or catheter tip thrombosis)
  • Catheter-related venous thrombosis
  • Fracture of catheter lumen
  • Oncologic therapy related adverse events

Management

1. Corticosteroids
   1. Dexamethasone 10mg IV followed by 4mg PO or IV q6hr
   2. Consider starting in ED if imaging is delayed
2. Radiotherapy (emergent)

See Also

Spinal Cord Compression (Non-Traumatic)