Spinal Cord Compression

Question 1

Symptoms of SCC

Answer 1

• back pain (> 90%)
  
  • localized, radicular, mechanical
  • worsens with laying down, coughing, sneezing
  • 2-3 months before neuro sx
• Motor weakness (late symptoms) (60-95%)
  
  • ataxia
  • paralysis
• sensory changes
  
  • less common 40-80%
• Autonomic symptoms
  
  • last symptom
  • urinary retention / incontinence
  • Constipation/ fecal incontinence

Question 2

Risk factors for SCC

Answer 2

• inability to walk
• increased DTR
• Compression fracture on Xray
• bone mets > 1 year
• age < 60
• multiple site of bone mets
• 24 months hormonal therapy
• If all risk factors, 87% risk
• If no risk factors, 40% risk SCC
• Breast, lung, prostate

Question 3

Diagnostic tests for SCC

Answer 3

• Whole spine MRI
• likely to have skip lesions at other levels, poor correlation of pain and level of SCC
• sensitivity 93%
• specificity 90-98%
• CT myelography if MRI not tolerated or CI

Question 4

Steroids for SCC

Answer 4

• Moderate dose just as good as high dose
• Dexamethasone 10 mg loading dose, then 16 mg daily (8 mg po bid)
• reduces vasogenic edema - better neurologic outcomes
• Taper once definitive plan

Question 5

Outcomes in SCC

Answer 5

• ambulatory patients more likely to keep functional status (90%) with RT alone
• if already paraplegic or quadraplegic, very unlikely to recover (< 30%)
• RT and surgery > RT alone
• surgery morbidity and mortality : 13% mortality in 30 days, 54% complication rate

Question 6

Radiotherapy

Answer 6

• treatment of choice if no bony instability
• within 24 hours of diagnosis
• single fraction 8Gy to 20 fr of 40 Gy
• Pain control in 40-80%
• Sphincter control 45-90%

Question 7

Surgery for SCC

Answer 7

• previously reserved for :
  
  • previously irradiated areas
  • neurological deterioration during RT
  • spinal instablity
  • bone compression
• indications changing and individualized

Question 8

Other novel treatments for SCC

Answer 8

• SRS
• Transarterial embolization
• no evidence for bisphosphonates in SCC
• CHemotherapy : no role as slow effect

Question 9

Prognosis after SCC diagnosis

Answer 9

• median survival 3-6m onths
• poor prognositic indicators:
  
  • non ambulatory,
  • SCC within 15 months of cancer dx
  • visceral or other mets
  • lung cancer
  • rapid motor symptoms < 7 days

Question 10

Epidemiology of SCC

Answer 10

• MM, breast, lung, prostate
• thoracic spine 70% (narrow epidural space and dense vascularization)
• lumboscaral (20%)
• cervical (10%)

Question 11

Pathophysiology of SCC

Answer 11

• hematogenous spread to epidural space most common
• direct invasion of neural formamen
• in epidural space, presses on dura mater causing ischemia and demyelination of spinal cord

Question 12

Signs of SCC

Answer 12

• weakness (85%)
• sensory level deficit (50-60%)
• poor correlation of pain and level of SCC
• Myotomes
• Dermatomes