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Spinal Cord Compression—Do We Miss 476 Oncology Spinal cord compression—do we miss it? We present here an interesting case of a woman who presented with features of stroke but later emerged to have metastatic spine disease as the cause of her symptoms. The learning point to take from this case report is to maintain a broadly open mind to the possibility of other diseases (malignancy in particular), as these can clearly present in disguise. Dr Kiran Chandan* General Practice Specialist Trainee, KSS Deanery, Conquest Hospital, Hastings Dr MJH Rahmani Consultant Physician in Healthcare for the Elderly, Stroke Lead and Foundation Programme Director, Conquest Hospital, Hastings email* [email protected] An 84-year-old lady was referred to including calcium levels and liver were absent and triceps exaggerated, our stroke clinic in March 2007 with and renal function. She was seen by suggesting inversion of the supinator a history of gradual-onset dizziness the community stroke rehabilitation jerk. She had normal reflexes on the and unsteadiness on her feet since team, who noted an 11% reduction left side but exaggerated knee jerks Christmas 2006. She had also in body weight over the three with an up-going planter response. noticed weakness in her right upper months since March. Her appetite She was also found to have bilateral limb, without further deterioration was also poor and she appeared ankle clonus. since the time of onset, until seen depressed. Her CT scan and carotid An X-ray of the cervical spine in the clinic. There was no history Doppler came back normal. She said revealed soft tissue swelling on of bowel or bladder complaints, that she felt as if “blood is running the right side of the cervical spine nausea, vomiting or diplopia. She very fast across both my right hand (Figure 1). The MRI showed an was a non-smoker and drank alcohol and leg, like a heat wave”, and also extensive, enhancing soft tissue very occasionally. When seen, she that her legs felt “very hot”. In view mass on the right side of the cervical was taking aspirin, simvastatin of her worsening neurology and spine that was compromising the and telmisartan for vascular new sensory symptoms, a brain C5, C6 and C7 nerve roots on the protection. On examination, she magnetic resonance imaging (MRI) right, and displacing the cervical had difficulty with balance, with scan was requested. cord on the left (Figures 2 and 3). residual right-sided weakness and She was seen in the clinic again The appearance was suggestive of a right, up-going plantar response. in June 2007, by which time she had metastasis. She was also found to The clinical impression was that become more ataxic, lost the sense of have multifactor canal stenosis at of a cerebrovascular event with feeling and developed a constant fear C2/C3 and the lumbar spine. residual right-sided weakness of falls. She did not report urinary or The orthopaedic team and unsteadiness. A computed bowel incontinence. biopsied the lesion, which tomography (CT) brain scan and On examination, she showed showed features consistent carotid Doppler were requested and powers of 2/5 on the right leg (both with metastatic carcinoma. The a referral made to the community proximally and distally), 3/5 in the immunohistochemical profile was in stroke rehabilitation team. right elbow flexion and 4/5 in the favour of possible primary renal cell The case was followed-up in elbow extension, but normal power carcinoma. A CT scan of the chest, May 2007, when she presented with in the right hand and wrist and abdomen and pelvis was normal continued weakness of the right the entire left side. Her right-sided with no renal mass. The bone scan arm. Her blood tests were normal, biceps and brachioradialis reflex showed metastatic disease in the GM | Midlife and Beyond | September 2010 www.gerimed.co.uk Soft tissue mass seen on the right side of the cervical region Figure 1: AP plain film of cervical spine cervical region only. By this time, she with bilateral signs. She did not have had become very frail and poorly, and any urinary or bowel symptoms on her it was decided to offer her palliative first or second visit to us, but developed treatment. She died peacefully on 22 double incontinence as an inpatient. August 2007. This shows that sphincter disturbance, if it occurs early, can indeed help in differentiating the spinal disease as the Discussion cause of the neurological symptoms. Another aspect that was noteworthy The thing that most caught our attention in this patient was the absence of in this case was the presentation of symptoms and signs above the neck. symptoms and signs of a stroke, and She had a normal conscious level, no how, later on, the symptomatology speech or language difficulties, normal shifted to that of something more than a facial strength and no difficulties in vascular phenomenon. The red herring visual fields. An indicator of spinal in this case was the right-sided weakness, disease, which remains an important with initial up-going plantar response distinguising feature in this, is the more only on the right side (suggestive of a often preserved neck flexion in the stroke), which then gradually worsened spinal disease. www.gerimed.co.uk 478 Oncology Spinal metastasis is common in patients with cancer. The spine is the third most common site where cancer cells metastasize, following the lung and the liver. Approximately 60–70% of patients with systemic cancer will have spinal metastasis; fortunately, only 10% of these patients are symptomatic. Approximately 94–98% of these patients present with epidural and/or vertebral involvement.1 About 70% of symptomatic lesions are found in the thoracic spinal region, particularly at the T4– T7 level. Of the remainder, 20% are found in the lumbar region and 10% in the cervical spine. More than 50% of patients with spinal metastasis have several levels of involvement. Isolated epidural involvement accounts for less than 10% of cases; it is particularly common in lymphoma and renal cell carcinoma.1 There is an extensive enhancing soft tissue mass in the cervical region Primary sources for spinal metastatic disease include the Figure 2: MRI cervical spine sagittal view - T2-weighted image following tumours.2 • Lung—31% • Breast—24% into the buttocks or legs choice. The sagittal image can be • GI tract—9% • Numbness or ‘pins and needles” used for rapid screening of the • Prostate—8% over the toes or buttocks. These can surrounding soft tissues. Contrast- • Lymphoma—6% help diagnose the level of lesion. On enhanced, fat-suppressed images • Melanoma—4% presentation of the first signs, an help to differentiate metastasis • Unknown—2% urgent MRI spine should be done from degenerative bone marrow. • Kidney—1% • Unsteadiness on the feet, and Diffusion-weighted images • Others, including multiple difficulty walking distinguish metastasis from myeloma—13% • Problems passing urine (difficulty osteoporotic bone. Osteoporotic in control of urine or passing very fractures are hypointense, and little urine) metastases are hyperintense. Bone Diagnosis • Constipation or problems scans are positive in 60% of patients, controlling your bowel. but they are not specific for spinal One should have a low threshold for cord metastasis. suspecting spinal cord metastasis. Procedures The signs and symptoms include Plain radiography is used to show motor, sensory and autonomic erosion of the pedicles or the Treatment disturbances. The red flag signs are vertebral body in cases of spinal listed below.3 cord metastasis. Radiologic findings Treatment should be started as • Back pain. This can feel like a band become apparent only when bone soon as possible after diagnosis. across the chest or abdomen, and can destruction reaches 30–50%.3 This is to prevent permanent sometimes radiate to the lower back, MRI is the imaging modality of damage to the spinal cord, which GM | Midlife and Beyond | September 2010 www.gerimed.co.uk Oncology 479 can result in paralysis. from operation on their spine for Conclusion Steroids are very good at spinal cord compression due to reducing pressure and swelling the tumour. Bisphosphonates can This is one of those cases that has around the cord, and can quickly be considered for pain relief in lots of points to take away. Patients relieve common symptoms such extreme cases, when steroids and who present with neurological as bone pain. Immediate treatment surgery are unsuccessful.5 features of stroke, such as is with high-dose dexamethasone. unilateral signs and symptoms of Steroids relieve pain within 24– weakness or sensory symptoms, 48 hours in approximately 64% Prognosis should be assessed for other of patients, whilst 57% report causes, particularly in the elderly improvement in motor function. Median survival of patients with population. This lady initially In most patients, steroids should spinal metastatic disease is 10 presented with features of stroke, be continued until radiotherapy months. Cord compression is but later lost weight and developed is completed.4 Bone pain may be often a preterminal event; median bilateral signs. Weight loss was related to root irritation and/or survival at that stage is about 3 clearly not defining as it could have meningeal irritation secondary to months.3 The most important been due to depression; however, cancer infiltration. Non-steroidal prognostic indicator for spinal the development of bilateral signs anti-inflammatory drugs (NSAIDs) metastases is initial functional was clearly not in favour of a stroke. are also commonly used to manage ability. The ability to ambulate bone pain. Use of spinal orthotics at presentation is a favourable Next of kin gave consent for and physiotherapy are useful prognostic sign. Loss of sphincter this article adjuvant therapies.4 control is a poor prognostic feature Radiotherapy and now surgical and mostly irreversible.
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