Spinal Cord Syndrome

Making the diagnosis early

Imaging studies

Conventional Therapy

New radiation approaches

New Surgical techniques

NCCN Guidelines on Management

Compression of the spinal cord is due predominantly to extradural metastases (95%) and usually results from tumor involvement of the vertebral column. A tumor may occasionally metastasize to the epidural space without bony involvement. Metastatic spinal cord compression affects 5 to 14% of all cancer patients. Although spinal cord compression occurs in a variety of malignancies, the most common are lung, breast, unknown primary, prostate, and renal cancers, as well as lymphoma and myeloma.

Site of Spinal Cord Syndrome 60-80 percent of cases occur in the thoracic spine 15-30 percent in the lumbosacral spine <10 percent in the cervical spine

Symptoms of Spinal Cord Syndrome

Pain

Motor

Sensory

Autonomic

the median delay to treatment in those with known malignancy was two months from the onset of back pain and ten days from the onset of symptoms of spinal cord compression Most importantly, the majority of patients deteriorated by at least one grade in motor or bladder function during the delay from initial symptoms of ESCC. The net effect of delayed recognition and therapy is that the majority of patients with ESCC are not ambulatory at diagnosis Even in recent series, between 48 and 77 percent of patients with newly diagnosed ESCC are non-ambulatory

Pain — usually the first symptom being present in 83 to 95 percent of patients at the time of diagnosis. On average, pain precedes other neurologic symptoms of ESCC by seven weeks . Affected patients usually notice a severe local back pain which progressively increases in intensity. Pain is often worse with recumbency , a feature attributed to distension of the epidural venous plexus. Over time, the pain may develop a radicular quality. Radicular pain is more common in lumbosacral lesions than thoracic lesions. Thoracic radicular pain is commonly bilateral and wraps around anteriorly in a bandlike fashion. Abrupt worsening of pain may herald a pathologic compression fracture.

Odds of finding epidural metastases based on symptoms in patients with bone metastases in spine myelopathy 78% radicular pain 61% back pain 36%

Motor findings — Weakness is present in 60 to 85 percent of patients When the lesion is at or above the conus medullaris, weakness is from corticospinal dysfunction and has the typical pyramidal pattern, preferentially affecting the flexors in the lower extremities and, if above the thoracic spine, the extensors of the upper extremities. Hyperreflexia below the level of the compression and extensor plantar responses may be seen. The progression of motor findings until diagnosis typically consists of increasing weakness followed sequentially by loss of gait function and paralysis

Sensory findings — Sensory findings are a little less common than motor findings but are still present in a majority of patients at diagnosis. Patients frequently report ascending numbness and paresthesias When a spinal sensory level is present, it is typically one to five levels below the actual level of cord compression . Saddle sensory loss is commonly present in cauda equina lesions, while lesions above the cauda equina frequently result in sparing of sacral dermatomes to pinprick.

Loss of bladder and bowel function — Bladder and bowel dysfunction due to ESCC is generally a late finding that may be present in as many as one-half of patients. The autonomic neuropathy most commonly presents as urinary retention and is rarely the sole symptom of ESCC

Radiography — Plain spinal radiographs In a cancer patient with back pain, either major vertebral body collapse or pedicle erosion with a matching radiculopathy predicts a 75 to 83 percent chance of ESCC when a definitive study is performed . However, false negative plain spinal radiographs occur in 10 to 17 percent of patients . Three factors are primarily responsible for the false negative results: 50 percent of bone must be destroyed before a radiograph becomes abnormal ; metastatic involvement of multiple vertebrae may obscure the clinically relevant lesion; and paraspinal tumor invading through the neural foramen may produce no radiographic abnormality.

Approximately one-third of patients with ESCC have multiple epidural tumor deposits on MR scanning or myelography . A retrospective study of 337 cases found that failure to image the cervical spine in patients with symptomatic thoracic or lumbar epidural lesions would have missed secondary epidural lesions in only 1 percent of patients; however, this figure increased to 21 percent with failure to image either the thoracic or lumbosacral spine when symptomatic disease was located elsewhere

Treatment

Steroids (10-100mg decadron IV then 4mg q 6h)

Surgical evaluation

Radiation

Estimated Life Expectancy Median Survival , n= 1,157, radiation for painful bone mets breast cancer 16 months (14.2 to 18.5 months) prostate cancer 9.5 months (7.8 to 11 months) lung cancer 3.2 months (2.8 to 3.5 months) One criterion to consider a patient eligible for surgery is an expected survival of at least 3 months . For radiotherapy , a minimum life expectancy of at least a month is considered appropriate since most beneficial effects are expected to occur after 3 to 4 weeks.

Survival is based on several considerations: - responders live longer (9.5 months versus 2 months) - ambulatory patients live longer than paralyzed (10 months versus 1 month) -favorable histologies (myeloma, breast, lymphoma) live longer than other types (12 months versus 4 months)

Outcome Percent ambulatory based on neuro status at time of treatment

Ambulatory = 98%

Plegic = 60%

Paralyzed = 11%

Improving radiation technology from radium and cobalt to image guided IMRT ( Tomotherapy ) and stereotactic radiosurgery ( Cyberknife )

WellSpring Oncology

Dose reconstruction for cord compressions retreatments using helical tomotherapy S.L. Mahan, C. Ramsey IJROBP Volume 60, Issue 1, Pages S640-S641 (September 2004) patients with cord compressions that had received previous radiation therapy were imaged and treated on a HI-ART helical tomotherapy system dose calculations for no image guidance, the mean increase in spinal cord dose was 86.4% making treatment delivery impossible without image-guidance. Dose calculations were also made considering image guidance. These doses represent what should have been delivered using daily MVCT imaging. The mean increase in spinal cord dose was 5.2% making fractionated treatment delivery to 30 Gy possible even with minimal immobilization.

Cyberknife of Tampa Bay

Results of Radiation

Pain relief in 50 – 73% (85% highly targeted radiation)

Cyberknife Radiosurgery of the Spine

CyberKnife frameless stereotactic radiosurgery for spinal lesions: clinical experience in 125 cases. Neurosurgery. 2004 Jul;55(1):89-98; 125 spinal lesions in 115 consecutive patients were treated with a single-fraction radiosurgery technique No acute radiation toxicity or new neurological deficits occurred and Axial and radicular pain improved in 74 of 79 (94%) patients who were symptomatic before treatment.

Spinal Cancer using Radiosurgery

Long-term axial and radicular pain improvement occurred in 65 of 73 patients (89%) Radiosurgery for the treatment of spinal lung metastases University of Pittsburgh Medical Center,Cancer 2006;107:2653

Combination kyphoplasty and spinal radiosurgery: a new treatment paradigm for pathological fractures. Gerszten. Neurosurg Focus 2005 Mar 15;18(3):e8. CyberKnife radiosurgery underwent single-fraction radiosurgery (at a mean of 12 days after kyphoplasty) in an outpatient setting. Axial pain improved in 24 (92%) of 26 patients during the follow-up period of 7 to 20 months.

Results of Therapy (older radiation and surgery) 3% 10% Plegic 45% 45% Paretic 79% 64% Ambulatory XRT Surg + XRT PreTherapy State

Results of Surgery

surgical decompression of the spinal cord with concomitant stabilization ability to walk postoperatively in 80% and postoperative retention of urinary control in 93%.

Only 7% had persistent pain.

Similar results 78% of 45 patients were postoperatively able to walk and 84% had relief of their pain. These operative results were superior to the results achieved by radiation alone or in combination with laminectomy.

Surgery for Spinal Cord Syndrome T 2 sagittal preoperative MRI (A), a collapse of the 12th vertebral body was seen, with compression on the spinal cord (arrow). decompression and resection of the vertebral body through a posterior lateral approach. The spine was afterward stabilized anteriorly as well as posteriorly. The postoperative lateral radiograph (B) of the involved segments depicts the spinal construct consisting of a cage, screws, and rods.

Results of a Selection of Recent Series of Patients Surgically Treated for Spinal Metastases Followed by Radiotherapy and/or Other Forms of Adjuvant Therapy

Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Surgery + Radiation Radiation Outcome Able to walk 84% 57% Duration ability to walk 122 days 13 days Non-ambulatory became ambulatory 62% 19% Lancet. 2005 Aug 20-26;366(9486):643-8

Neuro Oncol 2005 7(1):64-76 Treatment of Spinal Cord Syndrome Meta-analysis included data from 24 surgical articles (999 patients) and 4 radiation articles (543 patients) Outcome Surg XRT Ambulatory 85% 64% Pain Relief 90% 70% Continence 66% 26%

32% in the group that underwent radiotherapy before surgery 12% in the group of patients first treated by surgery. PostOp major wound complications (dehiscence or wound infection)