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Spinal mets


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Spinal mets

  1. 1. Mets spinal cord disease ED diagnostic approarch Ahmed Alhubaishi
  2. 2. overview <ul><li>Introduction and background </li></ul><ul><li>Statistics </li></ul><ul><li>Clinical history </li></ul><ul><li>Physical examination </li></ul><ul><li>Investigations </li></ul><ul><li>Treatment </li></ul><ul><li>pitfalls </li></ul>
  3. 3. introduction <ul><li>Epidural spinal cord compression is : </li></ul><ul><ul><li>true medical emergency that cannot be missed. </li></ul></ul><ul><ul><li>Over 90% of cases are due to spinal epidural metastases </li></ul></ul><ul><ul><li>primary risk factor for spinal epidural metastases is a history of malignancy </li></ul></ul>
  4. 4. <ul><li>Metastatic disease is 25 times more common than primary tumors </li></ul><ul><ul><li>Approximately 5-10% of cancer patients will have spinal metastases </li></ul></ul><ul><ul><li>Breast, lung, and prostate cancers are most common </li></ul></ul><ul><li>Where does epidural compression occur? </li></ul><ul><ul><li>15% cervical </li></ul></ul><ul><ul><li>68% thoracic </li></ul></ul><ul><ul><li>19% lumbar </li></ul></ul>
  5. 5. <ul><li>Although prostate, breast, and lung cancer most commonly cause bony metastases, it is important to realize that any systemic malignancy can metastasize to the spine. Lymphoma, renal cell cancer, gastrointestinal malignancies, and multiple myeloma are frequently overlooked, yet account for a significant percentage of cases </li></ul>
  6. 6. <ul><li>As many as 5% of all cancer patients will develop metastases to the spine and spinal cord at some point in the course of their disease </li></ul><ul><li>Posner JB. Back pain and epidural spinal cord compression. Med Clin N Am 1987 </li></ul>
  7. 7. <ul><li>Epidural spinal cord compression may be the first clinical manifestation of malignancy. Patient outcomes have been shown to be related to early diagnosis and rapid institution of therapy </li></ul><ul><li>Kim RY, Spencer SA, Meridith RF, et al. Extradural spinal cord compression: analysis of factors determining functional progress, prospective study. Radiology 1990 </li></ul>
  8. 8. <ul><li>How does spinal cord mets cause symptoms? </li></ul><ul><ul><li>Compression, invasion or destruction of spinal tracts </li></ul></ul><ul><ul><li>Symptoms will depend on location and growth of the tumour </li></ul></ul><ul><li>Jama ,760-765:1992 </li></ul>
  9. 9. Historical Clues Worrisome for Compression <ul><li>Pain </li></ul><ul><li>Neck pain or arm pain (cervical radiculopathy) </li></ul><ul><li>Low back pain or sciatica (lumbar radiculopathy) </li></ul><ul><li>Neuro complaints without pain (concerning for spinal cord) </li></ul><ul><li>Motor complaints </li></ul><ul><li>Unilateral weakness (suggests radiculopathy) </li></ul><ul><li>Bilateral weakness or spasticity (concerning for spinal cord) </li></ul>
  10. 11. <ul><li>Sensory complaints </li></ul><ul><li>Dermatomal sensory loss / paresthesias (suggests radiculopathy) </li></ul><ul><li>Multiple dermatomes (concerning for spinal cord) </li></ul><ul><li>Autonomic manifestations (Always concerning for central cause) </li></ul><ul><li>Impotence or priapism </li></ul><ul><li>Bowel constipation or incontinence </li></ul><ul><li>Urinary frequency, urgency, retention, or incontinence </li></ul>
  11. 13. <ul><li>Suspicion for serious pathology begins with an assessment of patient risk factors for disease . </li></ul>
  12. 14. RED FLAGS <ul><li>H/O CANCER </li></ul><ul><li>AGE > 50 </li></ul><ul><li>BACK PAIN ESPECIALLY AT NIGHT OR WITH </li></ul><ul><ul><li>Unexplained wt loss </li></ul></ul><ul><ul><li>Pain unreleived by bedrest [ sen > 90% but very non specific] </li></ul></ul><ul><ul><li>NIGHT SWEAT </li></ul></ul><ul><ul><li>FEVER </li></ul></ul><ul><li>SYMPTOMS MORE THAN 4-6 WKs with failure of conservative Rx </li></ul><ul><li>NEUROLOGICAL DEFICIT: motor, sensory </li></ul><ul><li>Lancet 373: 463-472, 2009 </li></ul>
  13. 16. Physical Exam Findings that Suggest Compression <ul><li>Pain on Exam </li></ul><ul><ul><li>Elicited with Spurling’s test (cervical radiculopathy) </li></ul></ul><ul><ul><li>Elicited with straight leg raise (lumbar radiculopathy) </li></ul></ul><ul><li>Motor Findings </li></ul><ul><ul><li>Unilateral weakness or reflex change (suggests radiculopathy) </li></ul></ul><ul><ul><li>Spasticity or bilateral weakness (concerning for spinal cord) </li></ul></ul><ul><ul><li>Positive Babinski’s reflex (concerning for spinal cord) </li></ul></ul><ul><ul><li>Bilateral reflex abnormalities (concerning for spinal cord) </li></ul></ul>
  14. 18. <ul><li>Sensory Findings </li></ul><ul><ul><li>Dermatomal sensory loss (suggests radiculopathy) </li></ul></ul><ul><ul><li>Sharp demarcation of sensory (suggests radiculopathy) </li></ul></ul><ul><ul><li>Multiple dermatomes (concerning for spinal cord) </li></ul></ul><ul><li>Autonomic Findings (Always concerning for central cause) </li></ul><ul><ul><li>Priapism, urinary retention, or decreased rectal tone </li></ul></ul><ul><ul><li>Horner’s syndrome (miosis, ptosis, anhidrosis) </li></ul></ul>
  15. 21. <ul><li>Motor Exam </li></ul><ul><li>Muscles Test all major joints flex and extend </li></ul><ul><li>Evaluate muscle tone, bulk, and tenderness </li></ul><ul><li>Determination of symmetry is very important </li></ul><ul><li>Upper Motor Neuron </li></ul><ul><li>Spastic paralysis Hyperreflexia </li></ul><ul><li>Hypertonicity Babinski reflex </li></ul><ul><li>Lower Motor Neuron </li></ul><ul><li>Flaccid paralysis Hyporeflexia </li></ul><ul><li>Hypotonicity Muscle atrophy </li></ul><ul><li>Sensory Exam </li></ul><ul><li>Pain: Spinothalamic tract - anterior cord (also temperature) </li></ul><ul><li>- cross immediately </li></ul><ul><li>Light touch: Posterior columns - posterior cord (also vibration) </li></ul><ul><li>- cross in brain stem </li></ul><ul><li>Determine: Right versus left </li></ul><ul><li>Dermatome distributions </li></ul><ul><li>Proximal versus distal </li></ul><ul><li>Reflexes </li></ul><ul><li>C5-C6 Biceps </li></ul><ul><li>C5-C6 Brachioradialis </li></ul><ul><li>C7-C8 Triceps </li></ul><ul><li>L3-L4 Patellar </li></ul><ul><li>S1-S2 Ankle </li></ul><ul><li>Cerebellum </li></ul><ul><li>Finger to nose </li></ul><ul><li>Heel to shin </li></ul><ul><li>Rapid alternating movements </li></ul><ul><li>Romberg’s test </li></ul><ul><li>Gait </li></ul><ul><li>Involves multiple sensory and motor systems </li></ul><ul><li>Vision </li></ul><ul><li>Proprioception </li></ul><ul><li>Lower motor neurons </li></ul><ul><li>Upper motor neurons </li></ul><ul><li>Basal ganglia </li></ul><ul><li>Cerebellum </li></ul><ul><li>Cortex </li></ul>
  16. 22. clinical <ul><li>It is imperative to perform a complete neurologic examination including, when indicated, a rectal examination and post-void residual measurement </li></ul><ul><li>In cases of spinal cord compression, motor deficits are the most common neurologic finding and are present in up to 85% of patients </li></ul>
  17. 23. ED assesment <ul><li>attention to the motor examination of the lower extremities </li></ul><ul><li>Appropriate examination should include an assessment of : </li></ul><ul><ul><li>hip flexion and extension </li></ul></ul><ul><ul><li>leg flexion and extension </li></ul></ul><ul><ul><li>ankle dorsiflexion and inversion </li></ul></ul><ul><ul><li>great toe dorsiflexion </li></ul></ul><ul><li>In cases of thoracic spinal cord compression , the iliopsoas muscles are preferentially affected, producing weakness of the proximal lower extremities when testing hip flexion </li></ul><ul><li>Prasad D, Schiff D. Malignant spinal-cord compression. Lancet Oncol 2005 </li></ul>
  18. 24. ED assessment <ul><li>Sensory abnormalities occur slightly less often than motor deficits, whereas bowel and/or bladder dysfunction is a late finding in patients with epidural spinal cord compression </li></ul><ul><li>Indications for rectal exam : </li></ul><ul><ul><li>fecal retention or incontinence and/or saddle anesthesia </li></ul></ul><ul><ul><li>severe pain and/or the presence of any neurologic deficit </li></ul></ul><ul><li>Prasad D, Schiff D. Malignant spinal-cord compression. Lancet Oncol 2005 </li></ul>
  19. 25. <ul><li>patients with suspected spinal cord compression should have a post-void residual measurement . A post-void residual greater than 100–200 ml is indicative of acute urinary retention.[90% sensitivity and 95% specificity for cauda equina syndrome ] </li></ul><ul><li>Small SA, Perron AD, Brady WJ. Orthopedic pitfalls: cauda equina syndrome. Am J Emerg Med 2005 </li></ul>
  20. 26. <ul><li>Physical examination may be less useful than history </li></ul><ul><li>Neurologic deficit will depends on the tumour location </li></ul><ul><li>Look for primary cancer when suspected [ prostate, lung,breast] </li></ul><ul><li>Emerg med clin NA,17:1999 </li></ul>
  21. 27. Investigation approach <ul><li>plain films may be falsely negative in up to 17% of patients with cord compression </li></ul><ul><li>Pooled sensitivity of plain radiographs for spinal metastases is just 60% </li></ul><ul><li>Bone scanning, computed tomography, and positron-emission tomography not superior to MRI [ MRI diagnostic accuracy is 95%] </li></ul><ul><li>For patients suspected of cord compression due to metastatic disease, MRI of the entire spine is recommended, as compression can occur at multiple levels </li></ul>
  22. 29. <ul><li>Should we go straight to MRI when cancer suspected? </li></ul><ul><ul><li>Plain film X-rays are recommended first </li></ul></ul><ul><ul><li>MRI is not cost effective for back pain with no history of cancer </li></ul></ul><ul><ul><li>Emergent MRI for abnormal X-rays or neurologic findings </li></ul></ul><ul><li>When performing MRI, do the entire spine </li></ul><ul><ul><li>10% with metastases will have other distant lesions </li></ul></ul><ul><ul><li>Limiting to symptomatic site may have worse outcome </li></ul></ul><ul><li>Emerg med clin NA 1999 </li></ul><ul><li>Jama 2003 </li></ul>
  23. 32. Treatment approach <ul><li>multi-disciplinary approach </li></ul><ul><li>If Dx suspected: consult neurosurgery, orthopedic surgery, and radiation oncology. </li></ul><ul><li>ED: supportive care i.e Parenteral pain medications and dexamethasone (10 mg followed by 6 mg every 4 h) should be administered to patients with suspected spinal cord compression. </li></ul>
  24. 33. <ul><li>Recent RCT: in the case of cord compression due to metastatic disease, patients who received corticosteroids were more likely to be ambulatory at long-term follow up </li></ul><ul><li>Dexamethasone is the corticosteroid of choice given its low cost and relatively low mineralocorticoid activity . Currently, there is no concensus on the optimal dose </li></ul><ul><li>Schiff D. Spinal cord compression. Neurol Clin N Am 2003 </li></ul>
  25. 34. <ul><li>Acute compressive myelopathy is oncologic emergency </li></ul><ul><ul><li>Treat immediately with dexamethasone (10 - 100 mg IV) </li></ul></ul><ul><ul><li>Steroids will decrease swelling and vasogenic edema </li></ul></ul><ul><ul><li>Admission for radiation and possible surgical intervention </li></ul></ul><ul><li>Neurologic status at presentation is important </li></ul><ul><ul><li>Inability to walk is a very poor prognostic sign as only 5 - 30 % of patients will regain ambulatory status </li></ul></ul><ul><ul><li>60 - 90% of patients ambulatory at diagnosis will still walk </li></ul></ul><ul><ul><li>Jama 2003 </li></ul></ul><ul><ul><li>J emerg med 1992 </li></ul></ul>
  26. 35. pitfalls <ul><li>“ Classic” presentations are the exception rather than the rule in back pain emergencies and they often present with symptoms mimicking other disease </li></ul><ul><li>Risk factors assessment is crucial to help identify patients requiring emergent imaging </li></ul><ul><li>Patients with back pain require a careful neurological examination to identify those requiring emergent treatment. </li></ul>
  27. 36. pitfalls <ul><li>Plain films of the back are almost never indicated for nontraumatic back pain </li></ul><ul><li>MRI is currently the only test that can exclude spinal cord compression </li></ul><ul><li>Steroids are indicated for patients with spinal cord compression </li></ul><ul><li>Patients with motor deficits should have urgent appropriate referral </li></ul>
  28. 37. <ul><li>Shukran </li></ul><ul><li>No Q? allowed </li></ul>