Literature

Clinical Pearls & Morning Reports


Published April 5, 2017

What types of spinal epidural metastases are responsive to radiotherapy?

The cardinal features of acute spinal cord compression are relatively symmetric paralysis of the limbs, urinary retention or incontinence, and a circumferential boundary below which there is loss of sensation, referred to as the “sensory level.” Read the Review Article for more information.

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Clinical Pearls

Q: How is the severity of the neurologic effects of traumatic spinal cord injury most commonly graded?

A: The neurologic effects of traumatic spinal cord injury are classified on the basis of anatomical level and severity of the neurologic deficit. The level is determined by the lowest cord segment with normal motor and sensory function. Severity may be graded with the use of a number of systems, but the most common is the American Spinal Injury Association Impairment Scale (AIS), which grades impairment on a five-point scale from A (complete loss of neurologic function below the affected level) to E (normal function).

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Table 2. ASIA Impairment Scale for Traumatic Spinal Cord Injury.

Q: What primary tumors are associated with spinal epidural metastases?

A: Breast, prostate, and lung cancers are frequent causes of metastasis to the vertebral column, but non-Hodgkin’s lymphoma, renal-cell cancer, and myeloma are also common causes. In some instances, the primary tumor cannot be identified. In children, sarcoma, neuroblastoma, and lymphoma have been reported as the most frequent causes of spinal cord compression.

Morning Report Questions

Q: What types of spinal epidural metastases are responsive to radiotherapy?

A: Treatment of malignant spinal cord compression by radiotherapy and surgical decompression is partly palliative, but relief of paraplegia and reduction of pain are possible for considerable periods. Definitive treatment is guided by the extent of symptomatic cord compression, by the mechanical stability of the spine, and partly by the responsiveness of the tumor to radiation. Lymphoma, myeloma, and seminoma are regarded as highly responsive and are treated with radiotherapy almost independently of the degree of cord compression. Breast, prostate, and ovarian tumors are associated with varied but intermediate responses to radiotherapy and are considered for surgical resection, although they may be treated with radiotherapy. Non–small-cell lung cancer and renal, thyroid, and gastrointestinal cancers, as well as sarcoma and melanoma, are relatively radioresistant and are generally treated with surgery, but some data support the use of conventional radiotherapy or radiosurgery.

Q: What are some of the features of spinal epidural abscesses?

A: Bacterial infection of the spinal epidural space is a treacherous condition with a high rate of delayed diagnosis. The myelopathy of epidural abscess may appear abruptly or remain indolent for weeks. Mechanical compression of the spinal cord occurs as a result of the mass effect of the infectious collection, but vasculitic infarction has also been implicated. The thoracic spine is most often affected, and abscesses usually occupy several contiguous or noncontiguous levels of the spine. Bacterial infection at a site distant from the spine is found in only half of affected patients, and one fourth have no primary infection, even at autopsy. Diabetes, in particular, but also cancer, immunosuppression, renal failure, and intravenous drug and alcohol abuse are underlying conditions. Staphylococcus aureus, evenly distributed between methicillin-resistant and methicillin-sensitive organisms, is the most common pathogen cultured from the abscess or blood, but a range of bacteria are found, including anaerobes.

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