Malignant spinal cord compression
Malignant spinal cord compression (metastatic epidural spinal cord compression) is an oncologic emergency from vertebral metastasis that requires whole-spine MRI within 24 hours, immediate high-dose dexamethasone, and urgent radiotherapy or surgical decompression to prevent irreversible paralysis.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
Definition: malignant spinal cord compression, also called metastatic epidural spinal cord compression, is compression of the spinal cord or cauda equina by tumor extending from a vertebral body…
- Epidemiology
Frequency: develops in roughly 2.5% of patients with metastatic cancer, the most common cause of spinal cord dysfunction in this population.
- Risk factors
Known bone-metastatic cancer: any cancer with a predilection for vertebral metastasis (lung, breast, prostate, kidney, myeloma, lymphoma) raises risk, particularly once vertebral lesions are documented.
- Pathophysiology
Mechanical cord compression: tumor in the epidural space, or vertebral collapse from osteolytic or osteoblastic metastasis, compresses the cord or cauda equina and the surrounding venous plexus.
- Clinical features
Back or neck pain, the cardinal symptom: present in more than 90% of patients and often precedes neurologic deficit by weeks; worse lying flat, at night, and with coughing, sneezing, or the Valsalva maneuver.
- Differential diagnosis
Nonmalignant spinal cord compression: degenerative spinal stenosis or disc herniation can look similar, but imaging shows no epidural tumor and there is often chronic degenerative disease rather than malignancy.
- Diagnosis
First, establish the diagnosis with contrast-enhanced MRI of the entire spine: the gold-standard test, obtained emergently within 24 hours of suspected compression, because 10-40% of patients have…
- Management
First, give high-dose dexamethasone on clinical suspicion: started before imaging is complete if suspicion is high, since glucocorticoids rapidly reduce cord edema and can slow progression while workup proceeds.
- Complications
Irreversible paraplegia or quadriplegia: the feared outcome of delayed treatment, most likely once complete motor loss has been present over 48 hours.
- Prognosis
Ambulatory status at treatment start is the strongest predictor: patients still ambulatory when treatment begins are far more likely to remain ambulatory, while patients already paraplegic rarely regain the ability to walk.
- Prevention
Early recognition of new back pain: a low threshold to image any cancer patient with new or worsening back pain is the modifiable window during which progression to paraplegia can be prevented.
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Spinal cord compression
Spinal cord compression is mechanical narrowing of the spinal canal by tumor, hematoma, abscess, disc herniation, or trauma that produces myelopathy; it is a neurologic emergency requiring urgent MRI of the affected level and immediate treatment of the cause, since surgical decompression rarely restores function once paraplegia develops.
- Cauda equina syndrome
Cauda equina syndrome is compression of the lumbosacral nerve roots below the spinal cord causing saddle anesthesia, bladder or bowel dysfunction, bilateral leg weakness with areflexia, and low tone, most often from a large central lumbar disk herniation. It is a surgical emergency diagnosed by emergent MRI of the lumbar spine and treated with urgent decompression.
- Radiculopathy
Radiculopathy is dysfunction of a spinal nerve root, most often from disk herniation or degenerative spinal disease, producing radicular pain, dermatomal sensory loss, myotomal weakness, and reduced reflexes in a nerve-root distribution. Diagnosis is clinical; most cases resolve with conservative therapy within 6 to 12 weeks, and imaging is reserved for red flags or persistent symptoms.
- Multiple myeloma
Multiple myeloma is a clonal plasma cell neoplasm that produces a monoclonal immunoglobulin and end-organ damage summarized by CRAB (hypercalcemia, renal failure, anemia, bone lesions), diagnosed by marrow clonal plasma cells of 10% or more plus a CRAB or SLiM myeloma-defining event. Treatment combines a proteasome inhibitor, an immunomodulatory drug, and dexamethasone, followed by autologous stem cell transplant and maintenance in eligible patients.
- Lung cancer
Lung cancer is the leading cause of cancer death worldwide, split into non-small cell lung cancer (NSCLC, 80% of cases: adenocarcinoma, squamous cell, large cell) and small cell lung cancer (SCLC, 10-15%), both driven overwhelmingly by cigarette smoking. Diagnosis requires tissue histopathology, staging drives treatment (TNM staging for NSCLC, limited versus extensive stage for SCLC), and management ranges from lobectomy in early-stage disease through concurrent chemoradiation and consolidation immunotherapy in locally advanced disease to targeted tyrosine kinase inhibitors, immune checkpoint inhibitors, or platinum-based chemotherapy in metastatic disease.
- Breast cancer
Breast cancer is a malignancy of ductal or lobular epithelium, most often presenting as a firm, painless mass in the upper outer quadrant. Diagnosis rests on core needle biopsy with estrogen, progesterone, and HER2 receptor testing, and first-line treatment pairs breast-conserving surgery or mastectomy with sentinel node biopsy, radiation, and receptor-guided systemic therapy such as tamoxifen or trastuzumab.
- Prostate cancer
Prostate cancer is the most commonly diagnosed cancer in men, usually found through an elevated PSA in an asymptomatic patient, with risk stratified by PSA, Grade Group (Gleason score), and TNM stage. Localized low-risk disease is often managed with active surveillance, while higher-risk and metastatic disease require radiation, surgery, or androgen deprivation therapy escalated through castrate-sensitive and castrate-resistant phases.