Back pain and weakness of both legs had bothered this 60-year-old woman for 1 week. Left breast cancer, stage 2, had been diagnosed 2 years before, and subsequently she underwent a lumpectomy followed by chemotherapy and radiation therapy.
On physical examination, her vital signs, chest, heart, and abdomen were normal, but the neurologic examination confirmed the weakness of the lower extremities with diminished sensation and hyperactive deep tendon reflexes below the T10 level. Results of the complete blood cell count and serum chemistry evaluation were normal. An MRI of the thoracic spine, pictured here, demonstrates a lesion at T8 that compresses the spinal cord (arrow).
Drs Hesham Taha, Gamil Kostandy, and David Dosik of Brooklyn, NY, write that spinal cord compression secondary to metastic lesion follows brain metastasis as the most common neurologic complication of malignancy.1 The compression occurs more typically in patients with previously diagnosed cancer, but 8% of persons with spinal cord compression secondary to malignancy have a clinical and radiologic manifestation of compression as an initial presentation of cancer.2 Lymphoma and myeloma and cancers of the breast and lung are the malignancies most frequently associated with spinal cord compression.
MRI is the best diagnostic modality for spinal cord compression, because it obviates the need for lumbar puncture during myelography and is useful in planning radiation therapy and surgery. If spinal cord compression is suspected, give corticosteroids immediately and continue this drug therapy throughout the course of treatment. Radiotherapy is the first-line treatment for spinal cord compression; surgery may be necessary to obtain tissue for diagnostic evaluation or may be indicated in patients with spinal instability or in whom radiotherapy has been unsuccessful.
Drs Taha, Kostandy, and Dosik tell us that their patient was given intravenous dexamethasone and radiotherapy to the spine; there was marked improvement of the pain and weakness after 2 weeks of treatment. Subsequently, a bone scan revealed multiple bone metastases. The patient was treated with taxol, and follow-up bone scans indicate that her condition has stabilized. Spinal cord compression needs to be treated immediately, because the degree of neurologic dysfunction at the start of treatment is the strongest determinant of therapeutic outcome. About 80% of patients with little or no ambulatory impairment retain the ability to walk, while 20% to 60% of patients with paraparesis recover ambulation. However, only 16% of those with paraplegia improve in response to treatment.3
1. Black P. Spinal metastasis: current status and recommended guidelines for management. Neurosurgery. 1979;5:726-746.
2. Stark RJ, Henson RA, Evens SJW. Spinal metastasis. A retrospective survey from a general hospital. Brain. 1982;105:189-213.
3. Fuller B, Heiss J, Oldfield E. Spinal cord compression. In: DeVita VT, Hellman S, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology. 5th ed. Philadelphia: Lippincott-Raven; 1997:2476-2486.