Tumors of the Spine

1. Causes: Benign Primary spinal tumors
   1. Osteoid Osteoma
   2. Eosinophilic Granuloma
   3. Aneurysmal bone cyst
   4. Osteoblastoma
2. Causes: Malignant Primary spinal tumors
   1. Sarcoma
   2. Multiple Myeloma (most common in adults)
3. Causes: Metastatic Tumors of the Spine
   1. General
      1. Spine is third most common metastatic site
      2. More common than primary spine tumors by 25 fold
   2. Sources
      1. Breast Cancer
      2. Lung Cancer
      3. Renal cancer
      4. Prostate Cancer
      5. Lymphoma
      6. Thyroid Cancer
4. Symptoms
   1. Back pain
      1. Worse at rest, lying supine
      2. May awaken patient at night
   2. Later changes
      1. Weakness (75%)
      2. Autonomic or sensory symptoms (50%)
      3. Urinary Incontinence
5. Signs: Neurologic Exam (Motor Exam)
   1. Symmetric motor weakness
   2. Early changes
      1. Flaccidity
      2. Hyporeflexia
   3. Later changes
      1. Spasticity
      2. Hyperreflexia
6. Labs
   1. Erythrocyte Sedimentation Rate > 50 mm/hour
7. Imaging
   1. Protocol
      1. Back pain without myelopathy or radiculopathy
         1. Start with plain Spine XRay
         2. Spine XRay negative: Obtain Bone Scan
         3. Spine XRay positive: Obtain MRI
      2. Back pain with myelopathy or radiculopathy
         1. Mild: MRI within 24 hours
         2. Severe or progressive: Emergent MRI now
            1. Also administer empiric Dexamethasone (below)
   2. Xray spine
      1. Will demonstrate solid tumor
   3. Spine MRI (first line test)
      1. Non-contrast study is preferred
      2. Evaluates for cord compression
   4. Other testing
      1. Spine Bone Scan
      2. Myelography (replaced by MRI)
8. Management: Neurologic compromise (emergency)
   1. Indications (see complications below)
      1. Epidural Spinal Cord Compression
      2. Sudden Myelopathy
   2. Systemic Corticosteroids (Pretreatment)
      1. Indicated in all cases of neurologic involvement
         1. Reduces spinal cord edema
         2. Alleviates pain
      2. Protocol
         1. Start as soon as diagnosis is suspected
            1. Delay in diagnosis can result in paraplegia
         2. Dosing
            1. Dexamethasone
               1. Protocol 1: 10 mg IV, followed by 4 mg q6 hours
               2. Protocol 2: 6 mg IV q6 hours
            2. High dose (up to 100 mg) is controversial
               1. Heimdal (1992) J Neurooncol 12:141-4
   3. Immediate Consultations
      1. Neurosurgery consultation
      2. Radiation Oncology Referral
   4. Mass Reduction
      1. Radiation Therapy (Standard)
         1. Localized radiation up to 3000 Gy
      2. Surgery Indications
         1. Unsure diagnosis
         2. Unstable spine
         3. Severe, rapid, progressive neurologic deterioration
         4. Radiation Therapy not expected to be effective
9. Complications
   1. Epidural Spinal Cord Compression
      1. Thoracic Spine (66%)
      2. Lumbosacral spine (20%)
      3. Cervical spine (14%)
   2. Acute Myelopathy Causes
      1. Irradiation
      2. Paraneoplastic necrotizing myelitis
      3. Ruptured intervertebral disc
      4. Meningeal carcinomatosis
10. References
    1. Arce (2001) Am Fam Physician 64(4):631-8
    2. Bilsky (1999) Oncologist 4:459-69
    3. Joines (2001) J Gen Intern Med 16:14-23