Multiple myeloma presenting with acute bony spinal cord compression and mechanical instability successfully managed nonoperatively

Objective To explore the clinicopathological features, imaging features and treatment of spinal cord myeloma in patients with spinal cord compression as the first symptom. Methods The retrospective cross-sectional study was conducted which the clinical data of five patients with spinal myeloid sarcoma confirmed by bone marrow aspiration and pathology from January 2014 to December 2017 in Changzheng Hospital. There were 3 males and 2 females, aged from 15 to 54 years old. the tumors were located in 3 cases of thoracic vertebrae and 2 cases of lumbar vertebrae. Four cases were treated with open surgery. After discharge, they were treated with chemotherapy and hematological tumors according to bone marrow puncture and pathological results. Another patient underwent conservative treatment (anti-inflammatory analgesia, nutritional support, chemotherapy, etc.). The observation items were analysed. Results All the 5 patients had a low back pain, three of them had a lower limbs weakness, and one of them was accompanied by paralysis of both lower limbs. X-ray examination showed no abnormal findings. CT and MRI showed bone destruction or soft tissue shadow. Bone marrow aspiration and postoperative pathological examination showed that five cases were leukemia including four acute myeloid leukemia(AML)and one chronic myeloid leukemia(CML). All patients' preoperative symptoms were relieved after treatment. All patients were followed up. One patient underwent IA regimen chemotherapy for five courses, and was treated with allogeneic hematopoietic stem cell transplantation. It had been followed up for 28 months after surgery and still in good condition without tumor recurrence. The other four patients relapsed after chemotherapy, all died of infection, and the survival period was from 5 to 26.5 months. Conclusions Spinal cord compression caused by myeloid sarcoma as an initial symptom is rare. The imaging manifestations of the myeloid sarcoma are lack of specificity and and it is easy to be misdiagnosed. Bone marrow aspiration and pathological examination can confirm the diagnosis. When the symptoms of spinal cord compression occur, it is recommended to perform early tumor decompression. The allogeneic hematopoietic stem cell transplantation and systemic chemotherapy should be performed after surgery. Key words: Sarcoma, myeloid; Leukemia; Spinal compression; Diagnosis; Treatment outcome

Acute dorsal compression of the spinal cord was applied to adult cats, and magnetic resonance signal intensity, spinal cord evoked potentials, and morphologic changes of the spinal cord were examined after 5 hours. The present study investigated the correlation of magnetic resonance signal intensity with spinal cord evoked potentials and spinal cord morphology after 5 hours of spinal cord compression in cats. Neurologic prognosis of the injury might be predicted by an analysis of magnetic resonance signal intensity pattern. Little information is available on relationships between magnetic resonance images and functional or morphologic damage of spinal cord in acute animal experiments. Acute dorsal compression of the spinal cord was performed in 24 anesthetized cats. After laminectomy, the L2 segment was compressed for 5 hours. Spinal cord evoked potentials were recorded by electrodes placed in the epidural space at L4, and the spinal cord was stimulated at T12. The animals were divided into four groups based on changes in the amplitude of spinal cord evoked potentials. Immediately after compression for 5 hours, magnetic resonance images were obtained. Signal intensity of the spinal cord was measured on sagittal midline images. Morphologic changes were assessed. Spinal compression significantly increased the signal intensity of the L1, L2, and L3 segments on T2-weighted and proton density-weighted images. The increase in signal intensity was remarkable in the animals whose spinal cord evoked potentials were reduced greatly (< 40% of the control group). Histologically, edema was present in the high intensity area on T2-weighted and proton density-weighted images. In summary, the present study documents that spinal compression causes tissue edema, which produces high signal intensity on magnetic resonance imaging. The magnetic resonance signal intensity is correlated closely with decreased amplitude of spinal cord evoked potentials.

Acute compression of the spinal cord is a devastating but treatable disorder. Diseases that cause acute spinal cord compression constitute a special category because they originate in the spinal column and narrow the spinal canal. This review addresses the disorders that account for most instances of acute spinal cord compression: trauma, tumor, epidural abscess, and epidural hematoma. The pathophysiological features and management of these disorders are similar to those of other acute and serious spinal conditions. The medical context of spinal cord compression determines the diagnosis and directs treatment. Traumatic cord compression is often self-evident. Cord compression in patients with . . .

We studied MR images of the spine in a consecutive series of 100 patients with acute compression of the spinal cord due to metastases. All patients had documented neurological deficit and histologically proven carcinoma. MRI was used to localise bony metastatic involvement and soft-tissue impingement of the cord. A systematic method of documenting metastatic involvement is described. A total of 43 patients had compression at multiple levels; 160 vertebral levels were studied. In 120 vertebrae (75%), anterior, lateral and posterior bony elements were involved. Soft-tissue impingement of the spinal cord often involved more than one quadrant of its circumference. In 69 vertebrae (43%) there was concomitant anterior and posterior compression. Isolated involvement of a vertebral body was observed in only six vertebrae (3.8%). We have shown that in most cases of acute compression of the spinal cord due to metastases there is coexisting involvement of both anterior and posterior structures.

Spinal cord compression secondary to spinal extradural myeloid sarcoma in acute myeloid leukaemia: A case report and literature review

Acute spinal cord compression with myelopathy is a neurologic emergency. Recognition of spinal cord compression, timely imaging, and treatment are important to restore and preserve neurologic function. This chapter reviews the causes and clinical approach to spinal cord compression. Traumatic and nontraumatic causes of spinal cord compression are addressed together because of their overlapping symptoms and management. The chapter concludes with a brief discussion of peripheral nerve injury.

Whether they are spinal metastases or primary spinal neoplasms, spinal tumors cause a myriad of complications given their critical location. Spinal tumors can be extradural, intradural extramedullary, or intramedullary, with extradural metastatic tumors the most commonly encountered. Spinal cord and/or cauda equina compression is one of the most devastating complications of cancer and represents a true oncologic emergency. Patients present with progressive paralysis, paresthesiae, and/or autonomic dysfunction. In addition to spinal cord compression (SCC), extradural spinal tumors can cause mechanical spinal instability and axial loading pain which often warrant surgical consultation. The diagnosis of SCC begins with clinical suspicion even before neurological deficits ensue. Patients presenting with back or neck pain who have a history of cancer should be evaluated carefully for SCC. MRI is the imaging modality of choice. Management of SCC generally requires a multidisciplinary approach, with goals of symptom control and prevention of irreversible functional loss. Patients with metastatic epidural SCC who undergo surgical decompression and reconstruction followed by radiotherapy exhibit better outcomes in preservation of function and symptom control than do those undergoing radiotherapy alone. Recent advances in the surgical management of SCC include minimally invasive spinal surgery (MISS), spinal laser interstitial thermotherapy (SLITT), and vertebral augmentation of pathologic vertebral compression fractures. Generally, SCC in patients with cancer serves as evidence of uncontrolled and aggressive disease. Although it is associated with poor outcome in most patients, effective palliation is possible with early diagnosis and careful application of modern surgical techniques for the elimination of cord compression, prevention or reversal of neurological deficits, and restoration of mechanical spinal stability. In addition to SCC from spinal tumors, other spinal complications can be seen in cancer patients who develop spine infections such as surgical site infection (SSI), spinal epidural abscesses (SEA), subdural empyema (SDE), or vertebral osteomyelitis. These complications can be due to inoculation from the spinal surgery itself or as a result of the patients’ immunocompromised state. This article provides a scoping review of the clinical presentation, pathophysiology, and diagnosis of major spinal oncologic emergencies and summarizes current modes of surgical and nonsurgical management.

Vertebral hemangioma is common, benign lesion that occurs mostly in the body of vertebral bones and is mostly asymptomatic although they may occasionally extend into the posterior elements. An isolated location in the neural arch of vertebrae is extremely rare. An acute spinal cord compression by an exceptional hemangioma involving spinous process of the seventh thoracic vertebra and respecting vertebral body in a 40-year-old woman is reported. On magnetic resonance imaging of the spine, the lesion was hypointense on T1-weighted image, hyperintense on T2-weited image, and enhancing avidly, causing compression of spinal cord. Our case is exceptional by the rapidly character of symptom installation and by atypical and elective involvement of spinous process.

Primary hepatocellular carcinoma (HCC) ranks as the most lethal malignancy in Taiwan. Its initial presentation as acute spinal cord compression from epidural metastasis is rare. Because of newer treatment modalities and better control of the primary tumor, the mean survival has increased, making early diagnosis and detection of distant metastases of utmost importance. The authors describe a 60-year-old man presented with a sudden onset of bilateral lower limb weakness and a sensory level at T8. Plain film of the thoracic spine was normal. Magnetic resonance imaging of the thoracic spine showed a large intraspinal epidural tumor at T6 level causing spinal cord compression. A diagnosis of HCC with epidural metastasis was made after surgical removal of the tumor mass.

OBJECTIVE Spinal extramedullary hematomas stemming from cavernous angiomas in the epidural compartment are rare. It is more common for spinal epidural cavernous angiomas to present with slow and progressive myelopathy or radiculopathy. They seldom present with clinical evidence of acute spinal cord or nerve root compression. CLINICAL PRESENTATION Three consecutive cases of acute spinal cavernous angiomas with overt neurological deficits were presented. These presentations included acute onset of neck pain and tetraparesis, bilateral lower extremity pain and paraparesis, and acute sciatic pain with plantar flexor weakness. The lesions were located in the cervical, thoracic, and sacral spine, respectively. The cases included either abrupt lesion enlargement secondary to a pure intralesional hemorrhage or a cavernous hemorrhage that invaded the epidural space. INTERVENTION All patients were treated with either laminotomy or complete resection of the hematoma and cavernoma within 12 hours after admission. CONCLUSION Spontaneous spinal epidural hematomas presented with significant pain and acute spinal cord and nerve root compression may represent the manifestation of a cavernous angioma. Appropriate interpretation of preoperative imaging studies may prevent delay in proper management, especially for patients in whom nerve root deficit is the only clinical expression.

Background: Spinal cord compression is a formidable complication of advanced cancer, and clinicians of copious specialities often have to encounter significant complex challenges in terms of diagnosis, management, and prognosis. Metastatic lesions from cancer are a common cause of spinal cord compression, affecting a substantial portion of oncology patients, and only in the US has the percentage risen to 10%. Acute metastasis-correlated spinal cord compression poses a considerable clinical challenge, necessitating timely diagnosis and intervention to prevent neurological deficits. Clinical presentation is often non-specific, emphasizing the importance of thorough evaluation and appropriate differential diagnosis. Diagnostic workup involves various imaging modalities and laboratory studies to confirm the diagnosis and assess the extent of compression. Treatment strategies focus on pain management and preserving spinal cord function without significantly increasing patient life expectancy, while multidisciplinary approaches are often required for optimal outcomes. Prognosis depends on several factors, highlighting the importance of early intervention. We provide an up-to-date overview of acute spinal cord compression in metastases, accentuating the importance of comprehensive management strategies. Objectives: This paper extensively explores the pathophysiology, clinical presentation, diagnostic strategies, treatment modalities, and prognosis associated with spinal cord metastases. Materials and Methods: A systematic literature review was conducted in accordance with the PRISMA guidelines. Conclusions: We aim to help healthcare professionals make informed clinical decisions when treating patients with spinal cord metastases by synthesizing current evidence and clinical insights.

Axonal injury was examined in 18 human cases of acute spinal cord compression using amyloid precursor protein as a marker of AI. To topographically map and semiquantitate axonal injury in spinal cord compression of sufficient severity to produce para- or quadriplegia. Amyloid precursor protein is carried along the axon by fast axoplasmic transport and has been extensively used as a marker of traumatic axonal injury. The study group comprised 18 cases of spinal cord compression (17 due to fracture dislocation of the vertebral column and 1 iatrogenic compression from Harrington rods) and two normal control. All the cords were examined according to a standard protocol, and at least 10 segmental levels were immunostained using a monoclonal antibody to amyloid precursor protein and immunopositive AI was semiquantitated using a grading system to provide the axonal injury severity score (AISS). The focal injury at the site of cord compression (haemorrhage, haemorrhagic necrosis, ischaemic necrosis) was also semiquantitated to provide the focal injury area score (FIAS). AI occurring around the site of focal compression (focal axonal injury severity score or FAISS) was distinguished from AI distant to the focal injury (nonfocal axonal injury severity score or NFAISS). All 18 cases showed widespread amyloid precursor protein immunoreactive axonal injury and the AISS ranged from 28 to 60%. In all cases, the FAISS was greater than the NFAISS and there was a statistically significant relationship between the AISS and the FIAS. Acute spinal cord compression of sufficient severity to produce permanent paralysis causes widespread axonal damage that is maximal at the site of compression but also present throughout the length of the cord in segments far distant from the site of the focal injury.

Case report. To describe the radiographic features and management of spinal brown tumor and to document tumor mineralization after parathyroidectomy. Brown tumors are classic skeletal manifestations of hyperparathyroidism usually seen in severe forms. They are increasingly rare because hyperparathyroidism is now diagnosed and treated at an early stage. A case of brown tumor of the spine in a 37-year-old woman on chronic hemodialysis is described. The imaging findings before and after parathyroidectomy are discussed. In a woman on chronic hemodialysis, a brown tumor of T8 caused acute spinal cord compression with paraplegia. Magnetic resonance imaging provided an accurate evaluation of the lesion, and needle biopsy confirmed the diagnosis. Emergent surgery was needed to relieve the spinal compression and stabilize the spine. The vertebral lesion underwent remineralization after parathyroidectomy. Brown tumor is a benign tumor that resolves after parathyroidectomy. When brown tumor arises in the spine, surgery may be needed to preserve neurologic function.

Thirty-six cancer patients with extradural spinal metastatic disease and acute symptoms of spinal cord compression underwent magnetic resonance (MR) imaging at 1.5 T. Cord involvement was found in all 36, 7 of whom had lesions at 2 different sites. Vertebral metastases in addition to those corresponding to the cord compressions were detected in 27 patients, and 18 of these had widespread deposits. MR displayed the extent of the tumors in the craniocaudal and lateral directions. The ability to identify multiple sites of cord and vertebral involvement and to delineate tumor accurately makes MR the examination of choice in cancer patients with suspected spinal cord compression. It obviates the need for myelography and postmyelography CT in this group of patients.

Metastatic renal cell carcinoma may involve the vertebrae, resulting in acute spinal cord compression. Embolization has been used to reduce operative blood loss during surgical decompression, but it has not been considered as an alternative that may eliminate the need for open debulking. A case is presented of a 30-year-old woman with renal cell carcinoma who developed increasing severe back pain, lower extremity weakness, and sensory loss. Magnetic resonance evaluation revealed a T5 metastasis, resulting in significant spinal cord compression. Transarterial embolization was performed with polyvinyl alcohol particles and platinum microcoils. One month after embolization, the patient's lower extremity strength and sensation had improved, and magnetic resonance imaging demonstrated a dramatic response with a significant reduction of cord compression. She deteriorated again 4 months later, and a new sacral mass was embolized. She again improved after treatment. This report illustrates that embolization may be used as palliative treatment for spinal cord compression and obviate the need for open surgical decompression.