Neurosurgical emergencies in spinal tumors: pathophysiology and clinical management

Background and Objectives: Metastatic spinal cord compression represents a substantial risk to patients, given its potential for spinal cord and/or nerve root compression, which can result in severe morbidity. This study aims to evaluate the effectiveness of a diagnostic-therapeutic algorithm developed at our hospital to mitigate the devastating consequences of spinal cord compression in patients with vertebral metastases. Materials and Methods: The algorithm, implemented in our practice in January 2022, is based on collective clinical experience and involves collaboration between emergency room physicians, oncologists, spine surgeons, neuroradiologists, radiation oncologists, and oncologists. To minimize potential confounding effects from the COVID-19 pandemic, data from the years 2019 and 2021 (pre-protocol) were collected and compared with data from the years 2022 and 2023 (post-protocol), excluding the year 2020. Results: From January 2022 to December 2023, 488 oncological patients were assessed, with 45 presenting with urgency due to suspected spinal cord compression. Out of these, 44 patients underwent surgical procedures, with 25 performed in emergency settings and 19 cases in elective settings. Comparatively, in 2019 and 2021, 419 oncological patients were evaluated, with 28 presenting with urgency for suspected spinal cord compression. Of these, 17 underwent surgical procedures, with 10 performed in emergency scenarios and 7 in elective scenarios. Comparing the pre-protocol period (years 2019 and 2021) to the post-protocol period (years 2022 and 2023), intrahospital consultations (commonly patients neurologically compromised) for spine metastasis decreased (105 vs. 82), while outpatient consultations increased remarkably (59 vs. 124). Discussion: Accurate interpretation of symptoms within the context of metastatic involvement is crucial for patients with a history of malignancy, whether presenting in the emergency room or oncology department. Even in the absence of a cancer history, careful interpretation of pain characteristics and clinical signs is crucial for diagnosing vertebral metastasis with incipient or current spinal cord compression. Early surgical or radiation intervention is emphasized as it provides the best chance to prevent deficits or improve neurological status. Preliminary findings suggest a notable increase in both the number of patients diagnosed with suspected spinal cord compression and the proportion undergoing surgical intervention following the implementation of the multidisciplinary protocol. The reduced number of intrahospital consultations (commonly patients neurologically compromised) and the increased number of visits of outpatients with vertebral metastases indicate a heightened awareness of the issue, leading to earlier identification and intervention before neurological worsening necessitating hospitalization. Conclusions: A comprehensive treatment planning approach is essential, and our multidisciplinary algorithm is a valuable tool for optimizing patient outcomes. The protocol shows potential in improving timely management of spinal cord compression in oncological patients. Further analysis of the factors driving these changes is warranted. Limitations: This study has limitations, including potential biases from the retrospective nature of data collection and the exclusion of 2020 data due to COVID-19 impact. To enhance the robustness of our results, long-term studies are required. Moreover, the single-center study design may limit the validity of the findings. Further multicenter studies would be beneficial for validating our results and exploring underlying factors in detail.

Cost-effectiveness of surgery plus radiotherapy versus radiotherapy alone for metastatic epidural spinal cord compression

An evidence-based analysis of published radiologic criteria for assessing spinal canal compromise and cord compression in patients with acute cervical spinal cord injury. This study was conducted to determine whether literature-based guidelines could be established for accurate and objective assessment of spinal canal compromise and spinal cord compression after cervical spinal cord injury. Before conducting multicenter trials to determine the efficacy of surgical decompression in cervical spinal cord injury, reliable and objective radiographic criteria to define and quantify spinal cord compression must be established. A computer-based search of the published English, German, and French language literature from 1966 through 1997 was performed using MEDLINE (U.S. National Library of Medicine database) to identify studies in which cervical spinal canal and cord size were radiographically assessed in a quantitative manner. Thirty-seven references were included for critical analysis. Most studies dealt with degenerative disease, spondylosis, and stenosis; only 13 included patients with acute cervical spinal cord injury. Standard lateral radiographs were the most frequent imaging method used (23 studies). T1- and T2-weighted magnetic resonance imaging were used to assess spinal cord compression in only 7 and 4 studies, respectively. Spinal cord size or compression were not precisely measured in any of the cervical trauma studies. Interobserver or intraobserver reliability of the radiologic measurements was assessed in only 7 (19%) of the 37 studies. To date, there are few quantitative, reliable radiologic outcome measures for assessing spinal canal compromise or cord compression in patients with acute cervical spinal cord injury.

Background:Acute low back pain is a common cause for presentation to the emergency department (ED). Since benign etiologies account for 95% of cases, red flags are used to identify sinister causes that require prompt management.Objectives:We assessed the effectiveness of red flag signs used in the ED to identify spinal cord and cauda equine compression.Patients and Methods:It was a retrospective cohort study of 206 patients with acute back pain admitted from the ED. The presence or absence of the red flag symptoms was assessed against evidence of spinal cord or cauda equina compression on magnetic resonance imaging (MRI).Results:Overall, 32 (15.5%) patients had compression on MRI. Profound lower limb neurologic examination did not demonstrate a statistically significant association with this finding. The likelihood ratio (LR) for bowel and bladder dysfunction (sensitivity of 0.65 and specificity of 0.73) was 2.45. Saddle sensory disturbance (sensitivity of 0.27 and specificity of 0.87) had a LR of 2.11. When both symptoms were taken together (sensitivity of 0.27 and specificity of 0.92), they gave a LR of 3.46.Conclusions:The predictive value of the two statistically significant red flags only marginally raises the clinical suspicion of spinal cord or cauda equina compression. Effective risk stratification of patients presenting to the ED with acute back pain is crucial; however, this study did not support the use of these red flags in their current form.

Objectives:We aimed to assess the efficacy of surgical decompression of metastatic epidural spinal cord compression (MESCC) in patients ≧65 years and review our multidisciplinary surgical decision-making process.Methods:We identified all patients operated for MESCC from August 2008 to June 2012. Patients ≧65 years, with a single area of cord compression, back/radicular pain, neurological signs of cord compression, surgery within 48 hours after onset of MESCC-related paraplegia, and follow-up for ≧1 year or until death were included. Files were reviewed retrospectively. The requirement for informed consent was waived. Neurological status was assessed with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). Duration of ambulation and survival were assessed with Kaplan–Meier and Cox regression analysis.Results:Twenty-one patients met inclusion criteria (11 women/10 men; mean age 73 years, range 65–87). All presented with debilitating back/neck pain. Ten patients (48%) were not ambulatory before surgery and four suffered urinary incontinence/constipation (19%). Preoperative AIS was E in 5 patients (24%), D in 11 (62%), and C in 5 (24%). Motor symptoms had been present for a mean of 3·8 days (range 1–14). All patients regained ambulation. Overall, mean survival was 320 days (range 19–798) and mean ambulation was 302 days (range 18–747). On 31 March 2013, 7 patients (33%) were alive and ambulatory at a mean of 459 days (range 302–747); 14 patients had died (67%) at a mean of 251 days (range 19–798), with a mean ambulation of 223 days (range 18–730).Discussion:With careful patient selection, surgery may achieve long duration of ambulation in patients ≧65 years with MESCC.

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

Simple SummarySpinal meningiomas are the most common adult primary intradural spinal tumors. While mostly benign, they may give rise to spinal cord compression with acute or chronic neurologic dysfunction. The primary treatment is surgical resection. Previous studies, limited by small sample sizes and short follow-up times, report that histopathological grade, tumor localization and size affect outcomes following surgery. In this population-based cohort study, we retrospectively reviewed 129 cases of surgically treated spinal meningiomas to assess postoperative complications, long-term clinical and radiological outcomes, predictors of neurological improvement and potential differences between elderly and non-elderly patients. Our median follow-up time was 8.2 years. We found that surgery was associated with significant neurological improvement. There was no significant difference in postoperative complications, tumor control or neurological improvement between elderly and non-elderly. Shorter time from diagnosis to surgery, larger tumor size and spinal cord compression predicted postoperative outcomes.Spinal meningiomas are the most common adult primary spinal tumor, constituting 24–45% of spinal intradural tumors and 2% of all meningiomas. The aim of this study was to assess postoperative complications, long-term outcomes, predictors of functional improvement and differences between elderly (≥70 years) and non-elderly (18–69 years) patients surgically treated for spinal meningiomas. Variables were retrospectively collected from patient charts and magnetic resonance images. Baseline comparisons, paired testing and regression analyses were used. In conclusion, 129 patients were included, with a median follow-up time of 8.2 years. Motor deficit was the most common presenting symptom (66%). The median time between diagnosis and surgery was 1.3 months. A postoperative complication occurred in 10 (7.8%) and tumor growth or recurrence in 6 (4.7%) patients. Surgery was associated with significant improvement of motor and sensory deficit, gait disturbance, bladder dysfunction and pain. Time to surgery, tumor area and the degree of spinal cord compression significantly predicted postoperative improvement in a modified McCormick scale (mMCs) in the univariable regression analysis, and spinal cord compression showed independent risk association in multivariable analysis. There was no difference in improvement, complications or tumor control between elderly and non-elderly patients. We concluded that surgery of spinal meningiomas was associated with significant long-term neurological improvement, which could be predicted by time to surgery, tumor size and spinal cord compression.

255 Background: Metastatic epidural spinal cord compression (MESCC) is an oncologic emergency which can be associated with poor outcomes for cancer patients. Our aim was to study the differences in outcomes of MESCC in patients with gastric cancer (GC-MESCC) compared to those with other solid malignancies. Methods: Healthcare Cost and Utilization Project-Nationwide Inpatient Sample database (2016-2020) was queried to identify all solid (breast, prostate, lung, gastrointestinal, renal and thyroid) cancer patients admitted with spinal cord compression. Multivariate logistic regression was used to evaluate differences in socio-demographics, medical comorbidities and outcomes between MESCC in gastric cancer patients and those with other solid cancers. The primary outcome included inpatient mortality, length of stay (LOS), and total hospital charges (THC). Results: 78,385 patients with the above solid cancers were admitted for spinal cord compression. Among them, 710 had gastric cancer. Patients with gastric cancer were younger (Mean age: 59.1 vs 66.3 years, p < 0.001). They had higher prevalence of anemia (56 vs 41%), protein energy malnutrition (28.9 vs 18.9%, p < 0.001), and lower prevalence of COPD (8.45 vs 18.5%, p =0.003), smoking (22.5 vs 33.6%, p =0.007) and CKD (9.4 vs 12.3%, p =0.03). On multivariate regression, those with GC-MESCC had two-fold higher odds of all-cause mortality (adjusted odds ratio (aOR): 2.0; 95% CI: 1.05-3.96, p = 0.034). On subgroup analysis, mortality was about four times higher for females with GC-MESCC relative to the other group (aOR = 3.8, 95% CI: 1.69-8.52, p = 0.001). There was a trend towards increased LOS (8.9 vs 7.8 days) and THC ($115, 805 vs $96, 074) but it was not statistically significant. Compared with the other cohort, GC-MESCC patients had higher rates of blood transfusion (16.2 vs 9%, p = 0.003). Conclusions: Metastatic epidural spinal cord compression is associated with increased odds of inpatient mortality in gastric cancer patients compared to those with other solid malignancies. Hence, these patients ought to have urgent intervention and close monitoring to prevent adverse outcomes. [Table: see text]

Clinical Factors Associated with Increased Risk of Spinal Cord Compression in Multiple Myeloma Patients: Insights from National Inpatient Sample Database (2016-2020)

Approximately 1–15% of patients with metastatic castration-resistant prostate cancer eventually develop spinal cord compression (SCC) during their disease. 1 Tazi H Manunta A Rodriguez A Patard JJ Lobel B Guillé F Spinal cord compression in metastatic prostate cancer. Eur Urol. 2003; 44: 527-532 Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar , 2 Sutcliffe P Connock M Shyangdan D Court R Kandala NB Clarke A A systematic review of evidence on malignant spinal metastases: natural history and technologies for identifying patients at high risk of vertebral fracture and spinal cord compression. Health Technol Assess. 2013; 17: 1-274 Crossref Scopus (85) Google Scholar Guidelines recommend urgent investigation in case of clinical suspicion to diagnose and treat SCC with surgical decompression or radiotherapy, or both. 3 Vellayappan BA Kumar N Chang EL Sahgal A Sloan AE Lo SS Novel multidisciplinary approaches in the management of metastatic epidural spinal cord compression. Future Oncol. 2018; 14: 1665-1668 Crossref PubMed Scopus (5) Google Scholar However, a third of patients with asymptomatic metastatic castration-resistant prostate cancer have radiological signs of SCC by MRI, 4 Venkitaraman R Sohaib SA Barbachano Y et al. Detection of occult spinal cord compression with magnetic resonance imaging of the spine. Clin Oncol (R Coll Radiol). 2007; 19: 528-531 Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar which raises the question of whether screening followed by treatment of asymptomatic SCC might prevent the development of clinical symptoms of pain and debilitating neurological deficits. Observation versus screening spinal MRI and pre-emptive treatment for spinal cord compression in patients with castration-resistant prostate cancer and spinal metastases in the UK (PROMPTS): an open-label, randomised, controlled, phase 3 trialDespite the substantial incidence of rSCC detected in the intervention group, the rate of cSCC in both groups was low at a median of 22 months of follow-up. Routine use of screening MRI and pre-emptive treatment to prevent cSCC is not warranted in patients with asymptomatic castration-resistant prostate cancer with spinal metastasis. Full-Text PDF Open Access

Surgical resection in metastatic spinal cord compression

AMA Kurishima K, Kagohashi K, Mammoto T, Satoh H. Recovery from paraplegia with administration of erlotinib in a patient with lung adenocarcinoma. Contemporary Oncology/Współczesna Onkologia. 2014;18(2):140-142. doi:10.5114/wo.2014.41393. APA Kurishima, K., Kagohashi, K., Mammoto, T., & Satoh, H. (2014). Recovery from paraplegia with administration of erlotinib in a patient with lung adenocarcinoma. Contemporary Oncology/Współczesna Onkologia, 18(2), 140-142. https://doi.org/10.5114/wo.2014.41393 Chicago Kurishima, Koichi, Katsunori Kagohashi, Takeo Mammoto, and Hiroaki Satoh. 2014. "Recovery from paraplegia with administration of erlotinib in a patient with lung adenocarcinoma". Contemporary Oncology/Współczesna Onkologia 18 (2): 140-142. doi:10.5114/wo.2014.41393. Harvard Kurishima, K., Kagohashi, K., Mammoto, T., and Satoh, H. (2014). Recovery from paraplegia with administration of erlotinib in a patient with lung adenocarcinoma. Contemporary Oncology/Współczesna Onkologia, 18(2), pp.140-142. https://doi.org/10.5114/wo.2014.41393 MLA Kurishima, Koichi et al. "Recovery from paraplegia with administration of erlotinib in a patient with lung adenocarcinoma." Contemporary Oncology/Współczesna Onkologia, vol. 18, no. 2, 2014, pp. 140-142. doi:10.5114/wo.2014.41393. Vancouver Kurishima K, Kagohashi K, Mammoto T, Satoh H. Recovery from paraplegia with administration of erlotinib in a patient with lung adenocarcinoma. Contemporary Oncology/Współczesna Onkologia. 2014;18(2):140-142. doi:10.5114/wo.2014.41393.

President's Opening Remarks - Reflections on the Bond of Trust Between the Physician and his Patient.- Ernst von Bergmann and the Beginning of Neurosurgery in Berlin.- Extradural Tumors of the Spine.- Intraoperative Spinal Cord Monitoring.- Spinal Cord Tumors.- Basic Anatomic Considerations Concerning the Surgical Approaches to the Spinal Column.- Spinal Tumors.- Neurological Problems in Conjunction with Spinal Tumors.- Differential Diagnostics of Spinal Tumors.- Diagnosis by Examination of Cerebrospinal Fluid in Spinal Tumor Cases.- Conventional Radiologic Diagnosis of Spinal Tumors.- Nuclear Medicine in the Diagnosis of Spinal Tumors.- Spinal Tumors: Magnetic Resonance Imaging.- Spinal Tumors: A Multi-Center Study of the Deutsche Gesellschaft fur Neurochirurgie.- The Use of Transthoracic and of Ventro-lateral Access in the Surgical Treatment of Extradural Spinal Tumors in the Thoracic and Lumbar Areas.- Unilateral Approaches to Spinal Tumors.- The Transsacral, Transcoccygeal Approach to Prevertebral Spinal Tumors.- Operative Treatment of Aneurysmal Bone Cysts of the Spine - Radical Excision and Spinal Stabilization.- Osteosynthesis in Patients with Malignant Tumors of the Cervical Vertebral Column: Indications, Techniques, and Results.- Osteosynthesis with AO Plates in the Cervical and Lumbar Regions of the Vertebral Column in Cases of Spinal Metastases.- Differential Diagnosis and Operative Treatment of Rare Intraforaminal Space-Occupying Lesions.- Acute Leriche Syndrome in the Differential Diagnosis of Acute Paraplegia.- Misdiagnoses in Spinal Tumors.- Tumors of the Craniocervical Region: Difficulties in Diagnosis Microsurgery and Laser Surgery.- Diagnosis and Treatment of Space-Occupying Lesions at the Craniocervical Junction.- Inclincation of the Odontoid Process in Children and Adults - an Anatomical and Functional Investigation.- Cytostatic Treatment of Spinal Tumors.- Malignant Lymphomas and Spinal Cord Compression.- Aspects of Neurosurgical Intervention for Spinal Manifestations of Malignant Lymphomas.- Clinical and Neuropathological Aspects of Rare Semimalignant Spinal Tumors: Case Reports of a Giant Cell Tumor (Osteoclastoma) and an Atypical Osteoblastoma.- Experimental Neurosurgery.- Microsurgical Anatomy of the Transoral Approach for Anterior Processes of the Upper Cervical Spine.- CT Absorption Analysis in Intracranial Tumor Diagnostics.- Impulse Cytophotometry and the Biological Behavior of Gliomas.- Swelling Behavior of C6 Glioma Cells During Shutdown of Energy Metabolism.- Treatment of Vasogenic Brain Edema by Inhibitors of the Kallikrein-Kinin System.- Neurotransmitter Contents in Low-Grade Gliomas and Glioblastomas.- The Influence of Acutely Increasing ICP upon Diuresis and Water-Electrolyte Balance and Its Modification by Neurohypophysectomy (An Experimental Study).- Noninvasive Measurement of Local Cerebral Blood Flow (nl-CBF) with Stable Xenon Enhanced Dynamic CT - Description of Method and Analysis of Flow Data.- Perioperative Chemiluminescence of Polymorphonuclear Leukocytes and Monocytes in Brain Tumor Patients.- Experimental Hypertensive Intracerebral Mass Hemorrhage in Cats.- Cerebrospinal Fluid and Serum Levels of the Arachidonic Acid Metabolites 6-keto-PGF1? and Thromboxane B2 in Patients with Subarachnoid Hemorrhage.- The Effect of the Cleavage Peptide C3aDesArg of the Third Complement Component on the Accumulation of Leukocytesin Cerebrospinal Fluid (CSF) and on the Permeability ofthe Blood-CSF Barrier.- Rostral Spread of Epidural 3H-Labeled Morphine.- Subdural Implantation of RG2 Glioma Spheroids in Rat Cerebellum: A New Experimental Brain Tumor Model.- Testing of Hydrocephalus Shunt Systems.- Vessel Repairs of the Carotid Artery of the Rat Using the Modified Nd:YAG Laser.- Neurosurgical Intensive Care.- Legal Problems of Intensive Care.- Computer-Aided Neuromonitoring: Conditions, Techniques, and Clinical Applications.- Present Status of Barbiturates in the Acute Stage of Cerebral Damage.- Cerebrovascular Reserve and Brain-Protective Measures in Cases of Interruption of Carotid Artery Flow.- Intensive-Medical Aspects in the Treatment of Increased Intracranial Pressure.- Possibilities and Limitations of High-Dose Barbiturate Therapy in the Management of Intracranial Hypertension.- Treatment of Intracranial Hypertension Without Barbiturates.- Significance of Acute Disturbances of Pupillary Function in Postoperative Intensive Care After Operations for Craniopharyngiomas.- Provisional Diagnostic Value of the Anaphylatoxin Radioimmunoassay (C3a-desArg-RIA) in the Neurosurgical Intensive Care Unit.- Investigations of Pituitary Function in Severe Head Injury by Radioimmunoassay.- Biological Rhythms of Electrophysiological and Endocrinological Parameters in Acute and Chronic Intracranial Lesions.- Neuromonitoring Supplemented by nrCBF.- Postoperative Observation at the Neurosurgical Intensive Care Unit After Surgery of the Posterior Fossa.- Monitoring of Brain Stem Auditory Evoked Potentials (BAEPs) in the Intensive Care Treatment of Craniocerebral Traumata.- Auditory Evoked Potentials During and After Complete Ischemiaof the Brain.- Criteria for the Diagnosis of Brain Death.- Limitations of Intensive Care Medicine - as Viewed by a Neurosurgeon.

Detection of unsuspected spinal cord compression in melanoma patients by 18F-fluorodeoxyglucose—positron emission tomography

Local control and survival in spinal cord compression from lymphoma and myeloma