Intramedullary spinal cord metastatic tumors

Marc D Winkelman MD (Dr. Winkelman of Case Western Reserve University has no relevant financial relationships to disclose.)
Edward J Dropcho MD, editor. (Dr. Dropcho of Indiana University Medical Center has no relevant financial relationships to disclose.)
Originally released May 9, 1997; last updated October 12, 2016; expires October 12, 2019

Overview

Intramedullary spinal cord metastasis refers to invasion of the spinal cord by solid tumors that arise elsewhere in the body. It is a relatively rare cause of myelopathy in patients with cancer; compression of the spinal cord by epidural metastatic tumor occurs 25 times more often. Local back pain or radicular or referred pain in a limb is the most common initial symptom. Patients go on to develop a transverse myelopathy, a Brown-Sequard syndrome, or an ascending or descending myelopathy. The course of the illness is subacutely progressive. The most common primary tumors arise in the lung and breast. MRI is the diagnostic procedure of choice. The prognosis is poor: the majority of patients survive fewer than 4 months. The cause of death is usually widespread metastatic disease. Radiation therapy is the treatment of choice. Most patients achieve stabilization of spinal cord function, and some patients improve.

Key points

 

• Intramedullary spinal cord metastasis is an uncommon but treatable cause of myelopathy in patients with systemic cancer.

 

• It presents as a painful, subacutely progressive myelopathy.

 

• Untreated, it causes irreversible paraplegia or tetraplegia.

 

• Treatment with radiotherapy, if performed when the patient can still walk, is likely to stabilize, if not improve, spinal cord function.

Historical note and terminology

The term "intramedullary spinal cord metastasis" refers to invasion of the parenchyma of the spinal cord by solid tumors that arise elsewhere in the body. Willis was the first to review the pathologic aspects of the subject (Willis 1934). He pointed out that carcinomas of the lung and breast were the most frequent primary tumors and that cerebral metastases were often present. He also noted that intramedullary spinal cord metastases spread to the cord hematogenously or by direct extension from leptomeningeal deposits, that they were usually multiple, and that syringomyelia and hematomyelia were complications. Finally, he found that the frequency of intramedullary spinal cord metastases was hard to determine because the spinal cord was seldom examined at autopsy. The condition is so uncommon that no major clinical series appeared until 1972, and it contained only 9 patients (Edelson et al 1972). The authors found that the neurologic features were identical to those of compression of the spinal cord by epidural metastatic tumor, that the myelogram was often normal, and that radiation therapy was the treatment of choice. Schiff and O'Neill reported the largest clinical series (40 patients) (Schiff and O'Neill 1996). They concluded that symptoms of intramedullary spinal cord metastasis often appear before those of the underlying cancer, that long-term survival is poor because of widespread metastatic disease, and that radiation treatment preserves but does not restore neurologic function.

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