Spinal and meningeal metastatic disease
© International Cancer Imaging Society 2002
Accepted: 15 September 2001
Published: 5 May 2015
This contribution presents an approach to diagnosis in patients known to have malignant disease, who present with neurological symptoms and signs which may be a result of epidural spinal cord compression or intradural spinal disease.
Neurological complications in patients with known malignant disease appear to be increasing in frequency. It is possible that this is simply a result of more effective treatment resulting in prolonged survival, allowing more metastases to develop at all sites. Alternatively, it is possible that the central nervous system (CNS) acts a sanctuary site for malignant cells from common solid tumours The effects of metastatic disease on the CNS can be severely disabling. The brain and spinal cord are enclosed in bone and relatively small volume disease can have a disproportionately damaging effect. In addition, the CNS lacks lymphatics so that oedema and biological detritus are difficult to remove. In the patient with known malignancy, there is a variety of mechanisms which can affect the CNS and neurological symptoms in the cancer patient can be complex. For these reasons, the approach to imaging differs in some ways from that used in the previously well patient presenting with an acute neurological emergency (although it may transpire that such an emergency is the first manifestation of disseminated malignancy).
The more frequent spinal manifestations of malignancies are discussed below.
Epidural spinal cord compression
Cord compression is most frequently a result of metastasis in the vertebral body. A soft tissue mass may also extend from the posterior elements of the vertebrae, or from a paravertebral soft tissue mass invading through the neural foramen. The symptoms of cord compression in approximate order of frequency and importance are pain, power loss, sphincter disturbance and a sensory level. Pain is usually local or radicular, but may be funicular. Weakness begins in the legs regardless of the level of compression, and early in the development of symptoms is more marked proximally. Typical signs of upper motor neurone weakness, such as spasticity and hyper-reflexia, may be absent early in the clinical course[2,3]. In the patient with malignant disease, there may be more than one level, and compression of the lower motor neurones below the level of the conus may mask upper motor neurone signs from a cord compression more cranially. Sensory levels at the time of clinical presentation are frequently several segments below the actual level of compression.
The blood supply of the spinal cord is also an important consideration. The anterior spinal artery is the main blood supply of the anterior part of the cord and runs in close proximity to the vertebral body. Anatomically unspectacular disease may cause the clinical syndrome of cord compression by compromising the anterior spinal artery, resulting in infarction of the cord.
Meningeal metastatic disease
Spinal cord deposits
As with meningeal metastatic disease, lesions in the cord itself may present with an atypical history and confusing neurological signs. Gadolinium enhancement is necessary to make the diagnosis with confidence, and intraaxial deposits may be demonstrated when Gadolinium is given for suspected meningeal metastatic disease. Once again, breast, lung and melanoma are among the commonest lesions to metastasise to the spinal cord.
Neurological presentations are increasing in frequency and are clinically challenging problems in the cancer patient.
MRI is the investigation of choice for suspected epidural cord compression and should include the whole spine.
Craniospinal meningeal metastatic disease results in symptoms and signs which cannot be attributed to a single anatomical site.
Intra-axial spinal cord deposits may also present with atypical features, and both diagnoses are best made with gadolinium-enhanced T1-weighted imaging.
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