Spinal cord tumor clinical features [Neurosurgery Wiki]

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====== Spinal cord tumor clinical features ======

The clinical presentation of primary spinal cord tumors is determined in part by the location of the tumor, and in nearly all clinical instances pain is the predominant presenting symptom. Motor disturbance is the next most common symptom, followed by sensory loss. 

The clinical signs and symptoms of these tumors are due to mass effect and neurological dysfunction
((Kane PJ, el-Mahdy W, Singh A, Powell MP, Crockard HA. Spinal intradural
tumours: Part II--Intramedullary. Br J Neurosurg. 1999 Dec;13(6):558-63. PubMed
PMID: 10715723.
)).

The lack of any specific clinical characteristic often precludes early diagnosis of the lesion and results in most patients being diagnosed with advanced neurological impairments such as [[paralysis]] and [[bladder incontinence]]
((Malhotra N, BHowmick D, Whitfield P. Intramedullary spinal cord tumours: Diagnosis, treatment, and outcomes. Adv Clin Neurosci Rehabil. 2010;10:21–5.)).

===== Pain =====

Pain: the most common complaint. Almost always present in [[filum terminale tumor]]s (exception: lipomas).

Possible pain patterns:

a) radicular:increases with Valsalva maneuver and spine movement.Suspect SCT if dermatome
is unusual for disc herniation

b) local:stiffneckorback,Valsalvamaneuverincreasespain.

★ Pain during recumbency (“nocturnal pain”) is classic for SCT

c) medullary (as in syrinx): oppressive, burning, dysesthetic, non-radicular, often bilateral, unaf-
fected by Valsalva maneuver


----
van der Hoeven et al. from Hagaziekenhuis, The Hague, and Leiden The [[Netherlands]], present the case of a woman who developed severe nightly [[thoracic pain]] during pregnancy without neurological deficits upon examination. Spontaneously after childbirth, the pain was markedly reduced. Further investigation showed that her pain was caused by an [[intramedullary ependymoma]] in the [[cervicothoracic]] spinal cord. [[Gross total resection]] was accomplished, and the patient has been free of [[pain]] ever since. With this case, the authors want to draw attention to a rare, but possibly very disabling, cause of increasing nightly thoracic pain during pregnancy. Spontaneous improvement after childbirth could erroneously cause postponement of further investigation
((van der Hoeven MEM, de Pont LMH, Koppen H. Severe Nightly Thoracic Pain
Presenting during Pregnancy: A Case Report. Case Rep Neurol. 2018 Jun
7;10(2):135-139. doi: 10.1159/000488756. eCollection 2018 May-Aug. PubMed PMID:
29983701; PubMed Central PMCID: PMC6031941.
)).

===== Motor disturbances =====

a) weakness is 2nd or 3rdmost common complaint. Usually follows sensory symptoms temporally

b) children present most frequently with gait disturbances

c) syringomyelic syndrome: suggests IMSCT. Findings: UE segmental weakness, decreased DTR,
dissociative anesthesia 

d) long-tractinvolvement→clumsiness and ataxia(distinct from weakness)

e) atrophy,muscle twitches,fasciculations

===== Non-painful sensory disturbances =====

a) dissociated sensory loss:decreased pain and temperature,preserved light touch,as in Brown-Séquard syndrome. There is disagreement whether this is common or uncommon

in IMSCT. ± non-radicular dysesthesias (early), with upward extension b) paresthesias:either radicular or “medullary” distribution

===== Sphincter disturbances =====

a) usually urogenital(anal less common)→difficulty evacuating,retention,incontinence,and impotence. Early in conus/cauda equina lesions, especially lipomas (pain not prominent)

b) sphincter dysfunction common in age<1yr due tofrequency of lumbosacral lesions(dermoids, epidermoids, etc.)

=====  Miscellaneous symptoms =====

a) scoliosis or torticollis

b) SAH

c) visible mass over spine

===== Time course of symptoms =====

Onset usually insidious, but abruptness occurs (benign lesions in children occasionally progress in hours). The onset is often erroneously attributed to coincidental injury. Temporal progression has been divided into 4 stages:

1. pain only (neuralgic)

2. Brown-Séquard syndrome

3. incomplete transectional dysfunction

4. complete transectional dysfunction

Note: 78% (of 23) ependymomas, 74% (of 42) gliomas, all 7 dermoids, and 50% (of 8) lipomas reached the latter 2 stages before diagnosis (not affected by location in cross-sectional nor longitudinal dimension of SC (excludes conus lesions—more frequently diagnosed in 1st stage) (a pre-CT study)).