SPINAL CORD COMPRESSION

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SPINAL CORD COMPRESSION

• A CASE DISCUSSION

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J, 12 YEAR OLD MALE CHILD

• PRESENTED WITH
• PROGRESSIVE NECK SWELLING
• LOSS OF APPETITE AND WEIGHT 2MO
• VAGUE ACHES AND PAINS
• SKIN RASH
  1WK

INTP - PPO, PHO, IAP. P7 2/22
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• INVESTIGATED 3 MONTHS EARLIER FOR
  THROMBOCYTOPENIA
• BONE MARROW EXAMINATION THEN REVEALED
• NO ABNORMAL CELLS
• INCREASED MEGAKARYOCYTES
• TREATED AS A CASE OF ITP WITH ORAL PREDNISONE FOR
  4 WEEKS

INTP - PPO, PHO, IAP. P7 3/22
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PHYSICAL EXAMINATION

• SICK CHILD
• PALLOR
• GENERALISED LYMPHADENOPATHY
• PURPURIC SPOTS
• HEPATOSPLENOMEGALY
• NORMAL CNS EXAMINATION
• OTHER SYSTEMS WNL

INTP - PPO, PHO, IAP. P7 4/22
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INVESTIGATIONS

• CHEST X RAY MEDIASTINAL MASS
• LN BIOPSYLYMPHOBLASTIC LYMPHOMA
• BONE MARROW STUDY INFILTRATION WITH ABNORMAL
  CELLS RESEMBLING LYMPHOBLASTS 65
• CONSISTENT WITH LYMPHOBLASTIC LYMPHOMA WITH
  MARROW INFILTRATION

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TREATMENT

• TREATED AS PER PROTOCOL FOR ACUTE LYMPHOBLASTIC
  LEUKEMIA
• REMISSION ACHIEVED
• CHILD STARTED ON MAINTENANCE CHEMOTHERAPY

INTP - PPO, PHO, IAP. P7 6/22
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• 3 MONTHS LATER PRESENTED WITH
• GEN. LYMPHADENOPATHY 2 WEEKS
• SEVERE BACK PAIN -- 1
  WEEK
• - NOT RELIEVED IN SUPINE POSITION
• - AGGRAVATED BY COUGHING
• - RADIATION OF PAIN TO ANTERIOR
  THIGH
• - NUMBNESS OF LOWER LIMBS
• - NO H/O BOWEL/BLADDER INVOLVEMENT
• EXAMINATION FINDINGS?
• WHAT WOULD YOU LOOK FOR?

INTP - PPO, PHO, IAP. P7 7/22
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CLINICAL EXAMINATION

• NORMAL SENSORIUM
• NO CRANIAL NERVE PALSIES
• UNSTEADY GAIT TAKES FEW STEPS WITH SUPPORT
• TENDERNESS TO PERCUSSION OVER 1ST AND 2nd LUMBAR
  VERTEBRAE
• EXAGGERATED DTRS
• PLANTAR REFLEX B/L UPGOING
• LOSS OF CREMASTERIC REFLEX
• POSSIBLE DIAGNOSIS?

INTP - PPO, PHO, IAP. P7 8/22
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CLINICAL POSSIBILITIES

• RELAPSE OF LYMPHOBLASTIC LYMPHOMA WITH SPINAL
  CORD METASTASIS RESULTING IN SPINAL CORD
  COMPRESSION
• STEROID TOXICITY OSTEOPOROSIS AND VERTEBRAL
  COLLAPSE WITH SPINAL CORD COMPRESSION

INTP - PPO, PHO, IAP. P7 9/22
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PLAN OF MANAGEMENT

• EMERGENCY ADMINISTRATION OF STEROIDS
• FIRST AND MOST IMPORTANT STEP
• PRECEDES INVESTIGATIONS
• ORAL/IV DEXAMETHASONE IN PROPER DOSES
• INVESTIGATE TO ESTABLISH DIAGNOSIS AND ASSESS
  SEVERITY AND EXTENT OF LESION
• TISSUE DIAGNOSIS OF RELAPSE
• INVOLVE NEUROSURGEON, RADIOTHERAPIST AND
  RADIOLOGIST IN MANAGEMENT
• CLOSELY MONITOR FOR PROGRESSION OF NEUROLOGICAL
  SIGNS AND SYMPTOMS

INTP - PPO, PHO, IAP. P7 10/22
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INITIAL TREATMENT USED IN THIS CHILD

• CHILD GIVEN IV DEXAMETHASONE, LOADING DOSE
  FOLLOWED BY 6TH HRLY MAINTENANCE DOSES AND
  FOLLOWED UP CLOSELY
• AFTER STEROID ADMINISTRATION PLAIN X-RAY AND MRI
  SCAN OF SPINE WAS DONE
• LIKELY MRI FINDINGS?

INTP - PPO, PHO, IAP. P7 11/22
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X-RAY THORACO LUMBAR SPINE SHOWING NO EVIDENCE OF
OSTEOPOROSIS / COLLAPSE
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• SAGITTAL SECTION MRI SHOWING
• HYPERINTENSE PARAVERTEBRAL
• MASS (LARGE ARROW) (L1 LEVEL)
• NOTE DURAL DISPLACEMENT
• (SMALL ARROW) CAUSED BY
• EPIDURAL MASS EFFECT

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PRE (L) AND POST (R) CONTRAST SCAN SHOWS
VERTEBRAL BODY ENHANCES STRONGLY. NOTE CORD
COMPRESSION.
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• AXIAL T-1 WEIGHTED MRI
• SCAN AT L-1 LEVEL SHOWS
• EPIDURAL NHL (LARGE
• ARROWS) WITH THECAL
• SAC COMPRESSION (SMALL
• ARROWS)

INTP - PPO, PHO, IAP. P7 15/22
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• BY 48 HOURS
• BACK PAIN REDUCED
• SHOOTING PAINS REDUCED
• MARKED IMPROVEMENT IN MUSCLE POWER. CHILD ABLE TO
  WALK WITH MINIMAL SUPPORT
• DTRS BRISK AND UPGOING PLANTAR
• CLINICAL FINDINGS SUGGEST IMPROVEMENT IN
  NEUROLOGICAL STATUS

INTP - PPO, PHO, IAP. P7 16/22
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• CT GUIDED BIOPSY FROM THE MASS REVEALED
  LYMPHOBLASTIC LYMPHOMA
• DIAGNOSIS OF SPINAL CORD COMPRESSION DUE TO
  LYMPHOBLASTIC LYMPHOMA (RELAPSE) CONFIRMED
• (MRI SCAN BIOPSY)
• NEXT STEP IN THERAPY?

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• CHEMOTHERAPY?
• RADIOTHERAPY?
• SURGERY?
• WHAT MODALITY OF TREATMENT BEST FOR THIS CHILD?

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• CHEMOTHERAPY FOR RELAPSED LYMPHOBLASTIC LYMPHOMA
  WITH 2ND LINE AGENTS STARTED SINCE
• CHILD IMPROVED MARKEDLY WITH STEROIDS AND NO
  NEUROLOGICAL PROGRESSION PRESENT
• LYMPHOBLASTIC LYMPHOMAS ARE CHEMOSENSITIVE
  TUMOURS
• RADIO THERAPY USUALLY NOT FIRST LINE THERAPY
  MAY BE USED IF THERE IS NEUROLOGICAL PROGRESSION
  OR RADIO SENSITIVE TUMOUR
• RADIOTHERAPY CAN CAUSE IATROGENIC SPINAL
  DEFORMITIES AND SECOND CANCERS HENCE AVOID IF
  POSSIBLE

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CHILDS PROGRESS

• RESPONDED WELL TO CHEMOTHERAPY
• NEUROLOGICALLY STABLE BY 2 WEEKS
• AT 4 WEEKS - NO SIGNIFICANT NEUROLOGICAL DEFICIT
  EXCEPT FOR MILD WEAKNESS OF LOWER LIMBS

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KEY POINTS

• SPINAL CORD COMPRESSION A TRUE MEDICAL
  EMERGENCY
• SUSPECT IN ANY CHILD WITH KNOWN MALIGNANCY AND A
  PERSISTENT, SEVERE AND PROGRESSIVE BACK PAIN
• MAY BE A PRESENTING SIGN OF A MALIGNANCY
• EARLY ADMINISTRATION OF STEROIDS WILL OPTIMISE
  OUTCOME AND REDUCE MORBIDITY AND MORTALITY
• MRI PREFERRED FOR DIAGNOSIS
• MULTI DISCIPLINARY APPROACH

INTP - PPO, PHO, IAP. P7 21/22
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KEY POINTS

• DEFINITIVE THERAPY MAY INVOLVE CHEMOTHERAPY
  AND/OR RADIOTHERAPY OR SURGERY
• CHEMOTHERAPY PREFERRED OVER RADIOTHERAPY
  CHILDHOOD TUMOURS ARE USUALLY CHEMOSENSITIVE
• PROGNOSIS DIRECTLY RELATED TO EXTENT OF
  INVOLVEMENT AND TIME ELAPSED BETWEEN ONSET
• OF SYMPTOMS AND INTERVENTION

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