Neuroblastoma with symptomatic spinal cord compression at diagnosis: treatment and results with 76 cases

PURPOSE

To report on the treatment of patients with newly diagnosed neuroblastoma presenting with spinal cord compression (SCC).

PATIENTS AND METHODS

Of 1,462 children with neuroblastoma registered between 1979 and 1998, 76 (5.2%) presented with signs/symptoms of SCC, including motor deficit in 75 patients (mild in 43, moderate in 22, severe [ie, paraplegia] in 10), pain in 47, sphincteric deficit in 30, and sensory loss in 11. Treatment of SCC consisted of radiotherapy in 11 patients, laminectomy in 32, and chemotherapy in 33. Laminectomy was more frequently performed in cases with favorable disease stages and in those with severe motor deficit, whereas chemotherapy was preferred in patients with advanced disease.

RESULTS

Thirty-three patients achieved full neurologic recovery, 14 improved, 22 remained stable, and eight worsened, including three who become paraplegic. None of the 10 patients with grade 3 motor deficit, eight of whom were treated by laminectomy, recovered or improved. In the other 66 patients, the neurologic response to treatment was comparable for the three therapeutic modalities. All 11 patients treated by radiotherapy and 26 of 32 patients treated by laminectomy, but only two of 33 treated by chemotherapy, received additional therapy for SCC. Fifty-four of 76 patients are alive at time of the analysis, with follow-up of 4 to 209 months (median, 139 months). Twenty-six (44%) of 54 survivors have late sequelae, mainly scoliosis and sphincteric deficit.

CONCLUSION

Radiotherapy, laminectomy, and chemotherapy showed comparable ability to relieve or improve SCC. However, patients treated with chemotherapy usually did not require additional therapy, whereas patients treated either with radiotherapy or laminectomy commonly did. No patient presenting with (or developing) severe motor deficit recovered or improved. Sequelae were documented in 44% of surviving patients.

Hepatoblastoma with spinal metastases

Spinal cord compression secondary to metastases is an infrequent complication of childhood cancer. We describe an infant with hepatoblastoma in whom cord compression developed because of extensive epidural metastases during treatment. This is a hitherto undescribed metastatic site for hepatoblastoma.

[Spinal compression syndrome and circulatory disorders]

Disorders due to spinal cord compression or ischemic spinal cord lesions represent the most relevant nontraumatic spinal cord injuries causing acute para- and tetraplegia. In acute spinal cord compression early diagnosis is most reasonable to indicate early operative intervention with decompression to prevent progressive neurological deficits. In patients suffering from malignant disorders the indication for operation is directed to maintain quality of life in an appropriate level (pain treatment, mobility by wheelchair). In chronic spinal cord compression operations are aimed to prevent the development or progression of neurological deficits, as the outcome of rehabilitation is very much dependent to the neurogenic damage. In ischemic spinal cord lesion therapy is restricted to prevent further cadiovascular complications which additionally induce spinal cord dysfunction.

[Tuberculous spondylitis complicated by spinal disorders: diagnosis and treatment]

Complex diagnosis using additional radiation procedures (computed tomography and magnetic resonance imaging) for tuberculous spondylitis complicated by spinal disorders was made in 52 patients. It made the genesis of spinal cord disorders more clear. The genesis was due to epidural abscess, necrotic osseous tissue and bony compression of destroyed vertebrae. Spinal cord structural changes were detectable in the postoperative period. Hemosorption in combination with blood ultraviolet radiation was used in 25 (40%) patients for their indications, which allowed all the patients to be operated on. Surgical treatment of 60 patients by using radical interventions into the target site and extended corporolateral decompression of the spinal cord, by employing autograft spondylolodesis resulted in rehabilitation in 95% of cases.

Oncologic emergencies

Oncologic emergencies may occur in patients who have no prior diagnosis of malignancy as well as in patients who are known to have cancer. It is important for the primary care practitioner to consider an oncologic cause for symptoms or problems that may bring a patient into the office. These symptoms often are vague and could be indicative of numerous problems frequently associated with individuals who have cancer. A brief overview of the most common oncologic emergencies is given, along with differential diagnostic possibilities and management strategies.

Epidural spinal cord compression in cancer patients: diagnosis and management

In most patients with spinal cord compression due to epidural metastasis, the initial symptom is progressive back pain with an axial or radicular distribution, but early symptoms are often nonspecific. Since the key prognostic factor is the neurologic status at the time of presentation, and since early complaints are often nonspecific, a high index of suspicion is needed to diagnose this complication early.

Partial aplasia of the posterior arch of the atlas with an isolated posterior arch remnant: findings in three cases

We report the imaging findings in three symptomatic cases of partial aplasia of the posterior arch of the atlas with an isolated posterior remnant of the arch. These cases are instructive in illustrating the mechanism of cord impingement produced by the posterior arch remnant during extension of the cervical spine. Additionally, focal increased T2 signal was observed within the cord at the level of the anomaly in two of the patients.

Treatment of wobbler syndrome in dogs with electroacupuncture

Based on favorable experiences with acupuncture for the treatment of hind limbs paralysis, lumbo-sacral alterations, and other spinal cord problems; a clinical trial, involving 40 dogs affected with wobbler syndrome was carried out. Patients were graded in three categories according to the severity of each case and then randomly divided in two groups. Both groups contained all three grades. Group 1 (20 dogs) was treated using orthodox medical and surgical interventions, while Group 2 (20 dogs) were treated mainly with electroacupuncture, and in few cases with surgical intervention as well. The study was carried out in a three-year period. Acupuncture treatments were given every other day delivering 150 to 300 mVolts at 125 Hz, equivalents to approximately 20 microAmps, in ten acupuncture points per treatment. Deep needle insertion was used. Overall per cent success in Group I was only 20%, while in group II the corresponding value was 85%. The number of acupuncture treatments required to achieve full recovery in Group II was dependent upon the severity of the case, as follows: Grade I: 18.5 +/- 2.5; Grade II: 25 +/- 5.4; and Grade III: 34 +/- 6.7 (r = 0.962). No adverse effects were observed with acupuncture. The use of this technique is proposed for large-scale clinical trials.

Orthopedic emergencies in cancer patients

The most frequent orthopedic emergency in oncology patients is fracture. Stabilization of the entire fractured bone restores function and relieves pain. The site, quality, and extent of the lesion can identify impending fractures that should be stabilized. New methods of pelvic stabilization effectively bypass periacetabular bone deficiency. Spinal cord decompression is important to maintain neurologic function. Advances in segmental fixation of the spine have improved the outcome over what was achieved by radiation alone. Infection is common in neutropenic patients, and should be treated aggressively with antibiotics and drainage of abscesses of the musculoskeletal system. Extravasation of doxorubicin requires prompt local debridement to limit the extent of necrosis propagation. These treatments can effectively improve the quality of life of patients with metastatic cancer. They should be included as "best supportive care" for patients with more than 1 month to live.

Neurologic emergencies in the cancer patient

Neurologic complications of cancer and its therapy are varied and common, but there are few true neurologic emergencies. However, when a neurologic emergency does occur, rapid diagnosis and treatment can preserve neurologic function and, in some circumstances, save a life. Epidural spinal cord compression, raised intracranial pressure (ICP), status epilepticus, and intracerebral hemorrhage (ICH) are the most common neurologic emergencies in the cancer patient. This chapter details the clinical features, possible etiologies, diagnostic tests, and treatment options for each of these complications.

The degenerative cervical spine: pathogenesis and rehabilitation concepts

The degenerative process associated with spondylosis in the cervical spine has been reviewed. The two compressive syndromes commonly associated with spondylosis, radiculopathy and myelopathy, are briefly reviewed. Except for more severe, multilevel degenerative changes producing neurologic compromise, correlation between degenerative changes and patient symptoms or functional limitations is generally poor. A conceptual scheme for guiding rehabilitation of mechanical neck pain, based on irritability level and the effects of mechanical stress on symptoms, is proposed. Further research is required to test the reliability and validity of categorization schemes like the one proposed. Such schemes based on history and effects of mechanical stresses, rather than solely on degenerative radiographic findings, are necessary to classify patients in meaningful ways that help guide specific rehabilitation strategies and tactics. When meaningful classification schemes exist, treatments matched with specific categories of dysfunction can be tested for effectiveness.

Spinal cord compression: a rareness in pregnant thalassemic woman

Thalassemia is a common hematological disease in Southeast Asia. Extramedullary hematopoiesis is common sequelae in thalassemic patients but extramedullary hematopoiesis in the spinal epidural space that leads to paraparesis in pregnancy is very rare. We managed a thalassemic patient with extramedullary hematopoiesis and spinal cord compression during pregnancy. The diagnosis was made on clinical features and magnetic resonance imaging (MRI) showing a paravertebral mass infiltrating the epidural space. She was treated successfully with repeated blood transfusions until delivery. Fetal growth restriction was found but otherwise the fetus was clinically normal. She had an uneventful recovery when she was seen 6 weeks after delivery.

Increased signal intensity of the spinal cord on magnetic resonance images in cervical compressive myelopathy. Does it predict the outcome of conservative treatment?

STUDY DESIGN

Correlation between a lesion of the spinal cord that elicits increased signal intensity (ISI) on magnetic resonance images (MRIs) and the outcome of conservative treatment for cervical compressive myelopathy was retrospectively investigated.

OBJECTIVE

To investigate whether ISI could predict the outcome of conservative treatment for cervical compressive myelopathy.

SUMMARY OF BACKGROUND DATA

It is unknown whether ISI is related to the outcome of conservative treatment for cervical compressive myelopathy.

METHODS

Fifty-two patients with mild cervical myelopathy underwent conservative treatment with a cervical brace. The compressive lesions were spondylosis in 29 patients, disc herniation in 12, and an ossification of the longitudinal ligament in 11. They also underwent MRI (1.5 T), and ISI was evaluated on T2-weighted sagittal and axial images. The ISI areas were classified as focal or multisegmental. Thirty-nine patients underwent follow-up MRI after a mean interval of 2 years, 4 months. The transverse area of the spinal cord was also measured on T2-weighted axial images. The outcome of conservative treatment was assessed using the Japanese Orthopedic Association Score (JOA score). Patients showing either an improvement in the JOA score or with a JOA score of 15 or more were considered to have a satisfactory outcome.

RESULTS

The average JOA score was 14.0 +/- 1.4 (range, 10-16) before conservative treatment and 14.4 +/- 1.9 (range, 10-17) at follow-up. The average gain in the JOA score was 0.4 points +/- 1.9 (range, -5 to +6). The outcome was satisfactory in 36 patients (69%). An area of ISI was observed in 34 patients (65%) before treatment (24 focal and 10 multisegmental). A satisfactory outcome was obtained in 78% of the patients without ISI, in 63% of those with focal ISI, and in 70% of those with multisegmental ISI. No statistically significant difference was seen among these three groups in the percentages of patients with satisfactory outcome, JOA scores before and after treatment or transverse spinal cord area. Of the 39 patients who were re-examined by MRI, 28 showed an area of ISI. The ISI regressed in five patients (18%). Satisfactory outcome was obtained in all 5 patients with regression of ISI, in 16 (70%) of the 23 patients without regression of ISI, and in 10 (91%) of the 11 patients without ISI apparent on the the first images (difference, not significant).

CONCLUSIONS

Increased signal intensity was not related to a poor outcome of conservative treatment or severity of myelopathy in the patients with mild cervical myelopathy.

Outcome of patients treated for cervical myelopathy. A prospective, multicenter study with independent clinical review

STUDY DESIGN

This Cervical Spine Research Society (CSRS) Study is a prospective, multicenter, nonrandomized investigation of patients with cervical spondylosis and disc disease. In this analysis, only patients with cervical myelopathy as the predominant syndrome were considered.

OBJECTIVES

To determine demographics, surgeon treatment practices, and outcomes in patients with symptomatic myelopathy.

SUMMARY OF BACKGROUND DATA

Current data on patient demographics and treatment practices of surgeons do not exist. There are no published prospective studies in which neurologic, functional, pain, and activities of daily living outcomes are systematically quantified.

METHODS

Patients were recruited by participating CSRS surgeons. Demographic information, patients' symptoms, and patients' functional data were compiled from patient and physician surveys completed at the time of initial examination, and outcomes were assessed from patient surveys completed after treatment. Data were compiled and statistically analyzed by a blinded third party.

RESULTS

Sixty-two (12%) of the 503 patients enrolled by 41 CSRS surgeons had myelopathy. Patients (48.4% male; mean age, 48.7 +/- 12.03 years) had a mean duration of symptoms of 29.8 months (range, 8 weeks to 180 months). Surgery was recommended for 31 (50%) of these patients. Forty-three patients (69%) returned for follow-up and completed the questionnaire adequately for analysis. Twenty (46%) of the 43 patients on whom follow-up data are available underwent surgery, and 23 (54%) received medical treatment. Surgically treated patients had a significant improvement in functional status and overall pain, with improvement also observed in neurologic symptoms. Patients treated nonsurgically had a significant worsening of their ability to perform activities of daily living, with worsening of neurologic symptoms.

CONCLUSIONS

When medical and surgical treatments are compared, surgically treated patients appear to have better outcomes, despite exhibiting a greater number of neurologic and nonneurologic symptoms and having greater functional disability before treatment. Randomized studies, if feasible, should be performed to address outcome in cervical myelopathy further.

Case study: possible traumatic stress disorder in an infant with cancer

The posttraumatic stress disorder model has been used to describe some children's experience with cancer. This article presents the case of a 5-month-old infant in whom a neuroblastoma was diagnosed at age 2 weeks. His symptoms at the time of the psychiatric consultation were consistent with the criteria for traumatic stress disorder in infants from the ZERO TO THREE: Diagnostic Classification. This case study invites future clinical and research queries about traumatic stress disorder in infants with serious medical illnesses.

[Children with stumbling gait due to acute spinal cord compression]

Three previously healthy children, two girls aged 2 and almost 5 years and a boy aged 20 months, developed a progressively stumbling gait within days. In two this occurred after a period of weeks during which they complained of, or seemed to have back pain. In all three cases acute spinal cord compression by a malignant tumour was diagnosed. Histological examination revealed Ewing sarcoma, granulocytic sarcoma and T-cell lymphoma. Surgical decompression led to complete neurological recovery. Although rare, acute spinal cord compression during childhood is a medical emergency because of the risk of neurological morbidity. Back pain, weakness and a stumbling gait usually are the first symptoms. Sensory symptoms and sphincter dysfunction may develop later. Early recognition is essential, as prognosis depends on neurological findings and duration of symptoms when treatment is started.

Emergency department evaluation and treatment of back pain

Patients with back pain commonly present in the emergency department for evaluation and treatment. Because it is a common syndrome with a generally benign origin, the examiner may overlook markers of serious disease. This article reviews the important historical and physical factors to consider, with an emphasis on the red flags of serious disease. This article also reviews the management of acute lumbosacral strain, sciatica, and disc herniation, cauda equina syndrome and spinal cord compression, and back pain in the patient with a history of cancer.

Early recognition of spinal cord compression in cancer patients

Spinal cord compression is a relatively common complication of a number of malignant diseases. Back pain is the presenting symptom in more than 90% of cases. Early recognition and prompt treatment, while the patient can still walk, are the most important factors in preventing permanent and debilitating neurologic dysfunction.

Missed cervical spine fracture: chiropractic implications

OBJECTIVE

To discuss the case of a patient with an anterior compression fracture of the cervical spine, which had been overlooked on initial examination.

CLINICAL FEATURES

A 36-year-old man was seen at a chiropractic clinic 1 month after diving into the ocean and hitting his head on the ocean floor. He chipped a tooth but denied loss of consciousness. Initial medical examination in the emergency department did not include radiography, but an anti-inflammatory medication was prescribed. Radiographs taken at the chiropractic clinic 1 month later revealed an anterior compression fracture of the C7 vertebra, with migration of the fragment noted on flexion and extension views.

INTERVENTION AND OUTCOME

The patient was referred back to his medical doctor for further evaluation and management.He was instructed to wear a Philadelphia collar for 4 weeks. During this time period, he reported "shooting" pain and tingling from his neck into his arms. The patient reported resolution of his neck and arm symptoms at 2.5 months after injury. Follow-up radiographs at 6 months after injury revealed fusion of the fracture fragment with mild residual deformity. At that time, the patient began a course of chiropractic treatment.

CONCLUSION

After head trauma, it is essential to obtain a radiograph of the cervical spine to rule out fracture. Chiropractors should proceed with caution, regardless of any prior medical or ancillary evaluation, before commencing cervical spine manipulation after head and neck trauma.

Extraosseous extension of vertebral hemangioma, a rare cause of spinal cord compression

STUDY DESIGN

Case report.

OBJECTIVE

To illustrate a rare cause of thoracic spinal cord compression, its diagnosis, and its management.

SUMMARY OF BACKGROUND DATA

Asymptomatic vertebral hemangiomas are common, but extraosseous extension causing spinal cord compression with neurologic symptoms is rare, and few cases appear in the English-language literature.

METHOD

A previously asymptomatic 63-year-old man sought medical attention for acute back pain and thoracic myelopathy of 6 week's duration. Magnetic resonance imaging confirmed the presence of a mass in the T10 vertebral body with paravertebral and intracanalicular extension contributing to cord compression. Decompression and reconstructive surgery were performed and radiotherapy administered after surgery. Preoperative angiography was not performed because of the patient's rapidly progressive neurologic deterioration and the consideration that the differential diagnosis of vertebral hemangioma was less likely.

RESULTS

The diagnosis of benign capillary hemangioma was made histologically. Neurologic recovery was complete except for minor residual sensory changes in the legs. At follow-up 10 months after surgery the patient had returned to his usual active life and motor mower repairing business.

CONCLUSION

Extraosseous extension of vertebral hemangiomas is a rare cause of thoracic spinal cord compression. As such, the available data are derived from reports based on series involving only a small number of cases, rather than on results of randomized controlled trials. Those causing progressive neurologic symptoms should be surgically decompressed, with the specific procedure determined by the extent and site of the lesion. Preoperative angiography is recommended, but embolization is not always necessary or even possible. Postoperative radiotherapy is recommended when tumor removal is subtotal.

[Medullary compression in metastatic cancer]

Cancer patients with spinal cord compression may develop irreversible neurological deficit. The clinical picture implies back pain and subsequent neurological deficit. There is always a danger of rapid deterioration of the patient's condition. If spinal cord compression is suspected, the case is an emergency. MRI should be preferred in the diagnostic work-up, and corticosteroids be administered promptly. Radiation therapy or surgical treatment should be started as soon as possible. Patient outcome is related to the degree of neurological deficit at the start of treatment.

Brown-Sequard syndrome after management of vertebral hemangioma with intralesional alcohol. A case report

STUDY DESIGN

This report describes Brown-Sequard syndrome after intralesional injection of absolute alcohol into vertebral hemangioma.

OBJECTIVE

To discuss whether the described technique is safe in the management of vertebral hemangiomas.

SUMMARY OF BACKGROUND DATA

The management of vertebral hemangiomas remains controversial. There have been reports of successful management using intralesional absolute alcohol.

METHODS

The clinical and radiologic features of the reported complication are detailed.

RESULTS

Intralesional injection of absolute alcohol caused Brown-Sequard syndrome.

CONCLUSION

This case shows that intralesional alcohol injection cannot be considered a safe technique for management of vertebral hemangiomas with spinal cord compression.

The value of somatosensory- and motor-evoked potentials in predicting and monitoring the effect of therapy in spondylotic cervical myelopathy. Prospective randomized study

STUDY DESIGN

A 2-year follow-up prospective randomized electrophysiologic and clinical study of patients with spondylotic cervical myelopathy.

OBJECTIVE

To assess the value of somatosensory- and motor-evoked potentials in the evaluation and prediction of the effect of therapy.

SUMMARY OF BACKGROUND DATA

Previous studies have yielded conflicting data concerning the correlation between the changes in evoked potential parameters and the clinical postsurgical outcome in spondylotic cervical myelopathy.

METHODS

Sixty-one patients with magnetic resonance images suggesting spondylotic cervical cord compression and clinical signs of cervical myelopathy were divided into two groups according to the degree of clinical cervical cord involvement. The 49 patients with mild and moderate spondylotic cervical myelopathy were randomized into groups that underwent either surgical or conservative therapy. Patients were evaluated clinically and by the means of somatosensory- and motor-evoked potentials.

RESULTS

The clinical and evoked potential changes showed good correlation on the group level, but poor correlation intraindividually. There were no significant evoked potential and clinical group changes after 6 months and 2 years in the mild myelopathy group treated either surgically and conservatively, whereas patients with severe myelopathy displayed significant improvement in clinical and evoked potential parameters after surgery. In a subgroup of patients, the isolated segmental medullar N13 abnormality could potentially predict favorable postsurgical clinical outcome.

CONCLUSIONS

Longitudinal evoked potentials showed limited use for evaluating the results of therapy in an individual patient. They could be useful in the group assessment of therapy results and in labeling a subgroup of patients with potentially favorable postsurgical outcome.