Intramedullary spinal cord metastasis of lung adenocarcinoma presenting as brown-sequard syndrome

Intramedullary spinal cord metastases from non-small cell lung carcinoma (NSCLC) associated with carcinomatous meningitis: a case report

Background:

Carcinomatous meningitis with metastases to the spinal cord [intramedullary spinal cord (IMSC)] is very rare, and a quick intervention to management of these patients is important in preventing neurological deterioration.

Methods:

We report a case of IMSC metastases from a stage IV non-small cell lung carcinoma in a 57-year-old man who presented with Brown-Sequard syndrome along with multiple brain metastases with associated carcinomatous meningitis and managed with urgent palliative external beam radiation therapy.

Conclusion:

A quick, short course of palliative radiation therapy for inoperable patients with IMSC metastases provides improvement in neurological function in the management of these oncologic emergencies in patients with short survival times.

Brown-Séquard Syndrome Caused by Acute Traumatic Cervical Disc Herniation

Brown-Séquard syndrome (BSS) is an incomplete spinal cord injury caused by damage to one-half of the spinal cord. Most cases of BSS result from penetrating trauma or tumors, and acute cervical disc herniation is a relatively rare cause of BSS. In this case, a 34-year-old man with a sudden onset posterior neck pain and left side motor weakness was admitted to the local spine hospital. Pain and temperature sensation of pain was decreased below the right C4 dermatome. The left arm and leg motor grade was 0. Magnetic resonance imaging (MRI) showed a huge trans-ligamentous herniated disc rupture from the center to the left at the level of C3-4, and anterior cervical discectomy and fusion were performed. After emergency surgery, left arm and leg motor grade recovered to 2, and normal voiding function returned. MRI verified complete removal of the cervical herniated disc. This case describes the approach to rapid diagnosis in a patient with characteristic clinical symptoms of BSS and radiological findings of a herniated cervical disc. Rapid and accurate diagnosis and immediate decompressive surgery increased the possibility of a good surgical outcome, even if the neurologic deficits are grave at the time of admission.

Intramedullary spinal cord metastasis from thyroid carcinoma: Case report and a systematic pooled analysis of the literature

Intramedullary spinal cord metastasis (ISCM) is rare and occurs most commonly in the setting of advanced malignancy. The optimal management pathways are not well defined and treatment outcomes from contemporary therapies remain variable. We report a case of a 49-year-old woman with known primary papillary thyroid carcinoma, who presented with rapidly progressive clinical features of Brown-Sequard syndrome. A detailed pooled analysis of the literature was conducted to characterise the clinical and demographic features, management options, and expected survival outcomes for cases of ISCM. We secondarily performed a subgroup analysis on the incidence, clinical and management characteristics of thyroid carcinoma ISCM.

Multimodality therapy improves survival in intramedullary spinal cord metastasis of lung primary

BACKGROUND

Most metastatic spinal cord lesions are located either in the intradural, extramedullary, or in the epidural compartments. Intramedullary spinal cord metastasis (ISCM) is a rare central nervous system spread of cancer. The aim of this report was to evaluate ISCM in the published literature.

METHODS

A literature review of PubMed from 1960 to 2016 was undertaken for the publications having demographic, clinical, histological, and outcome data.

RESULTS

A total of 59 relevant papers were identified, showing 128 cases of intramedullary metastasis from lung cancer. The incidence of lung cancer as the primary malignancy with intramedullary metastasis was 56%. The median time from diagnosis of primary to intramedullary metastasis was 6months. Survival improved with multimodality therapy compared to monotherapy (4monthsvs. 6.3months) (hazard ratio=0.501; 95% confidence interval, 0.293-0.857).

CONCLUSION

Lung cancer is the predominant cause of intramedullary involvement of the spinal cord. Overall prognosis is poor, although a multimodality approach was associated with improved survival.

Brown-Sequard syndrome produced by calcified herniated cervical disc and posterior vertebral osteophyte: Case report

Brown-Sequard syndrome (BSS) produced by cervical disc disorders has rarely been seen clinically and only 50 cases have been reported in English literatures. However, most of which have resulted from acute disc herniation. Here, we report a case of BSS produced by calcified herniated C4-C5 disc and posterior vertebral osteophyte, in which decompression through anterior approach was performed. This case revealed the potential of cervical spondylopathy leading to BSS in a chronic manner. Once the diagnosis is established, it is advisable to perform decompression as early as possible.

Intramedullary conus metastasis from carcinoma lung

A 46-year-old male presented with progressive paraparesis and sensory impairment in both lower limbs since 2 months. He had urinary and bowel incontinence. On examination he had flaccid paraplegia with a sensory level at 11^th dorsal vertebral level. Magnetic resonance imaging (MRI) scans of the lumbosacral spine showed an enhancing intramedullary lesion in the conus. The patient underwent excision of the conus mass. Histopathology confirmed the tumor to represent a poorly differentiated metastatic carcinoma from an unknown primary. A positron emission tomography-computed tomography (PET-CT) scan of the whole body revealed hypermetabolic activity in the hilum of the right lung confirmed to be a lung carcinoma on a CT-guided biopsy. The patient was undergoing chemoradiation at 1 month follow-up. The author's literature search has yielded only four other case reports of conus metastasis of which only one is in English literature. The present case report and review of literature are presented.

Isolated solitary intramedullary spinal cord metastasis presenting as the first manifestation of small-cell lung cancer: report of a rare case

Background. Intramedullary spinal cord metastases presenting as the first manifestation of malignancies are extremely rare lesions. Case Description. The authors report a 74-year-old woman who presented with an isolated intramedullary spinal cord metastasis which presents as first manifestation of malignancy without central nervous system and/or other organ involvement. She went under surgery, and after histopathological evaluation, primary focus was determined in lung in positron emission tomography. She is still alive after 9 months since the first diagnosis of primary focus. Conclusion. In patients with solitary intramedullary lesion in the spinal magnetic resonance imaging, whole-body investigation might help for diagnosis of primary focus and approach to treatment.

Cervical disc herniation manifesting as a Brown-Sequard syndrome

Brown-Sequard syndrome is commonly seen in the setting of spinal trauma or an extramedullary spinal neoplasm. The clinical picture reflects hemisection of the spinal cord. We report a rare case of Brown-Sequard syndrome caused by a large cervical herniated disc. A 63-year-old man presented with progressive right hemiparesis and disruption of pain and temperature sensation on the left side of the body. Magnetic resonance imaging showed large C3-C4 disc herniation compressing the spinal cord at that level, with severe canal stenosis from C4 through C7. Decompressive cervical laminoplasty was performed. After surgery, complete sensory function was restored and a marked improvement in motor power was obtained.

Intramedullary spinal cord metastases: a 20-year institutional experience with a comprehensive literature review

OBJECTIVES

To review previous reports as well as our institutional experience to address the issues regarding patient management and also to assess the predisposing factors that might influence outcome and survival.

METHODS

We undertook a 20-year (1989-2009) retrospective study of a series of eight patients diagnosed with intramedullary spinal cord metastases (ISCMs) in our institute. We further reviewed 293 cases of ISCMs reported in the English literature since 1960. Characteristics regarding the site of the primary cancer, location of ISCM, the presence of other metastases, presenting neurological symptoms/signs, duration of symptoms, and the time interval from diagnosis of the primary tumor to ISCM were pooled. We analyzed the different treatment approaches, the functional outcome, and the factors influencing survival.

RESULTS

Lung and breast cancers appear to be the most frequent source of ISCM with cervical, thoracic, and lumbar spine being equally affected. Motor weakness predominates as the commonest symptom at presentation, followed by pain and sensory disturbance. At diagnosis, most patients with ISCM have a known primary cancer often associated with cerebral and other systemic metastases. Overall survival of ISCM is poor (median: 4 months from the time of diagnosis). Survival in surgical patients is 6 months, compared with 5 months in those conservatively managed. Clinical improvement was observed in more than one-half of those treated surgically, whereas neurological status was maintained in most patients treated conservatively.

CONCLUSION

ISCM is an unusual site for metastasis. Regardless of the treatment, its prognosis is generally poor as its presence often signifies end-stage cancer. However, with early diagnosis and appropriate treatment, selected patients may benefit from improved neurological outcome and quality of life.

Intramedullary spinal cord metastases: review of the literature

AIMS

To review the epidemiology, dissemination, clinical presentation, diagnosis, treatment, survival and functional outcome of intramedullary spinal cord metastases (ISCM).

METHODS

Literature review of all surgically treated cases of ISCM and all described cases of ISCM of breast carcinoma.

RESULTS

42 references to 87 surgically treated cases of ISCM were found, 13 references to 27 cases with diagnosed and treated ISCM of breast carcinoma. In only 9 cases of spinal cord metastases of breast cancer was surgical resection of ISCM done (10% of all surgically treated ISCM).

CONCLUSIONS

Three treatment modalities are available for ISCM: radiotherapy, chemotherapy, and surgery. The gold standard remains radiotherapy. Microsurgical resection of a focal intramedullary mass appears to be feasible and should be considered in selected cases. Patients who have no evidence of widespread organ metastases or multiple intramedullary lesions and who have a life expectancy of at least a few months with tumours of non-lymphoma histology should be considered for tumor resection. In conclusion, ISCM are difficult to treat lesions, but early diagnosis, careful surgical management and maintenance therapy may substantially contribute to a satisfactory functional outcome and prolonged survival.

Brown-Sequard syndrome revealing intradural thoracic disc herniation

Brown-Sequard syndrome (BSS) is a rare form of severe myelopathy characterised by a clinical picture reflecting hemisection of the spinal cord. This syndrome is mostly due to a penetrating injury to the spine but many other non-traumatic causes have been described. Intradural thoracic disc herniation (TDH) is one of the rare aetiologies of this syndrome. Despite progress in imaging techniques, diagnosis and treatment remain difficult. We retrospectively reviewed one of the largest reported series of six patients with BSS revealing intradural TDH between 2003 and 2007. There was a marked female predominance and the mean age was 44 years. Before surgery, half of the patients had a severe neurological deficit. The mean duration of symptoms until surgery was 8.5 months (range 0.5-24 months). Spine magnetic resonance imaging (MRI) or spine computer tomography scan showed calcified TDH between T5-T6 and T9-T10. The intradural location of the thoracic herniation was strongly suspected from the clinical data. All the patients underwent posterolateral transpedicular surgery with an operative microscope to open the dura mater. The intradural location of the herniation was overlooked in one case and the patient underwent a second procedure. The dura mater was carefully closed. Two patients' condition worsened immediately after the surgery before slowly improving. All the other patients improved their neurological status immediately after the surgery and at 12 months follow-up. BSS with TDH on the spine MRI scan may be a warning symptom of the intradural location of the herniated disc. In such cases, spine surgeons are advised to use an operative magnification and to open the dura mater to avoid missing this potentially curable cause of severe myelopathy.

Paraspinal muscle impingement causing acute Brown-Sequard syndrome after posterior cervical decompression

STUDY DESIGN

A case report.

OBJECTIVE

To present a previously unreported cause of neurologic compromise after cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Several different causes of postoperative neurologic deficit have been reported in the literature. The authors present a case of acute postoperative paralysis after posterior cervical decompression by a mechanism that has not yet been reported in the literature.

METHODS

A 54-year-old muscular, short-statured man underwent posterior cervical laminectomy from C3-C5 without instrumentation and left C5 foraminotomy. Within hours of leaving the operating room, he began to develop postoperative neurologic deficits in his extremities, which progressed to a classic Brown-Sequard syndrome. Magnetic resonance imaging revealed regional kyphosis and large swollen paraspinal muscles impinging on the spinal cord without epidural hematoma. Emergent operative re-exploration confirmed these findings; large, swollen paraspinal muscles, a functioning drain, and no hematoma were found.

RESULTS

The patient was treated with immediate corticosteroids at the time of initial diagnosis, and emergent re-exploration and debulking of the paraspinal muscles. The patient had complete recovery of neurologic function to his preoperative baseline after the second procedure but required a third procedure in which anterior discectomy and fusion at C4-C5 was performed, which led to improvement of his preoperative symptoms.

CONCLUSION

When performing posterior cervical decompression, surgeons must be aware of the potential for loss of normal lordosis and anterior displacement of paraspinal muscles against the spinal cord, especially in muscular patients.

Intramedullary Spinal Cord Metastases from Atypical Small Cell Lung Cancer: A Case Report and Literature Review

Intramedullary spinal cord metastases (ISCM) are usually the result of rapidly progressing systemic malignancy. Lung cancer represents the most common solid tumor associated with the development of ISCM. We describe a 47-year-old female with atypical small cell lung cancer (SCLC) developing ISCM. After a thoracoscopic biopsy she was treated with combination chemotherapy consolidated by mediastinal radiotherapy leading to complete remission. Three months later, she developed a Brown-Sequard syndrome and an MRI scan revealed ISCM at the T10-T12 levels, and secondary brain lesions. Despite treatment with steroids and thoracic spine/brain radiotherapy, no recovery of her motor function was seen and she died 4 months later due to progressive disease in the CNS. The present case, adds to the existing list of ISCM cases reported so far for lung cancer, undermine the ominous prognosis and limited treatment options available, and an extensive literature overview and discussion of similar cases is provided.

Retrospective study of 19 patients with intramedullary spinal cord metastasis

OBJECT

Intramedullary spinal cord metastasis (ISCM) is a rare but devastating complication of cancer. Due to both widespread MRI availability and longer survival of cancer patients, the probability of discovering an ISCM during the course of the disease has increased and raised issues regarding the management of these patients, and particularly the place of surgery. In this study, we assess predictive factors for surgical outcome and survival.

PATIENTS AND METHODS

We retrospectively reviewed a series of 19 patients consecutively admitted in our institution from 1993 to 2006 for ISCM, representing the second largest series published in the literature. MRI was performed on all patients. Thirteen underwent microsurgical excision of ISCM. Functional outcome was evaluated and factors influencing survival were statistically analyzed.

RESULTS

Median survival was statistically longer when surgery was performed (7.4 vs. 2.6 months). Preoperative neurological status, nature of primary cancer, presence of systemic and/or CNS metastases influenced survival, but differences were without statistical significance. Neurological status improved in 58% (11/19) of operated patients.

CONCLUSIONS

Optimal management of patients with ISCM is difficult due to the wide variety of clinical situations and the lack of controlled studies on the results of different therapeutic options. Diagnosis should be made as early as possible and surgical resection should be considered as the primary treatment whenever feasible, particularly in the case of rapidly progressive neurological deficits and when a clear cleavage plane exists. Our study shows that surgery could result in both increased survival rate and significant improvement of neurological function.

INTRAMEDULLARY SPINAL CORD METASTASIS FROM BLADDER CARCINOMA

OBJECTIVE

Intramedullary spinal cord metastases are rare complications of systemic cancer. Although the majority of these metastases spread from lung cancer, they have been seen to arise from a variety of other primary sources. The authors report the second known case of an intramedullary spinal cord metastatic lesion arising from primary bladder carcinoma.

CLINICAL PRESENTATION

A 74-year-old man presented with an 8-day history of rapidly progressive Brown-Séquard syndrome, with weakness in his left lower extremity and decreased pain and temperature sensation in his right lower extremity. The patient's history was significant for high-grade urothelial carcinoma that had been treated 6 months earlier with radical cystectomy. A magnetic resonance imaging scan showed an enhancing intramedullary lesion at T1–T2.

INTERVENTION

The patient underwent laminectomies, and removal of his intramedullary lesion was attempted. Intraoperative pathology revealed that the lesion was metastatic in nature, and the decision was made to perform a subtotal resection. Pathology later confirmed that the lesion was consistent with a less differentiated form of his bladder primary. Postoperatively, the patient experienced minimal improvement in his symptoms, and he was subsequently treated with fractionated external beam radiotherapy. The patient died 7 weeks after undergoing surgery for his spinal cord lesion.

CONCLUSION

The occurrence of metastatic primary bladder cancer in the intramedullary spinal cord has been reported in the literature only once previously. Despite the lack of similar cases, the acute onset of Brown-Séquard syndrome was highly suggestive of a metastatic lesion. A review of relevant literature is provided.

METASTASIS TO THE CONUS MEDULLARIS

OBJECTIVE

Metastasis from lung cancer to the conus medullaris has never been reported in the English literature, although three cases have appeared in the French and Japanese literature. Our case report is unique because the patient presented with a lumbar radiculopathy, an atypical presentation that was found to be caused by metastasis from lung cancer to the conus medullaris. A critical review of the pertinent literature related to metastatic neoplasms to the conus medullaris is also presented.

CLINICAL PRESENTATION

We report the case of a 54-year-old man who presented with an L5 radiculopathy and was initially found to have a small disc herniation at L4–L5 on magnetic resonance imaging scans, which was ruled out as the case of his initial symptoms. In 3 weeks, the symptoms progressed with the development of urinary incontinence and right leg weakness. A magnetic resonance imaging scan of the lumbar spine showed a tumor at the conus medullaris.

INTERVENTION

The patient underwent a laminectomy with removal of the tumor. Pathological examination of the tumor showed infiltrating differentiated adenocarcinoma. A 2.5 cm lung mass in the right middle lobe with surrounding adenopathy was found on a computed tomographic scan of the chest. The patient died 4 months later from systemic involvement and progression of his lung disease.

CONCLUSION

This case report illustrates the rare presentation of a lumbar radiculopathy caused by a metastatic tumor to the conus medullaris. This was the first presentation for the diagnosis of lung cancer in this patient.

[Intramedullary spinal cord metastasis from thyorid carcioma: case report]

We report a case of intramedullary spinal cord metastasis from thyroid cancer in a 70-year-old woman complaining for three months an intense cervical pain, without motor or sensitive deficits. Six months before the onset of symptoms, the patient underwent total thyroidectomy for a thyroid cancer. Magnetic resonance imaging with gadolinium enhancement showed an intramedullary spinal cord lesion. A partial resection of the medullar tumor was performed and the pathological findings showed an metastatic adenocarcinoma. Post operatively the patient developed a left crural monoplegia.

Brown Séquard syndrome due to cervical pen assault

Brown Séquard syndrome is an uncommon incomplete spinal cord injury with ipsilateral motor and proprioception loss and contralateral pain and temperature loss. A 14-year-old student with classic Brown Séquard syndrome after pen assault injury by his classmate in posterior neck area presented here; with medical and supportive care, the patient was discharged with good outcome. Brown Séquard syndrome is mostly due to penetrating trauma. Several types of penetrating objects have been reported but this appears to be the first report of a pen or pencil injury.

Surgical treatment of intramedullary spinal cord metastases of systemic cancer: functional outcome and prognosis

OBJECTIVE

Intramedullary spinal cord metastases (ISCM) of systemic cancer are rare. To date, patients with ISCM tend to benefit only to a limited extend from surgery and adjuvant therapy. Subject of this investigation is to assess predictive factors for surgical outcome and survival and to evaluate the value of surgical radicality in the treatment of ISCM.

PATIENTS AND METHODS

Between 1990 and 2004, a series of 146 patients with intramedullary tumors underwent surgical treatment in our institution. Among these, 13 patients with intramedullary cancer metastases (7 adenocarcinomas, 3 poorly differentiated carcinomas, 3 sarcomas) were identified. Standard microsurgical removal of the ISCM was performed. Functional outcome was graded according to a standardized scale and factors influencing outcome and survival were statistically analyzed.

RESULTS

Median progression-free survival was 13 weeks and median overall survival was 31 weeks. In 5 patients (38) the intramedullary lesion was the initial manifestation of the malignant disease. All poorly differentiated carcinomas and all sarcomas were resected incompletely. Surgical radicality presented a negative predictive factor for functional outcome, increasing radicality leading to functional deterioration. Age, sex, tumor localization, surgical radicality and the presence of neoplastic meningeosis did not affect survival.

CONCLUSION

Surgery of ISCM can be performed with an acceptable operative morbidity. Radicality depended on tumor histology. However, radical tumor removal did not affect survival and was correlated with a poor functional outcome. Therefore, complete surgical removal of ISCM should only be intended in patients in whom an unproblematic excision is feasible.

Metastatic spine disease: epidemiology, pathophysiology, and evaluation of patients

Spinal metastasis is the most commonly en-countered tumor of the spine and represents an ominous extension of neoplastic disease. Symptomatic spinal metastases produce a characteristic clinical syndrome beginning with local back or neck pain. All too often, the significance of presenting pain is not appreciated and correct diagnosis is delayed until more blatant manifestations of spinal cord or nerve root dysfunction are manifest. Pain is followed by weakness,numbness, and sphincter dysfunction. The natural history is one of relentless progression to complete and irreversible paralysis unless timely treatment is undertaken. Plain radiographs provide a simple and useful screening test. MRI is, however, the imaging method of choice, providing information concern-ing the level, location, and geometry of the spinal tumor as well as details concerning the bony integrity of the spine, particularly adjacent to a culpable tumor, all of which is essential to determine the management options and treatment strategies. Percutaneous image-guided biopsy is a useful test to establish a tissue diagnosis.