Neurosurgical emergencies in spinal tumors: pathophysiology and clinical management

Abstract

Whether they are spinal metastases or primary spinal neoplasms, spinal tumors cause a myriad of complications given their critical location. Spinal tumors can be extradural, intradural extramedullary, or intramedullary, with extradural metastatic tumors the most commonly encountered. Spinal cord and/or cauda equina compression is one of the most devastating complications of cancer and represents a true oncologic emergency. Patients present with progressive paralysis, paresthesiae, and/or autonomic dysfunction. In addition to spinal cord compression (SCC), extradural spinal tumors can cause mechanical spinal instability and axial loading pain which often warrant surgical consultation. The diagnosis of SCC begins with clinical suspicion even before neurological deficits ensue. Patients presenting with back or neck pain who have a history of cancer should be evaluated carefully for SCC. MRI is the imaging modality of choice. Management of SCC generally requires a multidisciplinary approach, with goals of symptom control and prevention of irreversible functional loss. Patients with metastatic epidural SCC who undergo surgical decompression and reconstruction followed by radiotherapy exhibit better outcomes in preservation of function and symptom control than do those undergoing radiotherapy alone. Recent advances in the surgical management of SCC include minimally invasive spinal surgery (MISS), spinal laser interstitial thermotherapy (SLITT), and vertebral augmentation of pathologic vertebral compression fractures. Generally, SCC in patients with cancer serves as evidence of uncontrolled and aggressive disease. Although it is associated with poor outcome in most patients, effective palliation is possible with early diagnosis and careful application of modern surgical techniques for the elimination of cord compression, prevention or reversal of neurological deficits, and restoration of mechanical spinal stability. In addition to SCC from spinal tumors, other spinal complications can be seen in cancer patients who develop spine infections such as surgical site infection (SSI), spinal epidural abscesses (SEA), subdural empyema (SDE), or vertebral osteomyelitis. These complications can be due to inoculation from the spinal surgery itself or as a result of the patients’ immunocompromised state. This article provides a scoping review of the clinical presentation, pathophysiology, and diagnosis of major spinal oncologic emergencies and summarizes current modes of surgical and nonsurgical management.