CIM Case: Spinal Cord Compression - Thoracic Metastasis

Clinical Scenario

Patient: 70-year-old man Presentation: 12-month history of progressive low thoracic back pain, now developing bilateral leg weakness over past 2 weeks Relevant history: Previously healthy, no prior malignancy, 30 pack-year smoking history (quit 10 years ago), 5kg weight loss over 6 months, no urinary or bowel symptoms (yet), no prior spine surgery Examination findings:

Thin, cachectic man
Point tenderness over T10-T11 spinous processes
Lower limb examination:
- Power 4/5 bilateral hip flexors and knee extensors
- Power 3/5 bilateral ankle dorsiflexors
- Increased tone bilaterally
- Brisk knee and ankle reflexes
- Upgoing plantars (Babinski positive) bilaterally
- Sensory level at T10 (reduced sensation below)
Anal tone intact, no saddle anaesthesia
Gait wide-based, uses walking stick

Investigations Provided

Laboratory Results

Test	Result	Normal Range	Interpretation
Hb	105 g/L	130-170 g/L	↓ Anaemia of chronic disease
WCC	9.5 ×10⁹/L	4-11 ×10⁹/L	Normal
Platelets	185 ×10⁹/L	150-400 ×10⁹/L	Normal
CRP	28 mg/L	<5 mg/L	↑ Elevated
ESR	65 mm/hr	<20 mm/hr	↑ Elevated
Calcium	2.45 mmol/L	2.2-2.6 mmol/L	Normal
Phosphate	1.0 mmol/L	0.8-1.5 mmol/L	Normal
ALP	185 U/L	30-120 U/L	↑ Elevated
Albumin	30 g/L	35-50 g/L	↓ Low
PSA	3.2 ng/mL	<4 ng/mL	Normal
Protein electrophoresis	No paraprotein	-	Excludes myeloma
LDH	320 U/L	120-250 U/L	↑ Elevated
Creatinine	95 μmol/L	60-110 μmol/L	Normal

Imaging

Image 1: Thoracic Spine X-ray

Radiological features:

Collapse of T10 vertebral body
Loss of vertebral height anteriorly
Pedicle destruction on AP view ("winking owl" sign)
Increased kyphosis at T10 level
No obvious lytic lesions elsewhere on plain film

Image 2: MRI Thoracic Spine (T1, T2, STIR)

Findings:

T10 vertebral body collapse with posterior retropulsion
Epidural tumour extension causing cord compression
Cord signal change at T10 level (myelomalacia)
T1 hypointense lesion replacing normal marrow signal
Additional lesions at T6 and L2 (not causing cord compression)
Paraspinal soft tissue mass

Image 3: CT Chest/Abdomen/Pelvis (Staging)

Findings:

3.5cm spiculated mass in right upper lobe (primary lung cancer)
Ipsilateral hilar lymphadenopathy
Multiple small pulmonary nodules
No liver metastases
No adrenal metastases
Multiple bone lesions on bone windows

Questions & Model Answers

What is the diagnosis and how urgent is this presentation?

What prognostic scoring systems would you use?

What is the role of surgery versus radiotherapy?

Describe your surgical approach.

What adjuvant treatments are required?

What is the prognosis and how would you counsel this patient?

Key Teaching Points

Pattern Recognition

This pattern suggests Metastatic Spinal Cord Compression:

Older patient with progressive back pain
Constitutional symptoms (weight loss, fatigue)
Smoking history (lung cancer risk)
Progressive neurological symptoms
Upper motor neuron signs (hyperreflexia, Babinski)
Sensory level on examination

Red Flags for Spinal Cord Compression:

New back pain in known malignancy
Progressive weakness (hours to days)
Bladder/bowel dysfunction
Sensory level
Band-like chest/abdominal pain

Critical Management Points

This is an emergency - deteriorating neurology requires urgent action
Dexamethasone 16mg immediately on diagnosis
MRI whole spine - 30% have multiple levels involved
SINS score guides mechanical stability
Tokuhashi score guides prognosis and surgical extent
Surgery + RT superior to RT alone (Patchell trial)
Preserve ambulation - non-ambulatory patients rarely walk again

Common Examiner Follow-ups

Q: "What is the NOMS framework?"

NOMS is a decision framework for metastatic spine disease:

Component	Consideration
Neurological	Degree of cord compression, myelopathy
Oncological	Radiosensitivity, systemic disease control
Mechanical	Stability (SINS score)
Systemic	Medical fitness, expected survival

It guides treatment selection:

High-grade compression + instability → Surgery + RT
Low-grade compression + stable + radiosensitive → RT alone
Unstable + radiosensitive → Surgery for stabilisation + RT

Q: "When would you consider stereotactic body radiotherapy (SBRT)?"

SBRT considerations:

Indication	Rationale
Radioresistant tumour (RCC, melanoma)	Higher doses overcome resistance
Oligometastatic disease	Potentially curative
Re-irradiation	Can treat previously irradiated areas
Post-operative	Better local control after separation surgery

Contraindications:

Spinal cord directly abutting tumour (need separation surgery first)
Multiple contiguous levels
Poor expected survival (<3 months)

Q: "What is separation surgery?"

Separation surgery is a minimally invasive approach:

Goal: Create gap between tumour and spinal cord
Decompress cord circumferentially
Stabilise with instrumentation
Allows safe delivery of SBRT post-operatively
Not attempting gross total resection
Reduces surgical morbidity while enabling high-dose RT

Q: "What is the role of vertebroplasty/kyphoplasty?"

Cement augmentation:

Indication	Use
Painful vertebral metastasis	Pain relief
Prophylactic stabilisation	Prevent collapse
Augment pedicle screws	Improve fixation in poor bone

NOT indicated:

Epidural tumour extension (cord compression risk)
Vertebral body posterior wall breach
Neurological compromise
Infection

For this patient with cord compression, open surgery is required - vertebroplasty alone is contraindicated.

Metastatic Bone Disease
Spinal Tumours
Pathological Fractures
Posterior Spinal Instrumentation
Radiotherapy in Oncology
Palliative Orthopaedics

CIM Case: Spinal Cord Compression - Thoracic Metastasis

Clinical Scenario

Thin, cachectic man
Point tenderness over T10-T11 spinous processes
Lower limb examination:
- Power 4/5 bilateral hip flexors and knee extensors
- Power 3/5 bilateral ankle dorsiflexors
- Increased tone bilaterally
- Brisk knee and ankle reflexes
- Upgoing plantars (Babinski positive) bilaterally
- Sensory level at T10 (reduced sensation below)
Anal tone intact, no saddle anaesthesia
Gait wide-based, uses walking stick

Investigations Provided

Laboratory Results

Test	Result	Normal Range	Interpretation
Hb	105 g/L	130-170 g/L	↓ Anaemia of chronic disease
WCC	9.5 ×10⁹/L	4-11 ×10⁹/L	Normal
Platelets	185 ×10⁹/L	150-400 ×10⁹/L	Normal
CRP	28 mg/L	<5 mg/L	↑ Elevated
ESR	65 mm/hr	<20 mm/hr	↑ Elevated
Calcium	2.45 mmol/L	2.2-2.6 mmol/L	Normal
Phosphate	1.0 mmol/L	0.8-1.5 mmol/L	Normal
ALP	185 U/L	30-120 U/L	↑ Elevated
Albumin	30 g/L	35-50 g/L	↓ Low
PSA	3.2 ng/mL	<4 ng/mL	Normal
Protein electrophoresis	No paraprotein	-	Excludes myeloma
LDH	320 U/L	120-250 U/L	↑ Elevated
Creatinine	95 μmol/L	60-110 μmol/L	Normal

Imaging

Image 1: Thoracic Spine X-ray

Radiological features:

Collapse of T10 vertebral body
Loss of vertebral height anteriorly
Pedicle destruction on AP view ("winking owl" sign)
Increased kyphosis at T10 level
No obvious lytic lesions elsewhere on plain film

Image 2: MRI Thoracic Spine (T1, T2, STIR)

Findings:

T10 vertebral body collapse with posterior retropulsion
Epidural tumour extension causing cord compression
Cord signal change at T10 level (myelomalacia)
T1 hypointense lesion replacing normal marrow signal
Additional lesions at T6 and L2 (not causing cord compression)
Paraspinal soft tissue mass

Image 3: CT Chest/Abdomen/Pelvis (Staging)

Findings:

3.5cm spiculated mass in right upper lobe (primary lung cancer)
Ipsilateral hilar lymphadenopathy
Multiple small pulmonary nodules
No liver metastases
No adrenal metastases
Multiple bone lesions on bone windows

Questions & Model Answers

What is the diagnosis and how urgent is this presentation?

What prognostic scoring systems would you use?

What is the role of surgery versus radiotherapy?

Describe your surgical approach.

What adjuvant treatments are required?

What is the prognosis and how would you counsel this patient?

Key Teaching Points

Pattern Recognition

This pattern suggests Metastatic Spinal Cord Compression:

Older patient with progressive back pain
Constitutional symptoms (weight loss, fatigue)
Smoking history (lung cancer risk)
Progressive neurological symptoms
Upper motor neuron signs (hyperreflexia, Babinski)
Sensory level on examination

Red Flags for Spinal Cord Compression:

New back pain in known malignancy
Progressive weakness (hours to days)
Bladder/bowel dysfunction
Sensory level
Band-like chest/abdominal pain

Critical Management Points

This is an emergency - deteriorating neurology requires urgent action
Dexamethasone 16mg immediately on diagnosis
MRI whole spine - 30% have multiple levels involved
SINS score guides mechanical stability
Tokuhashi score guides prognosis and surgical extent
Surgery + RT superior to RT alone (Patchell trial)
Preserve ambulation - non-ambulatory patients rarely walk again

Common Examiner Follow-ups

Q: "What is the NOMS framework?"

NOMS is a decision framework for metastatic spine disease:

Component	Consideration
Neurological	Degree of cord compression, myelopathy
Oncological	Radiosensitivity, systemic disease control
Mechanical	Stability (SINS score)
Systemic	Medical fitness, expected survival

It guides treatment selection:

High-grade compression + instability → Surgery + RT
Low-grade compression + stable + radiosensitive → RT alone
Unstable + radiosensitive → Surgery for stabilisation + RT

Q: "When would you consider stereotactic body radiotherapy (SBRT)?"

SBRT considerations:

Indication	Rationale
Radioresistant tumour (RCC, melanoma)	Higher doses overcome resistance
Oligometastatic disease	Potentially curative
Re-irradiation	Can treat previously irradiated areas
Post-operative	Better local control after separation surgery

Contraindications:

Spinal cord directly abutting tumour (need separation surgery first)
Multiple contiguous levels
Poor expected survival (<3 months)

Q: "What is separation surgery?"

Separation surgery is a minimally invasive approach:

Goal: Create gap between tumour and spinal cord
Decompress cord circumferentially
Stabilise with instrumentation
Allows safe delivery of SBRT post-operatively
Not attempting gross total resection
Reduces surgical morbidity while enabling high-dose RT

Q: "What is the role of vertebroplasty/kyphoplasty?"

Cement augmentation:

Indication	Use
Painful vertebral metastasis	Pain relief
Prophylactic stabilisation	Prevent collapse
Augment pedicle screws	Improve fixation in poor bone

NOT indicated:

Epidural tumour extension (cord compression risk)
Vertebral body posterior wall breach
Neurological compromise
Infection

For this patient with cord compression, open surgery is required - vertebroplasty alone is contraindicated.

Metastatic Bone Disease
Spinal Tumours
Pathological Fractures
Posterior Spinal Instrumentation
Radiotherapy in Oncology
Palliative Orthopaedics

Spinal Cord Compression - Thoracic Metastasis

CIM Case: Spinal Cord Compression - Thoracic Metastasis

Clinical Scenario

Investigations Provided

Laboratory Results

Imaging

Questions & Model Answers

Key Teaching Points

Pattern Recognition

Critical Management Points

Common Examiner Follow-ups

Related Topics

Spinal Cord Compression - Thoracic Metastasis

CIM Case: Spinal Cord Compression - Thoracic Metastasis

Clinical Scenario

Investigations Provided

Laboratory Results

Imaging

Questions & Model Answers

Key Teaching Points

Pattern Recognition

Critical Management Points

Common Examiner Follow-ups

Related Topics