惡性脊髓壓迫

Buzzwords → Dx

Diagnostic Criteria

• Clinical: new back pain + motor / sensory / autonomic dysfunction in cancer patient.
• MRI whole spine with contrast (or CT myelogram if MRI contraindicated) — confirms compression + identifies all levels.
• Pre-treatment functional status (ambulatory vs non-ambulatory) = strongest prognostic factor.

Workup

• Detailed neuro exam (motor, sensory, reflexes, sphincter tone, post-void residual).
• MRI whole spine + contrast within hours of suspicion.
• CBC + CMP + coag + type & screen if surgical candidate.
• Tumor markers / staging workup if cancer dx not established.
• Functional assessment (Karnofsky / ECOG, ambulatory status, life expectancy).

Treatment Algorithm

flowchart TD
  A[Suspected MSCC] --> B[Dexamethasone 10 mg IV bolus<br>then 4 mg q6h<br>do NOT delay for imaging]
  B --> C[MRI whole spine STAT]
  C --> D[Confirm compression]
  D --> E{Surgical candidate?<br>single-level + LE >3 mo + good PS}
  E -- yes --> F[Surgical decompression + stabilization<br>followed by post-op RT 30 Gy / 10 fx]
  E -- no --> G[Radiation alone 30 Gy / 10 fx<br>or 8 Gy single fraction if poor prognosis]
  E -- radiosensitive (lymphoma, MM, germ cell) + neurologically stable --> H[RT alone often sufficient<br>± systemic therapy]
  F --> I[Post-Tx: monitor function<br>treat post-RT pain flare with dex / opioids]
  G --> I
  H --> I
  I --> J[Treat underlying cancer<br>palliative or curative per primary]

Pearls / Pitfalls

• Don't delay dexamethasone for imaging — start steroids on clinical suspicion. Reduces edema + may preserve neurologic function.
• MRI whole spine is mandatory — 30 % of MSCC have multiple noncontiguous lesions. Don't just MRI the symptomatic level.
• Patchell trial (Lancet 2005): surgical decompression + RT > RT alone for pts with single-area cord compression, ambulatory at baseline, life expectancy >3 mo, treated within 48 h. Best for pts who can tolerate surgery.
• Pre-treatment ambulatory status is the strongest prognostic factor — get to treatment before weakness sets in.
• Radiosensitive tumors (lymphoma, MM, germ cell, small cell): RT alone often sufficient.
• Radioresistant (renal cell, melanoma, sarcoma): higher likelihood of needing surgery.
• Vertebroplasty / kyphoplasty — for vertebral fracture / pain WITHOUT cord compression, not for MSCC.
• Cauda equina syndrome (below L1): saddle anesthesia + bladder retention + bowel dysfunction. Same urgency.
• Post-RT pain flare in 2–7 d: pre-medicate with dexamethasone or higher-dose during course.
• MM with cord compression can sometimes resolve with chemo + dexamethasone alone (radiosensitive) — but RT often given for symptomatic relief.
• Lymphoma cord compression often very responsive to chemotherapy — discuss with heme/onc and rad-onc.
• Lifetime cumulative spinal cord RT dose (~50 Gy) — re-irradiation possible but limited.
• Steroid-responsive cord syndrome vs MSCC: epidural lipomatosis, transverse myelitis, infection — biopsy / culture if doubt.

Cross-references

• MM — common cause of MSCC
• Hypercalcemia — co-occurring in MM
• DLBCL — radiosensitive cord lesions
• Pain — opioid + dexamethasone
• Drug Regimens — dexamethasone dosing

相關題目

• Q-184 — Cord compression — initial management
• Q-185 — Cord compression — Patchell trial
• Q-186 — Cord compression — radiosensitive lymphoma

Sources