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Myeloradiculopathy caused by Metastatic Spinal Cord Compression (MSCC) at

Thoracal Vertebrae Level in a 50-year-old Indonesian Male: A Case Report
Sepalawandika Alfindra1, Ompusunggu Sevline Estethia2

1
Departement of Surgery Hasan Sadikin Hospital
2
Departement of Neurosurgery Hasan Sadikin Hospital

ABSTRACT
Introduction and Importance: The most common site for malignant metastasis in the
musculoskeletal system is the spine. The incidence of metastatic spinal lesion is increasing due
to improvement of metastasis cancer patients’ survival and aging population. Metastatic spinal
cord compression (MSCC) is associated with pain, progressive neurologic decline, and a poor
prognosis.2
Case Report: A 50-year-old Indonesian male came to the emergency department of Dr. Hasan
Sadikin Hospital complaining of weakness of the lower extremities since 5 months ago. The
weakness kept worsening until the patient was not able to stand and walk since 3 months ago.
In the beginning, the patient experienced lower back pain accompanied by numbness radiating
to the toes of both feet. The patient underwent laminectomy tumor resection and posterior
stabilization.
Clinical Discussion: In this patient, sign and symptoms of MSCC preceded the identification
of the primary tumor, which is quite a rare occurrence. Even more exceptional is the rare
primary tumor in this patient, which is malignant lymphoma. The presentation and findings in
this patient are in accordance with literature review of sclerotic bone disease presence in MSCC
of lymphoma.
Conclusion: Multidisciplinary approach in patients with MSCC is associated with optimal care,
which further warrants prompt identification, diagnosis, and consequent treatment. Debilitating
consequences of MSCC should be prevented and treated accordingly to improve quality of life
and preserve function in oncology patients.
Keywords: myeloradiculopathy, metastatic spinal cord compression, case report
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INTRODUCTION
The most common site for malignant metastasis in the musculoskeletal system is the spine. The
incidence of metastatic spinal lesion is increasing due to improvement of metastasis cancer
patients’ survival and aging population.1 Metastatic spinal cord compression (MSCC) is
associated with pain, progressive neurologic decline, and a poor prognosis.2
Incidence of MSCC varies based on primary tumor type. Approximately 61% of MSCC is
caused by primary lung, prostate, or breast cancer, followed by hematologic malignancies.2
MSCC is an oncologic emergency that requires prompt diagnosis and management. Operative
management plays a key role in the management of MSCC to prevent irreversible loss of
motoric and sensory functions. Furthermore, operative management is also a part of palliative
treatment to maintain or improve quality of life and preserve function.1,2
This case report was conducted in line with the SCARE 2020 guideline: updating consensus
Surgical Case Report (SCARE) guidelines.3 Here we present a 50-year-old Indonesian male
myeloradiculopathy caused by MSCC at thoracal vertebrae level treated with laminectomy
tumor resection and posterior stabilization.
CASE REPORT
A 50-year-old Indonesian male came to the emergency department of Dr. Hasan Sadikin
Hospital complaining of weakness of the lower extremities since 5 months ago. The weakness
kept worsening until the patient was not able to stand and walk since 3 months ago. In the
beginning, the patient experienced lower back pain accompanied by numbness radiating to the
toes of both feet. The pain was aggravated by change of position.
Furthermore, the patient also complained of inability to defecate and urinate even though he
felt the need to defecate and urinate. The patient complained of night sweats and weight loss
of 10kg in the last 2 months. History of trauma, fever, and chronic cough were denied.
About 1 month before presentation, the patient went to the nearby hospital where he was
diagnosed with suspected spondylitis based on clinical manifestations and findings on the MRI
thoracal non-contrast. The patient was admitted to the hospital for 5 days and then discharged,
without significant improvement.
Past medical history of the patient did not include any significant personal and family history
of any disease, medication and/or genetic condition. The patient does not smoke.
Physical examination—including vital signs—was within normal limits. Neurological
examination revealed no meningeal signs, with 0 motoric on both lower extremities,
hypoesthesia as high as 6th thoracal, with positive fecal retention, urine catheter functioning
properly, sacral sparing with presence of perianal sensation, voluntary anal contraction, and
great toe extension. Neither pathological nor physiological reflex was found. Atrophy was
observed on both lower extremities, without fasciculation or clonus.
Laboratory examination revealed no abnormalities. On chest x-ray, thoracal kyphotic 11,
Cobb’s angle 16.4 degree, local kyphotic 16.8, and pathological fracture of the 5th thoracal
vertebrae were found. On MRI thoracal non-contrast, findings include isointense extradural
lesion on the 4th to 6th thoracal vertebrae and pathological fracture of the 5th thoracal vertebrae.
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Figure 1. Chest X-Ray of the patient

Figure 2. Thoracal Magnetic Resonance Imaging (MRI) non-contrast of the patient

Based on the Spinal Instability Neoplastic Score (SINS), the patient had a total score of 11,
which is indicative of surgical recommendations. The patient was scheduled for elective
laminectomy tumor resection and posterior stabilization.
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One hour before incision, the patient was administered prophylaxis antibiotic: 2 grams of
Ceftriaxone via intravenous. The surgery was done with the patient in prone position, under
general anaesthesia.
Initial findings include intact bilateral thoracal 4th-6th lamina. Pedicle screw was attached at the
bilateral thoracal 4th and 6th pedicles (thoracal 4th: 2 screws of 4.5x30; thoracal 6th: 2 screws of
4.3x35). Laminectomy was done at the bilateral inferior lamina of thoracal 4th-5th and superior
lamina of thoracal 6th. Then, facetectomy was done at the right superior facet of thoracal 5th.
Duramater was found to be intact, white in color, not tense, without pulsation. Tissue sample
biopsy was taken from the extradural and anterior of thoracal 5th. A 60mm rod was attached to
the bilateral pedicle screws of thoracal 4th and 6th and fixated with 4 nuts. The tissue sample
biopsy was sent for histopathology examination.
After the surgery, the patient stayed in the hospital for 5 days and complained of pain at incision
area. The patient reported no signs of surgical site infection or other digestive symptoms. The
patient was discharged with medications: Cefixime 200mg BID, Omeprazole 20mg BID,
Mefenamic acid 500mg TID.
Further follow-up was done at 8- and 14-days post-surgery at the outpatient department with
adequate wound healing, without any complications. At 1-week postoperative, the
histopathological report of the tissue biopsy revealed malignant lymphoma at the spine, with
differential diagnosis of plasmacytoma. Immunohistochemistry examination of CD138, CD20,
CD3, and KI 67 had not yet been finished when this case report was finalized.

DISCUSSION
Advances in cancer research and care have increased and prolonged the survival of patients
with metastatic disease to the spine. Although the outcome in metastases limited to the skeleton
is generally more favorable, the associated morbidity is still significant, reflected by the need
of radiotherapy or operative management for MSCC in more than 50% of patients.4
Multidisciplinary approach, consisting of oncology, surgery, radiotherapy, rehabilitation, and
palliative services in patients with MSCC is associated with optimal care, which further
warrants prompt identification, diagnosis, and consequent treatment.4
Spinal metastases of solid tumors are typically due to hematogenous spread of malignant cells
to the vertebral body. Extravasation of the circulating tumor cells will form a nidus in the
vertebral body, often spreading posteriorly to involve the pedicles. In general, tumors of the
spine can be classified based on anatomical location of intradural: intramedullary and
extramedullary, and extradural (Figure 3). Up to 90-95% of spinal metastases is extradural:
intravertebral lesion with or without epidural spread.5,6
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Figure 3. Anatomical locations of spine tumor

Increase of the mass size will result in compression of the adjacent epidural venous plexus,
spinal artery, thecal sac, and spinal cord. Moreover, direct extension of the tumor into the
vertebral column or direct tumor deposition can also contribute to the compromised vascular
and bony integrity. Prolonged and untreated compression causes vascular injury which results
in the unsalvageable, infarction of the spinal cord.6
Hematologic malignancies such as multiple myeloma typically presents with soft tissue
extension from lytic bone lesions because of activation of osteoclasts and inhibition of
osteoblasts, while lymphoma often presents with sclerotic bone disease with soft tissue growth
into the epidural space.2
In this patient, sign and symptoms of MSCC preceded the identification of the primary tumor,
which is quite a rare occurrence. Even more exceptional is the rare primary tumor in this patient,
which is malignant lymphoma. The presentation and findings in this patient are in accordance
with literature review of sclerotic bone disease presence in MSCC of lymphoma.
Symptoms of spinal metastases may present as the first clinical manifestation in 12% to 20%
of cancer patients.1 It is typically asymptomatic until complications, including weakening of
the bone, vertebral compression fractures, and MSCC, arise. MSCC is most often found in the
thoracal spine, followed by lumbosacral and cervical spine.2 Spinal metastases consequently
cause the loss of spinal column’s structural integrity. The Spinal Instability Neoplastic Score
(SINS) can be utilized to assess and classify spinal instability and the need of surgical
intervention.7
MSCC most often presents with back pain, motor weakness, sensory deficits, and bowel or
bladder dysfunction. The pain is constant, aching, worse at night or early morning, and may be
aggravated movement that exacerbates spine instability. The pain might progress to radicular
burning pain or referred pain as the disease progresses.2
Deficits of motoric function might be difficult to diagnose in non-ambulatory patients and can
be observed through clumsiness. Lesion in the upper motor neuron is generally symmetric,
whereas lesion in the lower motor neuron is usually asymmetric. Sensory deficits may correlate
poorly with the level of spine lesion. Progression of the disease will result in bowel or bladder
dysfunction.2
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These symptoms should alert treating physicians in suspecting the occurrence of MSCC and
urging spinal imaging. The gold standard in the diagnosis of MSCC is Magnetic Resonance
Imaging (MRI) with a sensitivity of 93% and specificity of 97%. The recommended
examination is MRI of the entire spine, as some patients have multiple, non-contiguous level
of compression. There is also concern that mass and symptoms sometimes do not correlate.
MRI also plays an important role in the planning of surgery and/or radiation therapy. Computed
tomography myelography is recommended only when MRI is contraindicated.2

Figure 4. Management algorithm of metastatic spine disease

CONCLUSION
Multidisciplinary approach in patients with MSCC is associated with optimal care, which
further warrants prompt identification, diagnosis, and consequent treatment. Debilitating
consequences of MSCC should be prevented and treated accordingly to improve quality of life
and preserve function in cancer patients.
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spinal tumors: A narrative review. Asian Spine J 2020;14:513–25.
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Assessment and management of patients with metastatic spinal cord compression: A
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https://doi.org/10.1200/jco.2018.78.1211.
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5. Kumar N, Tan WLB, Wei W, Vellayappan BA. An overview of the tumors affecting
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Br J Hosp Med (Lond) 2020;81:1–10. https://doi.org/10.12968/hmed.2019.0399.
7. Barzilai O, Boriani S, Fisher CG, Sahgal A, Verlaan JJ, Gokaslan ZL, et al. Essential
concepts for the management of metastatic spine disease: What the surgeon should
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FUNDING ACKNOWLEDGEMENT
This research received no specific grant from any funding agency in the public, commercial,
or not-for-profit sectors.

DECLARATION OF CONFLICTING INTEREST

The Authors declare that there is no conflict of interest.

ETHICAL APPROVAL
As it is a case report, ethical approval is not required nor published by our institution.

CONSENT
Written informed consent was obtained from patient about the writing and publication of this
case report. The patient understood well and gave consent. A copy of the written consent is
available for review by the Editor-in-Chief of this journal on request.