Case Report III

( Saturday / April 12th 2014)

Extradural Spine Tumor

Presentant : dr. Marfri Andy
Supervisor : dr. Hj. Yuliarni Syafrita, Sp.S (K)
Moderator : dr. Hendra Permana, Sp.S
Opponents : dr. Mella Berti Adriyani
dr. Daril AL Rasyid

Case Report
A 59 years old female patient was transferred from Internal
Department on March 18th 2014 with ;
Chief complaint : weakness of the lower limbs
Present ilness history :
Weakness of the lower limbs since 8 moths ago. The weakness started
with tingling on the right limb, followed by weakness a few weeks later.
The weakness progressively worsen and followed with the same pattern
on the lefy limb a month later. Since then, the patient cannot stand or
walk by her self and became fully dependent in daily activity. In the last
2 months, the patient started to feel back pain. The pain constant in
one location (above 2 fingers above umbilicus), unrelated to activity,
radiate to other parts of body, aggravated by cough, sneeze and other
movements. In the last 2 weeks, the patient also had difficulities in
urinate.

Past medical hostory :

No history of trauma
No history of infections
No history neoplasm (breast, lung or cervical cancer).

Family history :no history of neoplasms

Social history :
A housewife
Doesnt smoke
Fully dependent in daily activity

General Examinations
General appearance : moderately ill
Level of conciousness : alert
Blood pressure
Heart rate
Respiratory rate
Temperature

: 120/70 mm/Hg
: 76 x/min
: 24 x/min
: 37o

Eye : anemic congjungtiva, no icteric

Lymph nodes : no enlargement
Neck : JVP 5-2 cm H2O, no carotid bruit
Lungs : symmetrical chest wall, normal fremitus, normal
percussion, vesicular, no ronchi or weezing
Heart : no visible apex beat, palpable apex beat at the left
of 5th intercostal space medial to the mid clavicular line, HR
88 x/min, no arryhtmia, no gallop, no murmur
Abdomen : no signs of abdomnial distension, liver and
spleen within normal, timpanic percussion, normal bowel
sounds
Back

: ulcer decubitus at the right (grade 3-4)

Glasgow coma scale : E4 M6 V5 (15)

Meningeal signs : no ruchal rigidity, no brudizinkis, no
kernig sign
Cranial nerves : within normal
Motor system :
Extremities
Upper
Lower

Involunter movement

Right

Left

555

555

Eutonus, Eutrofi

Eutonus, Eutrofi

000

000

Hipotonus,
Diseus Atrpfi

Hipotonus,
Dissus atrofi

Physiological reflexes :
Reflexes

Right

Left

Biceps

++

++

Triceps

++

++

Knee pee reflex

Achiles Pee reflex

Right

Left

Hoffman Tromner

Babinski

Oppenheim

Gordon

Chaddock

Schaefer

Pathological reflexes :
Reflexes

ECG : sinus rhythm, ST depression ( - ), ST elevation

( - ), T inverted ( - ). SV1+RV5 <35mm. Conclusion:
within normal

Laboratory findings
Hb

: 7.3 g/dL

Ht

: 23.4 %

WBCs

: 10.300/mm3

Eritrosit : 2.8 /mm3

Platelets: 506.000/mm3
GDS

: 179 mg/dL

Natrium : 133 mmol/L

Kalium : 3.0 mmol/L
Clorida : 105 mmol/L
Ureu

: 14 mg/dL

Kreatinin

: 0.4 mg/dL

Protein total : 4.9 g/dL

Albumin : 2.3 g/dL

Urinalysis :
Protein

:(+)

Glukosa

:(-)

Leukosit

: 200-250

Eritrosit

: 1-2

Silinder

:(-)

Kristal

:(-)

Epitel

:(+)

Bilirubin

:(-)

Urobilinogen : ( + )

Peripher Blood Smear :

Eritrosit : anisositosis normokrom, hipokrom ( + ),
target cells ( + )
Leukosit

: normal, neutrofilia shift to the right

Trombosit : increased

Diagnosis
Clinical diagnosis : Paraplegia (spinal shock phase)
Topical diagnosis : Spinal cord 8th thoracal vertebrae
Etiology of diagnosis : Spinal cord tumor
Secondary diagnosis :
Ulcer decubitus
Hypochromic micositic anemia

Management
IVFD Aminofusin L600 : Triofusin = 1 : 2 = 8
hours/kolf
High calories and protein diet
Folley catheter
Medication given :
Ceftriaxon 1 x 2 gr (IV)
KSR 2 x 600 mg (PO)
PRC transfusion
Plasbumin 20% : 100 cc

Next Investigation
Laboratory :
SGOT, SGPT
Tumor marker (AFP, CEA)

Post transfusion laboratory examination : Haemoglobin,

hematocrit, white blood counts and trombosit
Radiology :
Chest X-Ray
Thoracic MRI

Follow Up : 2nd day

Subjectives : weakness of the lower limbs
Objectives :
General : alert, moderately ill, BP 120/70 mm/Hg,
HR rate : 82 x/min, RR : 21 x/min, T : 36,8
Neurological examinations :
Cranial nerves : within normal
Motor system : no improvement
Sensory system : bilateral hipestesia at imaginary line 8 th Thoracal
Autonom system : follet cath attached
Physiological reflexes : no improvement
Pathological reflexes : ( - / -)

Assesment :Paraplegia (shock spinal)

Plans :
Laboratory : electrolyte, SGOT, SGPT, tumor markers
Chest X-Ray

Chest X-Ray : CTR < 55 %, no mass and infiltrate.

Conclusion : within normal

Follow Up : 3rd day

Subjectives : weakness of the lower limbs
Objectives :
General : alert, moderately ill, BP 110/70 mm/Hg,
HR rate : 82 x/min, RR : 21 x/min, T : 36,8
Neurological examinations :
Cranial nerves : within normal
Motor system : no improvement
Sensory system : bilateral hipestesia at imaginary line 8th Thoracal
Autonom system : follet cath attached
Physiological reflexes : no improvement
Pathological reflexes : ( - / -)

Assesment :Paraplegia (shock spinal)

Plans : Thoracal Spine X-Ray

Laboratory finding
Natrium

: 133 mmol/L

Kalium : 3.2 mmol/L

Kalsium

: 7.0 mmol/L

Clorida: 105 mmol/L

SGOT : 16 u/l
SGPT : 8 u/l
Tumor markers
AFP

: 0.85

CEA

: 1.64

Follow Up : 4th day

Subjectives : weakness of the lower limbs
Objectives :
General : alert, moderately ill, BP 120/70 mm/Hg,
HR rate : 82 x/min, RR : 21 x/min, T : 36,8
Neurological examinations :
Cranial nerves : within normal
Motor system : no improvement
Sensory system : bilateral hipestesia at imaginary line 8 th Thoracal
Autonom system : follet cath attached
Physiological reflexes : no improvement
Pathological reflexes : ( - / -)

Assesment :Paraplegia (shock spinal)

Thoracal X-Ray : alignment, posterior angulation at 8th thoracic

vertebrae, destruction of 8th thoracal vertebrae corpus and pedicle
Conlusion : Destruction of 8th thoracic vertebrae pedicle.
Advised
for
thoracic
MRI

Follow Up : 7th day

Subjectives : weakness of the lower limbs
Objectives :
General : alert, moderately ill, BP 120/70 mm/Hg,
HR rate : 82 x/min, RR : 21 x/min, T : 36,8
Neurological examinations :
Cranial nerves : within normal
Motor system : no improvement
Sensory system : bilateral hipestesia at imaginary line 8th Thoracal
Autonom system : follet cath attached
Physiological reflexes : no improvement
Pathological reflexes : ( - / -)

Assesment :Paraplegia (shock spinal)

Plans :Thoracic Vertebrae CT

Thoracic Vertebrae CT : destruction of 7th, 8th and 9th

posterior thoracic corpus, extends to intervertebral foramen
with infiltration to the 8th costal

Follow Up : 14th day

Subjectives : weakness of the lower limbs
Objectives :
General : alert, moderately ill, BP 120/70 mm/Hg,
HR rate : 82 x/min, RR : 21 x/min, T : 36,8
Neurological examinations :
Cranial nerves : within normal
Motor system : no improvement
Sensory system : bilateral hipestesia at imaginary line 8th Thoracal
Autonom system : follet cath attached
Physiological reflexes : no improvement
Pathological reflexes : ( - / -)

Assesment :Paraplegia (shock spinal)

Plans : abdominal USG

Abdominal USG : hepatomegaly, spleen, pankreas

and kidney within normal.
Conclusion : Hepatomegaly

The patient ask for discharge

Care planning decision, choices and risks was given (informed)

Discussion
Diagnosis
A 57 years old female with no history of trauma, infections
and neoplasm
The history of present ilness ;
Tingling on the right limb
Progressively worsen weakness, strated on the right limb
followed with the the left side
Back pain ; dull, constant, unrelated to activity, radiate to
other parts of body, aggravated by cough, sneeze and other
movements
Bladder disfunction : difficulities in urinate
Physical examination revealed shock spinal

Further tests and radiological examination that was

taken :
Elevated Alkali Phospatase
SGOT and SGPT were normal
Tumor markers : AFP and CEA were normal
The chest X-ray : normal
Thoracal vertebrae X-ray : destruction of thoracal
vertebrae pedicle (thoracal VIII)
Thoracic vertebrae CT : destruction of posterior thoracal
vertebrae pedicles across Th VII, VIII, IX with infiltration to
the 8th costal (Suggestive extradural spinal cord tumor)
USG Abdomen : hepatomegaly, spleen ,pankreas, and
kidney within normal

The ethiology of the tumor remain unkonwn since theres

no suggestive values or clues (except elevated alkali
phospatse)
from
the
laboratory
and
radiology
examinations.
What is more likely to be considered as differential
diagnosis from the tumor is multiple myeloma. (bone
scanning need to be done).
CRAB :
Calcium elevation ; the breakdown of bone that leads release
of calcium into blood
Renal failure ; due to protein secreted by the malignant cells
Anemia ; tumor infiltration and inhibited red blood production
Bone pain (70 %) ; activated osteoclast that resorb bone

Thank You

 The spinal cord :

Surrounded by though fibrous
covering called the dura.
Located within a bony canal
created by the vertebral
column
Tumors can arise in any of
these spaces and are grouped
according to location.

Spinal tumors :
Extradural
Intradural Extramedullar
Intradural Intramedullar

Source : Brain and Spine Fondation ; a guide for patients and cares, 2002

Spinal Tumor
Extradural :
Well defined root pain
Pain aggravetd by cough, sneeze and spinal movements

Intradural Extramedullar :
Chronic progressive radicular pain
Pain noted especially at night
Myelopathic symptoms as tumor grows

Intradural Intramedullar :
Interruption of crossing fibers leading to sensory deficit
Followed by long tract signs
Subsequent weakness and wasting of muscles in extremities
Source : Brain and Spine Fondation ; a guide for patients and cares, 2002

General Symptoms of Spinal Cord Tumors

Back Pain that progressively worsen, unrelated to activity,
worsen when lting down and may radiate to other parts of
body
Gait disturbance
Decreased pain and temperature sensation
Paralysis/paresis
Scoliosis or other spinal deformity
Erectile dysfunction and or loss of bowel/bladder control
Taken from American Cancer Society. Brain and Spinal Cord Tumors in Adults, Atlanta, 2010.

Metastasis Tumor
Common primary sites :
Breast : 21 %
Lung
: 14 %
Prostate
: 7.5 %
Renal
:5%
GI
:5%
Thyroid : 2.5 %
Level of metastases
Thoracolumbar
Lumbosacral
Cervical

:
: 70 %
: 20 %
: 10 %

Taken from American Cancer Society. Brain and Spinal Cord Tumors in Adults, Atlanta, 2010.

Bone Tumors

Source : www.spineuniverse.com

History :
Age : high level of suspicion
Details of the pain : insidious acute, trauma, radiculopathy, unrelenting,
non mechanical, worse at night, change in features if chronique
Personal history on cancer
Constitutional symptoms
Review of the systems : thyroid, breast, chest, GI, GU and skin
Any age specicic screening tests by GP
Socail history : smoking, alcohol, exposure to carcinogen
Family history of malignancy
Taken from American Cancer Society. Brain and Spinal Cord Tumors in Adults, Atlanta, 2010.

Laboratory :
CBC, ESR, CRP, BUN, Creatinine
Ca, PO4, Alk phos
Urinalysis : routine, Bence-Jones proteins
Special : PSA, thyroid, serum and urine protein, electrophoresis,
liverfunction tests, CEA
Radiological evaluation :
X-ray of spine : AP, lateral, oblique
Bone scan : screening
CT : bony architecture
MRI + gadolinium : gold standard

Options of treatment :
Orthotic
Steroids
Radiotherapy
Chemotherapy
Hormonal therapy
Surgery
Combination

Source : The Diagnosis and Treatment of Metastatic Spinal Tumor

Mark H. Bilsky, Eric Lis, Jeffrey Raizer, Henry Lee and Patrick Boland Oncologist 2011 ;4;459-469

Surgical Intervention
Principles of surgical
treatment :
Estbalish diagnosis
Decompression
Realignment
Stabilization

Source : The Diagnosis and Treatment of Metastatic Spinal Tumor

Mark H. Bilsky, Eric Lis, Jeffrey Raizer, Henry Lee and Patrick Boland Oncologist 2011 ;4;459-469