Differential Diagnosis in Neurology

Topic 6. Radiculopathy

6.6. Epidural and Vertebral Metastasis

  • General features:
    • Metastatic tumor is the most common neoplasm of the intraspinal canal and nerve roots
    • Epidural > leptomeningeal > intraspinal tumor involvement of nerve roots
    • Epidural metastasis occur primarily from direct extension of metastatic vertebral tumors; rare metastasis occur through the intervertebral foramina or by direct metastasis to the epidural space
    • Radiculopathy is secondary to direct compression of the tumor, metabolic and cytokine effects; rarely a pathologic fracture of a vertebra may compress the entire cauda equina
    • Differential diagnosis of vertebral metastasis:
      • Lung
      • Breast
      • Prostate
      • Melanoma
      • Renal cell
      • Sarcoma
      • Multiple myeloma
    • Prostate and colon metastasize to lumbosacral spine
    • Lymphoma has a predilection for paravertebral lymph nodes; wraps around the lumbosacral roots; may also start in the epidural space
    • Most frequent sites of metastasis: thoracic >70%; lumbosacral >20%; cervical 10%
  • Clinical presentation:
    • Local pain is the initial symptom. It is particularly sensitive to mechanical stimuli (fist percussion over the spine)
    • Radicular pain:
      • Thoracic metastasis usually presents with bilateral radicular pain
      • Lumbosacral roots most often have a unilateral presentation
      • HZ may be reactivated at the site of the lesion
      • Motor, sensory and sphincter involvement follow the pain
      • Hyperhidrosis may occur at an upper thoracic T1–T2 level with sympathetic nerve irritation
    • Destroys posterior portion of vertebrae and pedicle
    • Affects nerve roots by continuity
    • Enters the intradural space through the nerve exit foramina
    • Deep boring pain; worse at night
    • Nerve root pain is often a deep ache, constant may have lancinating features
    • Weakness, sensory loss, atrophy, decreased or lost reflexes at the affected level
  • Solitary vertebral collapse:
    • Malignant features by MRI:
      • Ill-defined lesion margin
      • Abnormal signal involvement of the pedicle
      • Heterogeneous enhancement pattern
      • Irregular nodular paravertebral soft tissue lesion
      • Erosion of end plate (malignant)
      • Star burst pattern fracture (traumatic)
    • Clinical Presentation:
      • Destroys posterior portion of vertebrae and pedicle
      • Affect nerve roots by continuity
      • Enter the intradural space through the nerve exit foramina
      • Deep burning pain; worse at night
      • Nerve root pain often a deep ache, constant, may have lancinating fractures
      • Weakness, sensory loss, atrophy, decreased or lost reflexes at the affected level

Prostate Cancer

  • Osteoblastic and clastic bone destruction
  • Multiple levels are involved
  • L4–S1 most frequent levels
  • May metastasize through the perivertebral plexus to the posterior fossa (Batson's plexus)
  • Petrous apex may be affected (posterior fossa; Batson's plexus route of the metastasis)
  • Midline vertebral pain

Ovarian Caner

  • L1–L3 nerve roots > L4–S1 roots
  • Associated with peritoneal implantation
  • Higher incidence of anti-Yo and associated paraneoplastic syndromes
  • Often bilateral

Gastric and Colon Cancer

  • Colon cancer may destroy sacrum and sacral roots
  • Krukenberg metastases (dropped metastases to the ovaries)
  • Associated nonbacterial thrombotic emboli (NBTE) with stroke (adenocarcinoma)
  • Hypercoagulable state

Lung Cancer (Squamous Cell)

  • Multiple vertebral levels are involved
  • Most common metastatic lesion
  • L5–S1 most common level
  • Carcinomatosis of meninges frequently occurs concomitantly
  • Anti-Hu (antineuronal antibodies)

Breast Cancer

  • Multiple vertebral levels are involved
  • May be associated with thoracic meningioma (only in women)
  • Carcinomatosis of the meninges prominent
  • Hematogenous spread
  • May have delayed onset (years after bilateral mastectomy)

Lymphoma (Hodgkin's and non-Hodgkin's)

  • Arise in the epidural space
  • Associated with spinal cord and plexus involvement
  • L1–L3 > than L5–S1 roots
  • Associated paraneoplastic neuropathy (rare anti MA antigens)

Leukemia (CLL and Chronic Myelogenous Leukemia)

  • May affect all lumbar nerve roots
  • May have explosive onset due to hemorrhage
  • Insidious onset with carcinomatosis of the meninges

Malignant Bone Tumors of Lumbosacral Spine

  • Chordoma:
    • Chordomas (excluding plasmacytoma) are the most frequent primary malignant tumor of the spine
    • Occur in elderly men; mean age 54 years
    • Slow course; locally invasive
    • Metastasizes late; local recurrence is usual
    • The most common presenting symptom is severe back pain; painful sacral mass
    • Autonomic dysfunction at presentation (sacral location); impaired bladder and bowel control if S1 and sacral roots are involved
    • Dedifferentiated chordoma may develop at the primary site after X-RT
  • Liposarcoma:
    • Retroperitoneal origin; may be extremely large
    • Most frequent mesenchymal tumor
    • Presents as a palpable abdominal mass
    • May involve L5 and sacral nerve roots
    • Recurrence rate is high
  • Ewing's Sarcoma of Lumbosacral Spine
    • Rare; may arise from the pedicles of L4–L5, L5–S1
    • Greater incidence of bone and cerebral metastases
    • Involves local lumbar and sacral nerve roots
  • Osteosarcoma of the Pelvis
    • Chondroblastic in type
    • Macroscopic tumor emboli found in regional large vessels in a significant number of patients
    • Telangiectatic osteosarcoma may present as sacral mass
    • Familial incidence of Paget's disease and secondary osteogenic sarcoma

Chondrosarcoma

  • Chondrosarcoma most commonly involves the pelvis
  • Increased risks of local recurrence are: the tumor is epicenter, is in the pubis and high grade
  • High rate of metastases occurs with differentiated tumors
  • May enlarge during pregnancy
  • Pain, numbness and lumbosacral root involvement; L1–L2 and L5 pedicle origin; progressive weakness at presentation

Intrinsic Spinal Cord Tumors That Involve the Lumbosacral Roots

  • General Features:
    • Ependymomas (myxopapillary)
    • Neurofibromas of the cauda equina
    • Cauda equina tumors (rare):
      • Hemangioblastomas
      • Paragangliomas
      • Ganglioneuromas
      • Osteoma
      • Plasmacytomas
  • Clinical Presentation:
    • Back pain:
      • Presenting symptom
      • Increases and becomes unrelenting
      • Worse with recumbency
      • Exacerbated at night (burning pain)
      • Motor and sensory symptoms of the affected dermatomes follow pain by weeks or months
    • Cauda equina involvement is signaled by sphincter and sexual dysfunction

Benign CT Features of Acute Vertebral Lesion

  • Cortical fractures of the vertebral body without cortical bone destruction
  • Retropulsion of a bone fragment of the posterior cortex of the vertebral body into the spinal canal
  • Fracture lines within the cancellous bone of the vertebral body
  • Intravertebral vacuum phenomena
  • Thin diffuse paraspinal soft tissue mass

Malignant Features of Spine Lesions by CT and SPECT

  • Posterior portion of the vertebral body involved
  • Concomitant vertebral body and pedicle involvement
  • Extensive abnormalities that involve the vertebral body and vertebral arch but spare the pedicle are benign
  • Destruction of the anterolateral or posterior cortical bone of the vertebral body
  • Destruction of the cancellous bone of the vertebral body

Systemic Disease Affecting Lumbosacral Nerve Roots

  • Diabetes mellitus:
    • Diabetic amyotrophy (femoral nerve or thoracolumbar plexitis)
    • Vasculitis of vasovasorum
    • Clinical features:
      • Patients > 60 years of age
      • Present with pain
      • Neuropathic quality
      • Prominent weakness
      • Concomitant weight loss
      • Thoracoabdominal nerve root involvement
      • Lumbar pattern referred to as diabetic amyotrophy
  • Sarcoid
  • Periarteritis nodosa
    • Proximal L1–L3 nerve roots; all may be affected
  • Meningeal amyloid
  • Acute intermittent porphyria (L5, S1)
  • Coproporphyrinuria
  • Variegate porphyria
  • Mixed connective tissue disease
  • Necrotizing arteritis
  • Collagen vascular disease

Immune Mediated Processes Affecting Lumbosacral Roots

  • AIDP
    • May affect proximal nerve roots
    • May present with apparent radiculopathy (usually L5–S1)
  • CIDP
    • L5–S1 roots may be affected first
    • Multiple sclerosis
      • Affects the dorsal root entry zone at a junction of the central and peripheral myelin
      • More often encountered in familial cases:
    • Autoimmune epitopes:
      • GM1
      • MAG
      • GQ1b
      • GAL-NAc-GDT1a
    • Radiculopathy with increased sed rate (usually at L5)
    • Acute disseminated encephalomyelitis
    • Post vaccination
    • Post viral infection

Infection Affecting Lumbosacral Roots

  • Herpes zoster (lumbosacral, thoracic, cervical)
  • Brucellosis (L5)
  • Lyme's disease (L5)
    • General features:
      • Borrelia burgdorferi (spirochete) is the causative organism
      • Radiculopathy occurs early in the course of the illness; may be associated with cranial neuropathy and meningitis; may be chronic manifestation
        • Single root or asymmetric multiple root involvement
      • Chronic radiculopathy:
        • Presents months after the initial infection
        • Mild motor and sensory loss; not associated with meningitis or VIIth nerve involvement
        • Distal paraesthesia or radicular pain
  • CMV
    • General Features:
      • Affects lumbar and sacral nerve roots
      • HIV patients with CD count < 50 mm3
    • Clinical Presentations:
      • Rapidly progressive cauda equina syndrome
      • Need to rule out:
        • Infection or mass lesions of the conus medullaris
        • Lymphomatous infiltration of nerve roots
        • Syphilis
        • Herpes simplex ( congenital type II; sacral roots)
        • HIV related polyradiculopathy
      • Leg weakness, paresthesias, sphincter dysfunction that progresses to flaccid paralysis
      • Severe low back pain
      • Asymmetric motor and sensory loss of lower lumbar and sacral roots; areflexia
      • Polymorphonuclear pleocytosis with elevated protein; + PCR and viral titers in CSF
      • Gadolinium enhancement of involved roots in 50% of patients
  • Herpes virus 8 (lumbar and thoracic roots)
  • EBV (isolated nerve roots)
  • HIV (L5; sacral roots)
  • Tuberculosis (cold abscess; L1–L3 roots)
  • Syphilis (dorsal root entry zone lesions; pachymeningitis cervicalis > lumbosacral involvement; tabetic pain of thoracic > lumbosacral roots)
  • HTLV1 (cervical cord)

Spinal Epidural Abscess

  • General Features:
    • Thoracic and lumbosacral cord > cervical
    • Chronic lesions occur in the thoracic cord
    • Infecting organisms:
      • Staphylococcus aureus
      • Gram negative rods
      • Anaerobes
      • Mycobacterium
      • Fungus
    • Risk factors:
      • IV drug abuse
      • Spinal surgery
      • Diabetes mellitus
      • Epidural catheters
      • Epidural steroid injection
      • Immunocompromise
  • Clinical features:
    • Onset with severe back pain; delayed from onset of the infection
    • Spinal cord compression syndrome or that of cauda equina involvement
    • Fever, leukocytosis and elevated sed rate
    • MRI demonstrate gadolinium enhancement of involved roots

Miscellaneous Complications that Affect the Lumbosacral Roots

  • Endometriosis:
    • Endometrial tissue adherent to pelvic nerve roots (L5–S5)
    • Catamenial pain with bleeding and irritation of the lumbosacral roots
  • Laparoscopy:
    • L1–L3 roots > L5–S1
  • Epidural catheter trauma:
    • Prolonged exposure to bupivacaine (direct root toxicity)
    • Direct trauma during insertion
  • Arachnoiditis:
    • General Features:
      • Clumped scarred nerve roots in the dural sac (MRI evaluation)
      • Following multiple surgeries or hemorrhage during myelography with pantopaque
    • Myelogram/CT evaluation:
      • Clumped roots centrally
      • Root sleeve cut off
      • Featureless dural sac
    • Clinical Presentations:
      • Severe burning pain in several root distributions > motor weakness
      • Constant; no exacerbating or relieving factors
      • Asymmetric reflex loss
  • Neurenteric cyst (usually asymptomatic)
  • Spina bifida:
    • May be associated with congenital defects of the pedicle and foraminal exit cord
    • Associated with congenital defects of the nerve roots
  • Congenitally enlarged nerve roots: HSMNI and III; rarely CMT2E which may cause myelopathy (compression)
  • Myxopapillary ependymoma:
    • Asymmetric lumbosacral nerve root involvement
    • Lower extremity weakness
    • Bowel, bladder and sexual dysfunction
  • Dropped metastases:
    • Medulloblastoma
    • Lung, breast, gastrointestinal tumor
  • Traumatic nerve root avulsion
    • Usually cervical cord (C5–T1)
    • Severe trauma (motor cycle accidents)
  • Plate fixation screw displacement
  • Demyelinating Polyneuropathy (HSMN I and III)
    • Compression of hypertrophic nerve roots
    • Concomitant compression of the spinal cord
    • Cauda equina dysfunction
  • Hematoma:
    • Epidural in location
    • Anticoagulation
    • Blood dyscrasia
    • Lumbar puncture

Complications of Epidural and Spinal Anesthesia

  • General Features:
    • Toxic effects of anesthetic
    • Direct injury by needle or catheter
    • Subarachnoid injection of medication during epidural procedure
    • Contamination of anesthetic with detergents or chemicals (adhesive arachnoiditis)
    • Epidural abscess
    • Risk of epidural anesthesia increased with:
      • Lumbar spinal stenosis ("pooling") of anesthetic around specific nerve roots
      • Inadvertent subarachnoid injection of high volume of anesthetic
      • Combination of general and epidural anesthesia
      • Advanced age
  • Clinical features:
    • Radicular pain and weakness
    • Lower extremity myoclonus and severe spasm
    • Cauda equina syndrome
    • Usually clears after days to weeks
We do not use cookies on this website