Rosen & Barkin's 5-Minute Emergency Medicine Consult (737 page)

• Chest radiograph:
  
  • Spinal cord compression:
    
    • May identify a primary lung tumor
      
    • Helpful in excluding tuberculous spondylitis
      
  • SVC compression:
    
    • Mass present in 10%
      
    • Pleural effusion in 25%
      
    • Plain spinal radiography
      
  • Will show 85% of metastases causing compression
    
  • A normal spine (or 1 showing just degenerative changes) on plain radiology does not exclude the diagnosis of possible cord compression.
    
• CT:
  
  • Contrast CT is more sensitive and specific than plain radiography and radionucleotide imaging in distinguishing benign from malignant disease in spinal compression syndrome
    
  • May identify mass and impingement in vena cava obstruction
    
• MRI:
  
  • Study of choice for spinal cord compression
    
  • Indicated in patients with back or neck pain and:
    
    • History of cancer
      
    • Bowel or bladder dysfunction
      
    • Lower extremity weakness
      
    • Sensory loss
      
    • Saddle anesthesia
      

• CT myelography:
  
  • Indicated for spinal cord compression when MRI is unavailable or contraindicated (pacemaker, metallic implants, severe claustrophobia)
    
• Minimally invasive techniques can often be used to establish a tissue diagnosis in cases of SVC syndrome.
  
• Occasionally an invasive procedure is required to obtain a tumor biopsy in patients with SVC syndrome:
  
  • Bronchoscopy
    
  • Mediastinoscopy
    
  • Scalene node biopsy
    
  • Limited thoracotomy
    
  • Video-assisted thoracic surgery (VATS)
    
• Radiation therapy (RT) can be done to shrink the tumor:
  
  • Should be done after tissue diagnosis is made, as RT can obscure tissue and make definitive diagnosis difficult.
    
• Endovascular stents can be used to achieve more rapid relief than can be achieved using RT.
  

• Amyotrophic lateral sclerosis
  
• Arteriovenous malformations
  
• Epidural abscess
  
• Intervertebral disk disease
  
• Multiple sclerosis
  
• Neurologic diseases
  
• Osteoporotic vertebral fractures
  
• Primary bone tumors
  
• Spinal infarction
  
• Spondylitis
  
• Spondylosis
  
• Transverse myelitis
  

• Pericardial tamponade
  
• Nephrotic syndrome
  
• Cor pulmonale
  
• Cirrhosis
  
• Nonmalignant etiologies of SVC syndrome:
  
  • Goiter
    
  • Pericardial constriction
    
  • Primary thrombosis
    
  • Idiopathic sclerosing aortitis
    
  • Tuberculous mediastinitis
    
  • Fibrosing mediastinitis
    
  • Histoplasmosis
    
  • Indwelling central venous catheters
    

TREATMENT

• Early diagnosis and treatment are the keys to an improved outcome.
  
• Level of neurologic dysfunction on presentation is a key factor in the prognosis for spinal cord compression.
  
• Avoid IV line placement in upper extremities if severe SVC compression is present.
  

• Corticosteroids (dexamethasone):
  
  • Administer in ED.
    
  • Higher doses alleviate the pain more rapidly, but studies indicate no significant difference in outcome with regard to sphincter function or ambulation between the dose schedules.
    
• Radiotherapy:
  
  • Definitive treatment modality
    
  • Pain medication with narcotics
    
  • Oncology, radiotherapy, and neurosurgical consultation for further management of tumor/malignancy
    
  • Consider empiric broad-spectrum antibiotics prior to the MRI if an epidural abscess is being considered.
    
• Urgent neurosurgical consultation
  

• Manage the underlying malignancy with either radiotherapy or chemotherapy.
  
• Elevation of the head of the bed.
  
• Supplemental oxygen
  
• Administer steroids if there is respiratory compromise
  
• Judicious use of diuretics may transiently improve symptoms, but there is poor evidence to support efficacy.
  
• Urgent oncology referral
  
• Intravascular stents can relieve the obstruction more rapidly.
  

• For ESCC there is limited evidence suggesting steroids are beneficial, but it is still generally considered to be part of the standard regimen of treatment
  
• For paresis or paraplegia high dose dexamethasone: 1 mg/kg loading dose, then halve the dose every 3 days
  
• For patients with minimal neurologic dysfunction dexamethasone 10 mg followed by 16 mg daily initially in divided doses with a gradual taper once definitive treatment is underway
  
• For SVC syndrome steroids can reverse symptoms from steroid responsive malignancies such as lymphoma or thymoma.
  
• In patients undergoing RT steroids are often prescribed to prevent swelling
  
• Furosemide (Lasix): No prior use—40 mg IVP; prior use—double 24 hr dose (80–180 mg IV)
  
• Hydrocodone/acetaminophen: 5/500 mg PO q4–6h
  
• Oxycodone/acetaminophen: 5/500 mg PO q4–6h
  

FOLLOW-UP

• Admission is advisable for all patients presenting with a tumor compression syndrome.
  
• Transfer to a center with neurosurgical capabilities may be needed for patients with spinal cord compression.
  

None

• Radiation oncology should be consulted for patients presenting with tumor compression.
  
• Early neurosurgical consultation for patients with spinal cord compression
  

• Average life expectancy among patients who present with malignancy-associated SVC syndrome is ∼6 mo.
  
• Presentations may be subtle and compression syndromes should always be considered in patients with known malignancy and unexplained complaints.
  

• Cole JS, Patchell RA. Metastatic epidural spinal cord compression.
  Lancet Neurol
  . 2008;7(5):459–466.
  
• Graham PH, Capp A, Delaney G, et al. A pilot randomized comparison of dexamethasone 96 mg vs 16 mg per day for malignant spinal-cord compression treated by radiotherapy: TROG 01.05 Superdex study.
  Clin Oncol (R Coll Radiol)
  . 2006;18:70–76.
  
• Lanciego C, Pangua C, Chacón JI, et al. Endovascular stenting as the first step in the overall management of malignant superior vena cava syndrome.
  AJR Am J Roentgenol
  . 2009;193(2):549–558.
  
• Loblaw DA, Mitera G, Ford M, et al. A 2011 updated systematic review and clinical practice guideline for the management of malignant extradural spinal cord compression.
  Int J Radiat Oncol Biol Phys
  . 2012;84(2):312–317.
  
• Wilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes.
  N Engl J Med
  . 2007;356:1862–1869.
  

CODES

• 239.9 Neoplasm of unspecified nature, site unspecified
  
• 336.9 Unspecified disease of spinal cord
  
• 459.2 Compression of vein
  

BASICS

Perforations can be classified in several ways:

• Duration:
  
  • Acute (<3 mo)
    
  • Chronic (>3 mo)
    
• Site:
  
  • Pars tensa
    
  • Pars flaccida
    
• Extent:
  
  • Limited to 1 quadrant (<25%)
    
  • 2 or more quadrants
    
  • Total perforation
    

• Infection (acute otitis media):
  
  • Most common cause of an acute perforation
    
• Blunt trauma (slap to the ear):
  
  • Domestic violence, street fight
    
• Penetrating trauma (Q-tip)
  
• Extrusion of tympanostomy tubes
  
• Rapid pressure change (diving, flying):
  
  • Rupture usually occurs between 100 and 400 mm Hg (at a depth of 2.6 ft, there is a pressure differential of 60 mm Hg)
    
• Extreme noise (blast)
  
• Lightning
  
• Acute necrotic myringitis (β-hemolytic streptococcus)
  
• Slag burns (welding or metalworking)
  
• Complications of surgical procedures:
  
  • Myringotomy, tympanoplasty, tympanostomy tube insertion