Spinal Tumors Causing Cord Compression in the Emergency Department Without a Diagnosis: Should We Operate Without Knowing Histology?

Introduction: In spine tumor patients without known histology presenting to the emergency department (ED) with cord compression, we sought to: 1) describe presentation/histology, 2) determine if emergent surgery was indicated, and 3) compare survival to patients with known histology.

Methods: A retrospective, cohort study of patients undergoing spine tumor surgery between 2010-21 was undertaken. Inclusion criteria were: seen in ED without known tumor histology or cancer history. Histology was classified as: radiosensitive (lymphoma, leukemia, small-cell lung, germ cell), radio-intermediate (breast/prostate), and radioresistant (all others). Descriptive/bivariate statistics and Cox regression were performed.

Results: Of the 371 patients undergoing spine tumor surgery, 80(21.6%) presented to the ED without known histology. Mean follow-up was 530.5±738.0 days. While cord compression was seen in all 80(100%) patients, a neurologic deficit was seen in only 43(53.7%). Final pathology revealed: 59(73.7%) radioresistant, 12(15.0%) radio-intermediate, and 9(11.3%) radiosensitive tumors. Notably, 2/80(2.5%) were primary bone tumors. Accepting that radioresistant pathology would need surgery regardless, of the 21 patients with radio-radio-intermediate/radiosensitive pathology, 11/21(52.4%) had a neurologic deficit, necessitating surgery. In 10 patients without a neurologic deficit, the spinal instability neoplastic score (SINS) was stable/indeterminate in 8 patients (10% of sample), in whom surgery could have been avoided. Comparing patients without known histology prior to surgery to those with known histology, multivariable Cox regression showed patients without known histology had shorter overall survival (HR=1.64, 95%CI:1.17–2.30,p=0.004).

Conclusion : Among 80 patients with a spinal tumor causing cord compression without known histology, 26% harbored radiosensitive/radio-intermediate pathology, and 10% were neurologically intact with a stable/intermediate SINS score, meaning they may not have needed surgery. Two patients (3%) had primary bone tumors, foregoing the chance of curative surgery. Not knowing histology prior to surgery was independently associated with shorter overall survival. These results reinforce the importance of knowing histology prior to spine tumor surgery.