Introduction
The Initial symptoms of cancers depend on the type, location and disease duration. But in approximately 20 percent of patients, spinal cord compression by metastatic tumor are the initial manifestation of malignancy. Metastatic spinal tumors can induce pain and potentially irreversible loss of neurologic function. It usually affect lower thoracic or lumbosacral level and can induce symptoms of radiculopathy or myelopathy such as radiating pain, weakness, paraplegia and vesicorectal disturbance. But those affecting the cervical and upper thoracic level are rare. We report a patient who initially diagnosed C8-T1 level radiculopathy by electrodiagnostic study (EDx) and further imaging study revealed hepatocellular carcinoma (HCC) with T1 spinal bone metastasis.
Case presentation
A 65-year-old male presented with left upper extremity radicular pain that occurred 2 months ago. There was no weakness of bilateral upper extremities. He complained tingling sense and hypesthesia on left median cutaneous and medial antebrachial cutaneous nerve dermatome area. Clinically, cervical radiculopathy involving C8-T1 nerve roots or ulnar neuropathy was suspected and Edx was performed. In sensory nerve conduction study, medial antebrachial cutaneous, ulnar and dorsal cutaneous branch of ulnar nerve showed normal response. But it showed reduced amplitude of compound muscle action potential on the left abductor pollicis brevis muscle. In electromyography, there was abnormal spontaneous activity in left abductor pollicis brevis, 1st dorsal interossei muscles and paravertebral T1-T2 level. In conclusion, our EDx findings are compatible with left thoracic radiculopathy mainly T1 level involved. After discussion, We decided to treat him conservatively via medication and physical modality.
But he did not show any improvement, so conducted cervical spine MRI imaging for evaluation of anatomical lesion. In the MRI, mass lesion of T1 vertebral body compressing the left spinal cord was found(Figure 1). This finding was typical finding of tumor metastasis, so we consulted to hemato-oncology department for proper evaluation. They conducted additional study and concluded moderately differentiated hepatocellular carcinoma. Therefore, we made a final diagnosis as T1 radiculopathy due to spinal metastatic lesion of HCC.
Result & Discussion
This patient did not show any systemic symptoms such as weight loss, fever, being excessively tired and so on. Initial manifestation was radiating pain in left upper extremity by T1 metastasis. Early diagnosis of metastatic spinal disease is important because outcome depends on neurologic condition at onset time. Physician should consider the causes of radiculopathy not only intervertebral disk and spinal stenotic lesions but also systemic disease including malignancy, particularly in old age people. Proper use of imaging will greatly assist in screening for tumor and may help distinguish tumor from other spinal pathology.
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