Pain and stiffness of the back may antedate signs of spinal cord disease or dominate the clinical picture in some cases of extramedullary tumor. The back pain is usually worse when the patient lies down or may become worse after several hours in the recumbent position and be improved by sitting up. In children, severe back pain associated with spasm of paravertebral muscles is often prominent initially; scoliosis and spastic weakness of the legs come later. Because of this somewhat unusual clinical presentation and the rarity of intraspinal lesions in childhood, spinal cord tumors in this age group may be overlooked.
Sensorimotor spinal tract syndrome The clinical picture is related predominantly to compression and less often to invasion and destruction of spinal cord tracts. The signs of compression consist of a combination of (1) an asymmetrical spastic weakness of the legs with thoracolumbar lesions and of the arms and legs with cervical lesions, (2) a sensory level on the trunk below which perception of pain and temperature is reduced or lost, (3) posterior column signs, and (4) a spastic bladder under weak voluntary control. The onset of the compressive symptoms is usually gradual and the course progressive over a period of weeks and months, frequently with back pain. With extradural tumors, paralysis usually develops over a period of days to several weeks, but the tempo of progression may be more rapid or more leisurely. The initial disturbance may be of motor or sensory function and the distribution may be asymmetrical. High cervical or foramen magnum lesions produce special clinical syndromes, as described in Chap. 3 and below. With thoracic lesions, one leg usually becomes weak and stiff before the other one. Subjective sensory symptoms of the dorsal column type (tingling paresthesias) assume similar distributions. Pain and thermal senses are more likely to be affected than tactile, vibration, and position senses. Nevertheless, the posterior columns are frequently involved as the process progresses. Initially, the sensory disturbance is contralateral to the maximum motor weakness, but a sharply defined Brown-Séquard hemicord syndrome is rarely observed. The bladder and bowel usually become paralyzed coincident with paralysis of the legs. If the compression is relieved, there is recovery from these sensory and motor symptoms, often in the reverse order of their appearance; the first part affected is the last to recover, and sensory symptoms tend to disappear before motor ones.
Radicular-spinal cord syndrome Here the syndrome of spinal cord compression is combined with radicular pain, that is, pain in the distribution of a sensory nerve root. The discomfort is described as knife-like or as a dull ache with superimposed sharp stabs of pain, which radiate in a distal direction, that is, away from the spine, and are intensified by coughing, sneezing, or straining. Segmental sensory changes (paresthesias, impaired perception of pinprick and touch) or motor disturbances (cramp, atrophy, fascicular twitching, and loss of tendon reflexes) and an ache in the spine, in addition to the radicular pain, are the usual manifestations. Tenderness of the spinous processes over the tumor is found by percussion in about half the patients. The segmental changes, particularly the sensory radicular ones, often precede the signs of spinal cord compression by months if the lesion is benign.