Patients will typically present with a combination of back pain, radiculopathy, or myelopathy. The typical presentation of these lesions is back pain with a varying degree of neurological deficit related to compression of the neural elements.[8][9] The patient with metastatic disease will give a history of weight loss, general malaise, night sweats, or a history of cancer. The patient with a CES will give a history of back pain with radicular symptoms depending on the level of compression. The patient with a CMS will give a history of back pain with myelopathic symptoms. The patients may only complain of the slow onset of numbness or tingling in the lower extremities which can progress over some time. The most common sensory deficit is “saddle anesthesia” where the patients will complain of decreased sensation in the perineal and perianal areas. A varying degree of upper or lower motor neuron findings may also be present as well as bowel/bladder incontinence. The anal sphincter tone is diminished. Deep tendon reflexes may be diminished in the lower extremities but a lesion in the cauda will only have the Achilles tendon involved while those with a conus lesion will also have the patellar knee reflex involved. The diagnosis may be delayed due to the slow onset of neurological symptoms. Many lesions in the conus will present with similar history and physical exam as those in the cauda because the nerve roots compressed in the cauda originate from the conus area. Sexual dysfunction can be present in some patients. 

Features distinguishing CES from CMS are described below:

• Onset: gradual and asymmetric in CES; sudden and bilateral in CMS
• Pain: severe and radicular in CES; rare and bilateral perineum/thighs
• Sensory: saddle anesthesia on both. asymmetric in CES; symmetric in CMS
• Motor: marked and asymmetric in CES, not marked and symmetric in CMS
• Reflex: only ankle jerk absent in CES; ankle jerk & knee jerk may be absent in CMS
• Autonomic: bladder dysfunction and impotency later in CES; bladder dysfunction and impotency early in CMS

The evaluation of a patient with back pain without neurological deficit should be conservative as long as there are no significant risk factors, however, should risk factors exist then an evaluation with neuroimaging should be initiated. If the patient presents with a neurological deficit or bowel/bladder incontinence, then magnetic resonance imaging (MRI) with and without contrast should be obtained to identify any possible mass lesions. The MRI is the gold standard for the evaluation of nontraumatic spinal lesions. If a metastatic mass lesion is suspected, then an appropriate workup would include a computed tomographic (CT) scan of the chest, abdomen, and pelvis or a full-body PET scan to evaluate for any primary malignancy. Lumbar radiographs may show pathological fractures, destroyed pedicles, angulation, or enlarged neural foramina. When necessary, a lumbosacral CT scan is performed to visualize the bony anatomy of the spine.

Anti-inflammatory agents and steroids can be effective in patients with inflammatory processes and tumors.

Surgical indications are aimed at decompression of the neural elements, gross total tumor resection if possible, and stabilization of the spine should there be any instability. As always, a multidisciplinary approach is best to determine the appropriate treatment based on long term prognosis as well as other indicated systemic treatments. Schwannoma and meningioma lesions usually are benign.[10][11][12] If schwannoma or meningioma is suspected and the patient is asymptomatic, observation is usually appropriate if the lesion is small. However, should there be a large lesion or neurological symptoms, then surgical resection for decompression and gross total resection should be attempted. For malignant tumors, radiation or chemotherapy options are used. For astrocytoma or ependymoma, initial surgical resection for decompression and gross total resection is recommended. The role of chemotherapy and radiation and the timing of such treatments is still controversial. The indications for radiation or chemotherapy do depend on tumor type, histological grade, and degree of resection. For intramedullary metastatic lesions, the indications for surgery, radiation, and chemotherapy are more complex and depend heavily on a multidisciplinary approach.[13] Gross total resection is very difficult to obtain and very often worsening of neurological deficits is produced if attempted. The treatment of a patient with metastatic disease always should include systemic control of the disease if possible. If a primary lesion is known, surgery is usually not performed to avoid the worsening of deficits. Is there is not a known primary, a biopsy is warranted.

Prophylaxis for deep venous thrombosis and/or pulmonary embolism should be started in the perioperative period.

Astrocytoma

Ependymoma 

Myxopapillary ependymoma

Metastases

Herniated disc

Transverse myelitis

Spinal arteriovenous malformation

Spinal cord infarct

Multiple sclerosis

Diabetic Neuropathy

Guillain-Barré Syndrome

Amyotrophic lateral sclerosis

Sarcoidosis

Prognosis will depend on the pathology and the preoperative neurological deficits. The timing of surgical decompression is a significant factor in the prognosis and outcome; where the best results are obtained when surgery is done within the first 48 hours after the presentation of symptoms.[14] Some reports give the benefits until the 72-hour mark. Bladder dysfunction has a negative prognostic factor for poor outcome.[15][16] The return of bladder function is estimated to occur in approximately 50% of CES patients.

Neurological deficit (mild weakness to paraplegia)

Urinary incontinence/retention

Fecal incontinence

Sexual dysfunction

Saddle anesthesia

Radicular pain

Postoperative worsening  or new neurological deficits, infections, and cerebrospinal fluid leak

Neurosurgeon

Neurologist

Neuro oncologist

Radiation oncologist

Physical medicine and rehabilitation

Psychologist

Psychiatry

Pain specialist

Neuropathologist

The patient should be oriented about the diagnosis and management, so he can do informed decisions that will ultimately influence the outcome. After the pathology is obtained, the patient should be informed about the result and the possibility of further treatments with radiotherapy and chemotherapy. The patient needs education to cope with persistent deficits. An interprofessional team is necessary to maximize the medical, physical, psychological, educational, vocational, and social functions of the patient and improve outcomes.

Because the diagnosis and management of these patients is challenging, the patient should be managed by an interprofessional team that includes a neurosurgeon, neuropathologist, neuroradiologist, hematologist-oncologist, radiation oncologist, and pain specialist. The outcomes for patients with spinal cord tumors depend on many factors including age, comorbidities, the extent of resection, tumor spread, neurological deficits, and the pathology. Overall, the prognosis for most patients is guarded.[10][13][17]