2.3.2 Epidural Metastases/Spinal Cord Compression
Epidural metastasis is the most ominous complication of bone metastasis to the
vertebral spine and is a medical emergency. Failure to diagnose and treat this
condition will lead to permanent necrologic deficits due to spinal cord
dysfunction. Early diagnosis, before overt necrologic deficits, should result
in improved outcome (Byrne, 1992). Epidural metastasis is a common complication
in patients with breast, prostate, or lung cancer; multiple myeloma; renal cell
carcinoma; or melanoma. The tumor enters the-epidural space by contiguous
spread from adjacent vertebral metastasis in the vast majority of cases
(Rodriguez and Dinapoli, 1980). Th.html# remaining cases arise from the direct
invasion of retroperitoneal tumor or tumor located in the posterior thorax
through adjacent intervertebral foramina or, rarely, from bloodborne seeding of
the epidural space. The pain is usually midline, but patients whose tumor
involves nerve roots have sharp or shooting pain in a radicular distribution.
Untreated, the pain slowly intensifies with a mean duration of 7 weeks from the
onset of pain to the onset of necrologic deficits due to spinal cord
compression (Gilbert, Kim, and Posner, 1978). Signs of spinal cord compression
include motor, sensory, and autonomic bladder and bowel) dysfunction.
More than 70 percent of patients with spinal cord compression have an abnormal
plain radiograph in the region of pain (compression fracture, plastic, or lyric
metastasis) (Portenoy, Lipton, and Foley, 1987). Because pain is such a
reliable early sign, epidural metastasis can often be diagnosed and treated
before necrologic deficits develop. Patients with persistent back pain in the
region of abnormality on plain spine radiograph, with or without necrologic
deficits, should undergo evaluation with MRI. Patients with progressive back or
neck pain whose plain radiograph is normal should also undergo an imaging study
of the epidural space, even if their necrologic examination is normal.
Administration of analgesics and corticosteroids constitutes the mainstay of
pharmacologic treatment. Radiation therapy or surgical excision followed by
radiation therapy are the two standard treatments.
Common Cancer Pain Syndromes due to Peripheral Nerve Injury
Surgical Management of Pain due to Primary or Metastatic Tumor