Metastatic spinal disease is
common in patients with
prostate cancer. Spinal metastases may be asymptomatic (identified during
staging) or cause pain and other neurologic signs and symptoms. In approximately
30% of prostate cancer patients, metastatic epidural spinal cord compression is
the initial manifestation of the disease. Unfortunately, a secondary spinal
neoplasm usually represents incurable disease and may herald terminal
progression. As such, surgical management of spinal disease must be consistent
with the overall care of the cancer patient. An integrated palliative care model
generally appliesie, one that combines both life-prolonging and
Dr. Chen has presented a comprehensive review of the current
understanding of the pathophysiology of bony spinal metastasis. He discusses
surgical considerations that reflect his experience and proposes simple
algorithms to assist in clinical decision-making.
A thorough assessment of the patient is essential before making
treatment recommendations. The treating clinician should be familiar with the
patient’s personal values, preferences, and goals, as well as the family’s
goals and the resources available for professional care.
Clinical evaluation is often prompted by a complaint of pain.
Pain without other neurologic symptoms provides a window of opportunity in which
to act to preserve neurologic function. In some circumstances, however, surgical
intervention may be obviated by widespread disease and poor clinical condition.
Tumor growth contributes to mechanical pressure, vascular
compromise, and biochemical changes. Bony destruction may lead to vertebral
collapse, propulsion of fragments into the spinal canal, and narrowing of disc
space. Neural degeneration and secondary central nervous system changes will
progress without treatment.
An organized history should be taken that includes a description
of the temporal course of the pain and progression of other symptoms. Note that
patients may have bladder, bowel, and sexual dysfunction resulting from prior
The character of pain associated with spinal neoplasm varies.
Pain may be somatic nociceptive, neuropathic, or related to secondary
soft-tissue spasms. It can be reported in any part of the column and may be
referred to the trunk or extremities. It may be continuous when the patient is
at rest and markedly aggravated by body movements (incident pain). Pain made
worse by a supine position is typical of epidural compression. Radicular pain
may be paroxysmal, spontaneous, or provoked by movement or sensory stimulation.
Lesions confined to the vertebral body may produce nonradicular referred pain in
characteristic patterns. Valsalva maneuvers may induce or aggravate both local
and radicular pain; Lhermitte’s sign as well as positive tests of dural
traction may be present. As Dr. Chen points out, patients must undergo a
complete neurologic and mechanical examination.
Pain relief should be provided immediately (see "Treatment
and Algorithms" section) and further evaluation considered. In each case,
the "neurologic urgency" of further diagnostic testing is modified by
the potential for treatment, the general condition of the patient, and the
overall prognosis (see Figure 1).
Once the complete history, examination, and diagnostic tests
have been concluded, the treating clinician should correlate the presenting
symptoms with clinicoradiographic evidence. Treatment planning depends on proper
characterization of anatomic involvement (see Table 1).
Treatment and Algorithms
Surgical intervention in spinal disease may relieve pain and
prevent or reverse neurologic dysfunction. The author states clearly that pain
management does not simply involve the provision of anesthetic interventions.
Studies have shown that a comprehensive neurology-based evaluation of cancer
patients with pain will lead to a new diagnosis in the majority of cases. If
the pain specialist does not have neurologic training, the primary physician
will often need the assistance of a qualified neurologic specialist in
evaluating the patient and making treatment decisions.
Skillful use of opioids is mandatory in oncology. The author
notes that caution should be exercised when administering medications via spinal
routes (epidural and intrathecal) to patients with spinal disease. In the
setting of escalating pain, many patients will require rapid titration of an
opioid agonist concurrent with a high-dose bolus of a corticosteroid. Regardless
of the means used, the practitioner should be prepared to titrate opioid to
effect, and this may briefly require high doses, especially in patients with
neurologic involvement. Again, consultation with a neuro-oncologist to
discuss the risks and benefits associated with these approaches is encouraged
before initiating an intervention.
Surgical intervention for metastatic prostate cancer is
considered in the context of the patient’s overall disease status. The median
survival of prostate cancer patients after being diagnosed with epidural
compression by tumor is 6 months, and only 34% survive at least 1 year.
Other antineoplastic and supportive treatments may, at times, precede or
entirely supplant surgical interventions for spinal disease.
Treatment algorithms ought to be evidence based and revised as
new evidence becomes available. Although few studies of quality-of-life issues
have been conducted in this population, pain control should remain a high
priority. The complication rate for spinal surgery can be as high as 30% in
patients who have undergone prior irradiation. It would be helpful for
surgeons to continue to publish their experiences with complications and
complication rates so that we may refine our interdisciplinary decision-making.
A better understanding of the pathophysiology of spinal
metastasis will lead to interventions designed to prevent its complications.
More clinical research is also needed. The spinal radiosurgery approach
discussed by Dr. Chen is an exciting example of the new therapeutic strategies
In summary, a professional team led by the primary physician has
several responsibilities. They include (1) presenting the "big
picture" to the patient and family, (2) interpreting diagnostic test
results and specialist opinions, (3) organizing decision-making with
specialists, (4) recommending a coherent, practical plan to the patient and
family that respects their values and preferences, and (5) coordinating ongoing
professional care. Although this may require more time than can easily be
devoted, we must always strive to give patients and their families the best
compassionate, conscientious care.
1. Flynn DF, Shipley WU: Management of spinal cord compression
secondary to metastatic prostatic carcinoma. Urol Clin North Am 18:145-152,
2. Weinstein SM: Integrating palliative care in oncology. Cancer
Control 8(1):32-35, 2001.
3. Gonzales GR, Elliott KJ, Portenoy RK, et al: The impact of a
comprehensive evaluation in the management of cancer pain. Pain 47(2):141-144,
4. Grant R, Papadopoulos SM, Greenberg HS: Metastatic epidural
spinal cord compression, in Patchell RA (ed): Neurologic Complications of
Systemic Cancer, p 825. Philadelphia, WB Saunders, 1991.
5. Delattre JY, Krol G, Thaler HT, et al: Distribution of brain
metastases. Arch Neurol 45:741-744, 1988.
6. Perrin RG, Janjan NA, Langford LA: Spinal axis metastases, in
Levin VA (ed): Cancer in the Nervous System, p 259. New York, Churchill