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INTRODUCTION

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The spine is the commonest site of pain due to instability skeletal metastasis [1] and prostate cancer is one of the most common tumours to metastasize to bone. Spinal metastasis causes a spectrum of clinical presentations from pain due to instability and fracture to neurological compromise [epidural and spinal cord compression (ESCC)]. In prostate cancer, ESCC is much more common than pathological fracture. ESCC is in itself not fatal; nevertheless, incapacitating pain and subsequent neurological compromise, such as paraplegia and loss of sphincter control have major social and clinical implications. Complete loss of neurological function is irretrievable and, therefore, prevention of ESCC is desirable whenever possible. Although the average survival for prostate cancer patients after a diagnosis of metastatic spinal cord compression is only 5 months [2], the morbidity of metastatic spinal disease is such that an aggressive approach to management is justified. The aims of this chapter are to review the current management of metastatic prostate cancer to the spine.

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TREATMENT STRATEGIES FOR SPINAL CORD COMPRESSION

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PATHOANATOMY

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At post mortem the incidence of prostate carcinoma histologically is 24–46% in men over 50 years of age. Metastatsis most commonly occurs to lymph nodes but bone is the second commonest site [3] and is seen in up to 84% of cases at post-mortem [4–7]. The spine is the most commonly involved site for bone metastasis. Within the spine the commonest site is the vertebral bodies of the thoracic and lumbar regions, which reflects the greater volume of bone in the vertebral bodies, their anatomical relationship to the prostate and Batson’s valveless vertebral venous plexus, which drains directly from the pelvis to the spine. The commonest site of symptomatic neural compression is the thoracic region (67%), with 27% in the lumbar spine and 6% in the cervical spine [8, 9], in part reflecting the narrower volume of the spinal canal in the thoracic spine.

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Ninety per cent of prostatic spinal metastases are osteoblastic [10]. Spinal deformity is therefore unusual, although epidural compression is not uncommon, being the initial sign of malignancy in 36% of patients with epidural metastasis [11]. By contrast, the majority of spinal metastases from other primary tumours are osteolytic. Osteolytic metastases weaken bone resulting in pathological fracture with the potential for neurological compromise as a result of bony compression rather than tumour compression. Understanding this fundamental difference between the modes of presentation for prostate cancer and metastasis from other primaries is vital for the recognition of why epidural and spinal cord compression is significantly more common in prostate cancer than spinal instability at presentation.

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CLINICAL FEATURES

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The Patient
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The problems of spinal metastases and, in particular, imminent neural compromise in patients with prostatic carcinoma should not override an overall appreciation of ...

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