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Case history

image A 71-year-old man receiving second-line systemic therapy for metastatic renal cancer with known liver and spinal involvement was referred by his community palliative care nurse. He had a 3 week history of progressively worsening low back pain for which he had been taking co-codamol. He denied any history of trauma. For the past 24 h he had also had difficulty walking and climbing stairs at home because of leg weakness. He denied any urinary or faecal incontinence. He attended the assessment unit in a wheelchair.

On examination, he had reduced muscle power in both legs, with the right leg (Medical Research Council [MRC] grade 3) affected more than the left leg (MRC grade 4). He had no saddle anaesthesia and his anal tone was preserved. An urgent MRI scan of his spine demonstrated spinal cord compression at the L1 vertebral level due to a metastatic deposit.

How common is metastatic spinal cord compression (MSCC) in cancer patients?

What clinical features raised suspicion for MSCC in this man?

What investigation and initial management should be offered to someone with suspected MSCC?

What treatment options are available for patients with confirmed MSCC?

What is his expected long-term prognosis?

How common is MSCC in cancer patients?

Approximately 4000 cases of MSCC are diagnosed in England and Wales each year,1 although the number is likely to rise as the incidence of cancer and cancer survival rates increase. Although MSCC may occur in any malignant disease, certain primary sites appear to have a higher association with the condition. The majority of cases of MSCC are in patients with breast, lung and prostate cancer, largely because of the relative prevalence of these cancers.2 MSCC most commonly occurs in people with a pre-existing cancer diagnosis, although retrospective studies have consistently shown that around one in five cases of MSCC occur as a de novo presentation of cancer.3

What clinical features raised suspicion for MSCC in this man?

Our patient had several concerning features for MSCC: he had a history of metastatic cancer, he presented with worsening pain and reduced mobility, and there was objective evidence of motor dysfunction in his lower limbs.

Back pain is the most common symptom of MSCC, presenting in up to 95% of patients.4 The pain is often severe and carries features distinguishing it from mechanical back pain, such as exacerbation by straining (e.g. coughing, sneezing), nocturnal symptoms and pain in the thoracic region. Radicular pain, classically described as being ‘like a band’, is pain that radiates along the sensory distribution (dermatome) of a nerve, because of root compression by the tumour, and is a ‘red flag’ symptom that may be one of the earliest signs of MSCC, especially in cases involving the thoracic spine. It is crucial to recognize the importance of this symptom, as patients often have no ...

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