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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.78 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.395 The 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.176 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).378 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.
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