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Key Features

  • Complication of metastatic solid tumor, lymphoma, or plasma cell myeloma (formerly multiple myeloma)

  • Back pain is most common presenting symptom

  • Prompt diagnosis is essential because once a severe neurologic deficit develops, it is often irreversible

  • Emergent treatment may prevent or potentially reverse paresis and urinary and bowel incontinence

Clinical Findings

  • Back pain (in > 80%) aggravated by lying down, weight bearing, sneezing, coughing

  • Progressive weakness of the lower extremities

  • Sensory loss (usually in the lower extremities)

  • Late findings: bowel and bladder dysfunction progressing to incontinence

Diagnosis

  • MRI with and without contrast

  • Bone radiographs are neither sensitive nor specific for evaluating the cancer patient with back pain

  • Whole-body positron-emission tomography with 18F-2-deoxyglucose may be useful as a screening procedure if back pain symptoms are nonspecific

Treatment

  • Dexamethasone (10–100 mg intravenously followed by 4–6 mg every 6 hours intravenously or orally) should be given immediately to patients with a known cancer diagnosis and epidural impingement on the spinal cord

  • Emergent surgery should be performed in patients without a known diagnosis of cancer to

    • Relieve impingement

    • Obtain a pathologic specimen

  • Preoperative corticosteroids should not be given since they might induce a tumor response and compromise the pathology results

  • Surgical decompression followed by radiation therapy is indicated for patients with a single area of compression due to solid tumors

  • Fractionated radiation therapy is the preferred treatment option if multiple vertebral body levels are involved with cancer

  • Corticosteroids are generally tapered toward the end of radiation therapy

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