SPINAL CORD COMPRESSION IN PATIENTS WITH UROLOGICAL DISEASE
While cord compression is a relatively uncommon presentation in patients with malignant disease, it can have a devastating impact on quality of life. Urologists should be aware of the presentation and management of cord compression, particularly since prostate cancer is the second most common cause of malignant spinal cord compression. Local extension of a vertebral metastasis compresses the spinal cord, leading to venous obstruction and oedema (at this stage, steroids can decrease the oedema and reverse the neurological symptoms and prevent further progression). The majority of cases involve the thoracic or lumbar spine; the cervical spine is infrequently involved.
All too often patients with spinal cord compression have warning symptoms and signs, the significance of which is not appreciated until irreversible damage to the spinal cord has occurred. Patients are then condemned to spend their remaining
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months of life in a wheelchair. In a recent review of 24 patients presenting with cord compression due to metastatic prostate cancer (Tazi et al. 2003), 79% had thoracic or lumbar back pain severe enough to require opiate pain relief, on average for 60 days (and ranging from 10 to 840 days) before they finally presented with neurological symptoms such as paralysis. Occasionally cord compression is the first presenting event in a patient with metastatic prostate cancer.
Back pain is the most common early presenting symptom. It is usually gradual in onset and progresses slowly but relentlessly. The pain may be localised to the area of vertebral metastasis, but may also involve adjacent spinal nerve roots, causing radicular pain. Interscapular pain that wakes the patient at night is characteristic of a metastatic deposit. Associated symptoms suggestive of a neurological cause for the pain include pins and needles, weakness in the arms (cervical cord) or legs (lumbosacral spine), urinary symptoms such as hesitancy and a poor urinary flow, constipation, loss of erections, and seemingly bizarre symptoms such as loss of sensation of orgasm or absent ejaculation. From time to time the patient may present in urinary retention. It is all too easy to assume that this is due to malignant prostatic obstruction if other neurological symptoms and signs are not sought.