Thursday, October 06, 2022

I remember the first day of my fellowship in oncology many years ago. The day began at 8 a.m. on July 1—God help the patients who chose to get sick on July 1 with the new residents and fellows that day. The program director gave us a brief welcome speech—not very warm, he was a jerk. And the first actual activity of the day was a 60-minute lecture on oncologic emergencies. I think my own program, many years later now, begins in much the same way, though the program director is not a jerk.

There are many emergencies that can occur in oncology, of course, and most of them are not specific to cancer. Cancer patients can develop infections, respiratory distress, cardiac issues—just like anyone else. But there are certain problems that are of particular concern in the realm of oncologic disease. And if one is not aware and does not deal with it promptly and effectively, long-term problems may ensue.

One of these that stands out and I recall and fear to this day is spinal cord compression. The spinal cord is a bundle of nerves that runs down the back through openings in the vertebral column; the bones of the vertebral column normally serve to protect the spinal cord. However, various pathologic conditions or circumstances may compress and put pressure on these nerves at some point along the way. This may develop acutely or gradually.

We, of course, are addressing this issue in the context of a tumor causing the compression. While a primary tumor may rarely be the cause, the vast majority of malignant cord compressions stem from metastases to the vertebrae. Thus, it typically occurs in the setting of a bone metastasis. As a result, there is most commonly bone pain. This pain manifests itself as back pain since it is situated in the vertebral column.

Back pain, particularly low back pain, is so common in the general population as to be almost omnipresent and hardly worth commenting on. Those of us with physically demanding jobs have it worse than others, but everyone has it from time to time. But in the cancer patient, it can be a red flag and a true cause for concern. Therefore, how to distinguish the low back pain of normal life from the catastrophic back pain of spinal cord compression can be a real challenge. This is the kind of issue and question that drives emergency room doctors to distraction, and erring on the side of caution to avoid malpractice suits drives up healthcare costs tremendously but perhaps justifiably.

The presence of neurologic symptoms or signs, such as bowel or urinary dysfunction or the absence of appropriate reflexes, makes concern for a cord compression straightforward. Under such circumstances, a diagnostic work-up is mandatory. But the presence of pain alone without further signs or symptoms? It is one of those uncomfortable situations, like chest pain, where one feels uncertain as to how far to go. While plain X-rays can be helpful, usually the best test for evaluation is an MRI.

As I alluded to in my introduction, malignant spinal cord compression should be managed as an emergency so as to avoid and minimize long-term neurologic deficits. Three forms of treatment are typically utilized. Most acutely, systemic corticosteroids can be administered. This will reduce edema (swelling) and help acutely but is not usually a long-term solution to the problem.

The most common and traditional approach to this problem is external beam radiation therapy, which is generally very effective, particularly when utilized in conjunction with high-dose steroids.

The other alternative is surgery. Surgery may give a better outcome than radiation therapy but may be more difficult for patients. Hence it is reserved for patients with a generally better prognosis from the point of view of their malignancy and who have a better performance status. It is also indicated for those with spinal instability. It would only rarely be used in a patient with a very limited life expectancy. Surgery may sometimes be preferred as well if this is the initial manifestation of the cancer—the patient has no prior history of cancer and the back pain is the first sign of the disease—and no biopsy and tissue diagnosis has yet been made (20% of patients with cord compression); thus the surgery can provide the necessary histologic information as the needed symptomatic relief is provided.

Spinal cord compression occurs at some point in about 5-10% of patients with solid tumors and is associated with a prognosis of less than one year. It is most common with lung, breast or prostate cancer.

Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York.

This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.

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