see also:

• neurology
• neurosurgery
• oncology
• spinal stenosis
• cauda equina syndrome (CES)
• spinal cord syndromes and lesions
• sensory & motor testing including dermatomes, myotomes, reflexes, coordination & balance

• breast carcinoma
• lung carcinoma
• NHL & Hodgkin's lymphoma
• multiple myeloma
• prostate carcinoma

• 65% thoracic, 20% lumbosacral spine, 15% cervical
• May be first sign of neoplasm/ complicate pre-existing disease
• Result from bleeding, infection, fracture
• > 95 % long Hx (weeks ⇒ months) of back pain prior to Dx/other symptoms
• minimal weakness may ⇒ profound, irreversible weakness over hrs ⇒ rapid Rx
• myelopathy symptoms and signs are late findings
  • ⇒ once present, neurological deterioration increasingly rapidly

• continuous, localised back pain, progressive in severity and duration
• pain requiring analgesia
• +/- radicular (bilateral with thoracic spine) as nerve root compressed
• NB: lymphoma deposits may be painless
• myelopathy: 
  • weakness ⇒ complete paralysis
  • decreased sensation
  • urinary retention
  • difficulty walking

• may be subtle/ absent (does not exclude significant SC compression)
• localised spinal tenderness on percussion
• sensory level
• symmetrical weakness + hyporeflexia (very early)
• spasticity + hyperreflexia (later)
• decreased rectal sphincter tone
• abnormal gait

• looking for evidence of the primary tumour

• plain Xrays:
  • show evidence of tumour in 90% of vertebral metastases but now largely replaced by MRI scanning
  • any patient with unexplained persistent, progressive back pain of > 1 month duration, especially if > 50 years of age, known malignancy, persistent, progressive back/neck pain
• emergent MRI or, if MRI not available, CT myelogram

• high dose corticosteroids ⇒ IV dexamethasone ? dose 4mg- 20mg
• immediate neurosurgical consultation
• radiotherapy is definitive treatment for most
• surgical laminectomy and decompression if: architectural instability, tissue confirmation required, max. XRT given, tumor radio-resistant