Any cancer patient with new-onset back pain or neurologic change requires a thorough evaluation to rule out cord compression. A meticulous neurologic exam is performed to determine the initial spinal level and severity of compression. Interval changes are documented through periodic repeat examinations. A normal neurologic exam does not exclude the presence of impending cord compression. Up to 36 % of patients with back pain and no neurologic deficits will have epidural metastases demonstrated on imaging (Rodichok et al. 1981). MRI is the imaging modality of choice in cases of suspected spinal cord compression (Fig. 13.3) (Mangla-ni et al. 2000; Quinn and DeAngelis 2000). While plain radiography allows a quick assessment of vertebral collapse and deformity, MRI provides an accurate determination of both the degree of compression and the number of cord levels affected. A total of 10 % - 38 % of cases involve multiple noncontiguous levels; therefore, the entire spine must be imaged (Byrne 1992; Helweg-Larsen et al. 1995). The thoracic spine is the most common site of cord compression, and accounts for approximately two-thirds of cases involving PCa (Flynn and Shipley 1991). CT with or without myelography maybe used in cases where MRI is contraindicated or unavailable. Serum PSA and testosterone levels should be measured in cases of PCa to determine the androgen sensitivity of the malignancy.

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