Malignant Spinal Cord Compression

Spinal cord compression is a debilitating complication of metastatic cancer identified in 5%-14% of cancer patients (Patchell et al. 2005). Among urologic malignancies, it is most commonly seen with prostate cancer (PCa), which accounts for 9%-24% of cases overall (van der Linden et al. 2005; Flynn and Shipley 1991). In fact, PCa is the second most common cause of malig nant spinal cord compression, with a cumulative incidence of 7% (Manglani et al. 2000; Rosenthal et al. 1992; Sorenson et al. 1990). Although RCC and TCC account for 6 % and 2 % of cases, respectively, PCa, by virtue of its higher incidence and preponderance for vertebral metastases, warrants the bulk of discussion. However, despite a few minor variances, the treatment principles are the same regardless of malignant etiology.

Prostate cancer is the most commonly diagnosed noncutaneous malignancy in American men today and the second most common cause of cancer death (Jemal et al. 2005). Screening through the use of serum prostate-specific antigen (PSA) has led to both stage and risk migration such that the proportion of patients presenting with metastatic disease has fallen from 14.1 % in 1988 to 3.3% in 1998 (Paquette et al. 2002). While distant metastatic disease is now uncommon at presentation, an additional 70% of patients with locally advanced PCa can be expected to develop metastases in follow-up (Coleman 1997). Skeletal metastases are the most common form of extralymphatic disease, and based on venous drainage patterns the bony pelvis and spine often represent the first sites involved.

In addition to significant pain and the potential for pathologic fracture, metastases to the vertebral column may cause spinal cord compression through local growth into the epidural space (Byrne 1992). Direct compression of the spinal cord causes edema, venous congestion, and demyelination, all of which impair neurologic function (Patchell et al. 2005). Prolonged compression eventually leads to infarction of the spinal cord. Without prompt diagnosis and treatment, progressive and irreversible loss of neurologic function will occur. All too often, however, presentation and diagnosis are delayed.

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