Tumours of the spine are uncommon but the consequences of missing the diagnosis are potentially severe. A patient may have metastatic cancer without knowing, and the symptoms and signs don’t necessarily make the diagnosis simple.
A proven important clinical indicator of possible metastatic cancer is previous patient history of a cancer.
As we know, older age is also an association with this condition.
Sorting through presenting symptoms
- Back pain that comes and goes
Fluctuating patterns of pain are unlikely to be malignant and point to non-specific causes, which account for most back-pain complaints. It is the nature of most of these that they will resolve themselves over time. Reassure the patient that it will likely be okay and to keep moving.
Clinical review is a powerful way to confirm the pattern of pain over time and get a handle on what is going on.
- Unrelenting build-up of pain
Pain just gets worse, and no position is comfortable.
If pain is unrelenting, then think about cancer as a potential cause. Localise the pain, percuss the patient identified area, if tender that might indicate where the tumour is located (though the absence of tenderness does not exclude malignancy).
Request a CT scan or MRI of the part that is sore. Note that X-rays are not able to exclude cancers and are of little value in this context.
- Neurological deficit
Loss of nerve or spinal cord function with or without back pain demands further investigation with a scan, preferably MRI but CT can be a starting point.
- History of cancer
It has been shown that the most relevant clinical indicator of a metastatic lesion in the spine is a history of cancer, such as breast disease treated a few years previously.
Weight loss and other constitutional symptoms are not good indicators. Cancer can be present without weight loss, which is really quite a late phenomenon.
Scan results
Almost needless to say, but follow-up scan results quickly.
If the findings are adverse, patients need an early referral and sometimes require admission directly to hospital.
Patient case
I was happy to do an urgent consult for a young woman with severe back pain, impaired walking and loss of bladder control. She came with an MRI organised by her referring GP which showed a tumour compressing the spinal cord.
I arranged for her to be admitted and she had surgery the next day.
Her outcome was good in terms of recovery of function, though she faces a difficult battle with treatment for metastatic breast cancer.
If you come across a scan result like that, then a phone call to your spinal specialist or direct referral to a hospital emergency department would be appropriate.
You may also be interested in
- my article Sinister causes of back pain
- and the Webinar replay: Sinister causes of back pain.
And as always if you have any questions about a patient, please feel free to call me on 02 9650 4893. I will return your call and discuss how we can help.
You can also reach me via ralphstanford@powspine.com.au.
Further Resources for Referrers include:
- Spinal Fusion surgery
- Foot Drop
- Why I only operate when it makes a difference to my patient's quality of life
- The limited role of cortisone injections for spinal conditions
Dr Ralph Stanford is a spinal surgeon with over 20 years’ experience. He is adept in all surgical approaches to successfully treat his patients.
As a teacher Dr Ralph Stanford is Conjoint Senior Lecturer at the UNSW; Supervisor of Training for Orthopaedic Trainees, Prince of Wales Hospital; and Education Secretary for the Spine Society of Australia.
As a researcher and scientist, he is a well-published author and Honorary Senior Scientist at Neuroscience Research Australia (NeuRA). He is also a current member of Spinal PFET.
Posted 2 June 2022
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