High index of suspicion in those with known metastatic prostate cancer and corresponding symptoms.
May be due to vertebral collapse or fracture from tumour involvement, or from extradural tumour growth.
Most often thoracic and upper lumbar level.
Clinical evaluation:
- Back pain
- Lower limb paraesthesia
- Bladder or bowel dysfunction and incontinence (or retention)
- Loss of anal tone on examination
- Saddle anaesthesia
Management:
- Immediate steroids – optimal dose undefined, 16 mg IV dexamethasone
- Confirm diagnosis with MRI spine
- Urgent multidisciplinary approach with radiation oncology, spinal surgeons.
- Immediate hormonal deprivation if not already commenced – bilateral orchidectomy vs LHRH antagonist (Firmagon) vs bicalutamide or cyproterone
- Either immediate radiation therapy or surgical decompression depending on fitness of patient, co-morbidities and nature of compression
Longer time to treatment may lead to irreversible morbidity of mobility, lower limb function and continence.