While it is most common in the late stages of cancer, it can be the first manifestation of malignant disease. Malignant spinal cord and/or cauda equina compression is a relatively common complication of malignancy. Staging work-up was completed with a PET-CT, confirming large osseous destructive mass at T8 level ( Figure 7). Bone marrow aspiration and biopsy revealed plasma cell myeloma comprising 40% of marrow cellularity ( Figures 5 and 6).
#OLD T8 COMPRESSION FRACTURE TREATMENT FREE#
Further work-up revealed abnormal serum protein electrophoresis with a 3.53 g/dL monoclonal serum paraprotein, abnormal serum immunoglobulins (Ig 5365 mg/dl IgA, 23 mg/dL IgM, 11 mg/dL), abnormal free light chains (λ free light chain, 14.6 mg/L λ free light chain, 146.2 mg/L ratio, 0.1), and abnormal λ-2 microglobulin of 4.9 mg/L. A CT-guided biopsy of this large destructive mass revealed sheets of plasma cells ( Figures 3 and 4). Further evaluation with an MRI of the thoracic spine confirmed the T8 compression and associated soft-tissue mass causing moderate-to-severe central spinal stenosis ( Figure 2). He next saw his primary care provider, and a CT scan of his chest revealed a soft tissue mass measuring 6.2 x 3.5 x 2.8 cm in the posterior mediastinum/posterior chest wall with involvement of the posterior eighth rib and adjacent T8 vertebral body, with extension into the right aspect of the spinal canal ( Figure 1). During all this time he did not notice any extremity weakness or bladder or bowel incontinence, but he eighth area. He thought he pulled a muscle and saw a chiropractor, but he received no relief despite 5 chiropractic treatment sessions. While it was initially a sharp pain, it transformed into a dull continuous ache radiating to his right rib and right hemithorax. CaseĪ man aged 65 years presented with right-sided lower thoracic back pain of 1-month duration it was brought upon by pushing a sliding door in his garage. Identifying the patients who would most benefit from what initial approach-surgical, radiation, or medical treatment-is the most crucial part of appropriate management. The introduction of new spinal instrumentations and surgical approaches, along with advances in radiation and medical oncology treatments, has considerably improved the extent of therapeutic options, resulting in better outcomes. Regardless of the tumor histology causing the spinal cord compression, the 3 most widely utilized treatment modalities have been surgery, radiation therapy (RT), and the administration of glucocorticoids, with or without systemic anticancer therapy. Appropriate treatment of malignant spinal cord compression is complex and requires a multidisciplinary team approach. With prolonged compression, permanent neurological damage occurs. Initially, this causes reversible edema, venous congestion, and demyelination, followed by vascular injury and cord necrosis. 3-5 Direct tumor extension into the vertebral column or the collapse of a vertebral body that contains metastatic disease can lead to the compression of the spinal cord. The spinal cord compression may present as a primary tumor (solitary plasmacytoma) or as part of the systemic involvement of multiple myeloma. 2 Multiple myeloma is among the most common hematological malignancies leading to this complication. 1 Metastases to the spine occur most commonly in patients with breast, prostate, and lung cancer, followed by those with renal, gastrointestinal, and thyroid cancer and malignant melanoma. The true incidence of malignant spinal cord compression is not known, but the estimate is about 15% in patients with advanced cancer. Spinal vertebral bone involvement with or without neurological deterioration can occur as a skeletal-related event in various cancers. We discuss the case of a previously healthy man, aged 65 years, who presented with back pain and a large T8 spinal mass, leading to a diagnosis of multiple myeloma with spinal cord compromise. With the advances in surgical, radiation, and medical oncology approaches, the outcomes of patients with malignant spinal cord compression continue to improve. This complication occurs in 5% to 10% of patients with malignancy, often at the end stages of the patient’s illness however, it can be the presenting manifestation of malignancy in up to 23% of patients. Early recognition of the signs and symptoms permit diagnosis prior to the development of irreversible neurological damage. ABSTRACT: Spinal cord compression is a potentially devastating consequence of cancer.
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