Discussion:
The most common complaint in spinal metastatic cases is pain followed by
weakness, sensory impairment, bladder or bowel
dysfunction2. Spinal metastatic cases may have local,
mechanical referral or neuropathic pain. Local pain has a deep aching
nature, exacerbates while the patient sleeps and improves by
Non-Steroidal Anti-inflammatory drugs. Mechanical pain is due to the
spinal instability. It enhances with changing of position and decrease
with lying down. Neuropathic pain is seen in intradural metastasis and
has a burning quality. Finally, referral pain is a result of neural root
compression caused by the tumor and has a sharp or stabbing nature6.
Sciubba et al. stated that only one type of pain may present in spinal
metastasis6. This is in accordance with our finding,
as our patient had a referral pain to the inguinal L1 dermatome without
any history suggestive of neuropathic or mechanical pain.
As the spine is the third most common place for metastatic involvement,
it is recommended to maintain a high index of suspicion for this
diagnosis when managing patients with a known tumor. A back or neck pain
in those with a known tumor should be considered spinal metastasis until
proven otherwise2.
Our patient had no complaint of cervical or back pain; however, on
examination, a thoracolumbar tenderness hinted the medical team to
evaluate the spinal column. Therefore, this case scenario underscores
the importance of spinal examination in those with a known tumor, in
order not to miss the spinal metastasis in these patients.
Shaohui He et al. reported the local pain and night aggravating pain as
the symptom with most negative and positive predictive value for
diagnosing spinal metastasis respectively5. Our
patient did not complain of a local spinal pain; however, had a local
spinal tenderness in the thoracolumbar area.
Symptomatic spinal metastasis most commonly is seen in thoracic spine
followed by cervical and lumbar vertebrae2, 3. In a
study performed among patients with breast cancers, the least common
spinal metastasis revealed to be thoracolumbar, lumbosacral and sacral
vertebrae7. In our case, the thoracolumbar area (L1)
was involved.
Many studies have demonstrated that symptoms of spinal cord compression
caused by spinal metastasis can be effectively improved by spinal
decompression surgery. Our finding was similar, as our patient’s pain
significantly declined immediately after the surgery. Thus, operative
management not only may provide spinal metastatic cases with a chance of
tumor growth control but also has even more important role in improving
the quality of life in these cases.
As a missed spinal metastasis may lead to spinal cord compression, early
diagnosis has a paramount importance. This study demonstrates that a
spinal metastatic patient needing urgent management may not complain of
a neck/ back pain. Given the relative high possibility of spinal
metastatic involvement, routine examination of vertebral column in
patients with malignancy may help the physician in order not to miss
spinal involvement. However, higher level of evidence with larger sample
size may give a better understanding of the treatment of spinal
metastatic patients.