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.