Oncologic Emergencies – 7 – Back pain
Oncologic Emergencies PART – 7
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Welcome back to our oncology educational series. We had a 3 month break due to corona pandemic, leading to non publication of Gujarat Medical Journal. Last time we discussed Thrombocytosis – high platelet count. What is the next important emergency?
Ans: We discussed following example in our first part of this series:
“Back pain: a case of prostate cancer, treated two years ago with bilateral orchidectomy, with last PSA 0.2 (done 6 months ago), not on any treatment, doing very well otherwise. Now he has significant back pain for 2 days, and possibly some weakness in one leg. Visits a doctor. Prescribes analgesics and advised to return after one week. Develops complete paralysis of both legs over next 3 days. Rushes to his old oncologist – diagnosed spinal cord compression, now with irreversible neurological injury.”
Back pain is a much more common symptom than all the other ones we have discussed so far. And seen by a wide range of practitioners – family doctor, physician, orthopedic, others. Most of the back pain are benign. And yet, some of these patients will have a serious underlying cause.
Que: Agree. We see so many back pain cases. I cannot order an MRI or even xray on every patient.
Ans: True. And yet you cannot miss a cancer, especially at a stage when risk of spinal cord compression is there. This may be first sign of a cancer. Many cancers metastasize to spine, such as lung, breast, thyroid etc. Also multiple myeloma frequently presents with back pain. Following points will help in your practice: screening questions and brief examination. And take hardly few minutes.
- Is this a new back pain or old? Persistent? Severe or mild? Bothering with daily life? Change in pattern of pain recently? History of injury or precipitating factor?
- Associated symptoms? Fever, weight loss, leg weakness or tingling, urinary or other symptoms, pain in other body sites.
- Examination normal? Tenderness? Neurological signs?
A new back pain, without obvious precipitating factor requires some evaluation. More so if it is lasting more than 2-3 weeks, even with some intermittent improvement. And even if it is mild. If patient has come to you, means it is a concern for him/her.
If it is severe, OR associated with other symptoms as noted above in point 2 OR any neurological signs on examination, requires rapid evaluation regardless of duration of pain.
Patient with long standing history of back pain or recurrent similar pattern episodes (which have been evaluated in past) require no or little evaluation. Unless there is a major change in pattern or severity or neurological signs.
Every patient will of course not have cancer. Could be a prolapsed disc too. However with above findings, a significant number of them will have underlying cancer, with potential for spinal cord compression if not diagnosed in time. Hence it is important.
Basic Evaluation should be in form of X-ray (or MRI if you are more concerned based on number of above findings), and screening blood work, at least CBC, ESR, Creatinine. Blood work will help raise concern for myeloma. Also high ESR points towards need for more evaluation.
Que: Thank you for brief history and examination points. If there is no neurological abnormality or leg weakness, how much should we worry about risk of spinal cord compression?
Ans: For patients who fit above criteria on screening history, Even with absence of leg weakness, work up should be done in a matter of days, if not same day. Progression from back pain to paralysis is sudden in many patients. It is not always gradual.
Also, very importantly, recovery from paralysis correlates well with severity of paralysis at time of treatment initiation. Means if we can diagnose and treat before paralysis, it is the best. If patient comes walking, with grade 4 to 5 power, recovery will be generally complete. If he comes in wheelchair, recovery will frequently be incomplete. And if he comes in stretcher, recovery chances are very low. Hence timely evaluation is so important in spine metastases to prevent lifelong paraplegia and for good quality of life.
June 18th 2020. Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com