History and exam
Key diagnostic factors
common
known cancer diagnosis
Back pain or neurological symptoms in a patient with a known cancer diagnosis should elicit a high degree of suspicion of MSCC. Prostate, lung, breast, renal, and thyroid cancers have been particularly associated with MSCC, but any systemic cancer can metastasise to the spine.[7] Other common cancers associated with MSCC include non-Hodgkin's lymphoma, neuroblastoma, myeloma, soft-tissue sarcoma, and high-grade meningioma.[12][13][14]
≥40 years of age
Malignancy involving the spine is a common cause of spinal cord compression in this age group.[17]
back pain
Back pain is the most common first symptom of spinal metastases, occurring in around 95% of patients, and may be present for several weeks before the appearance of other signs and symptoms indicative of MSCC.[7][9]
Pain can be localised (in and around the spinal column), radicular (nerve root pain affecting one or both sides of the body), or mechanical (transitional movement related). Pain often becomes more severe over time, and may be worse when the patient is lying down (preventing sleep), or coughing or straining.
weakness or paralysis
Limb weakness is a common symptom of MSCC, affecting up to 80% of patients at time of MSCC diagnosis.[7][9] Symptoms may be present for days or weeks before diagnosis. An unsteady gait or increased difficulty in walking, standing, or transferring that has worsened over days or a few weeks is typical.[7] Symptom onset may be less obvious for very ill patients with advanced cancer.
Non-spinal causes should be ruled out if these are the only symptoms.
numbness or paraesthesias
Sensory symptoms and signs such as paraesthesias or numbness of toes and fingers are often seen in patients with MSCC, but are less common than motor symptoms. They may be present for days or weeks before MSCC diagnosis.[7]
Non-spinal causes should be ruled out if these are the only symptoms.
sensory loss
Sensory loss such as loss of pinprick, temperature, position, anal wink, bladder sensation, and vibratory sensation may be present for days or weeks before MSCC diagnosis.[19]
Sensory changes that are symmetrical raise the possibility of neuropathy, even if associated with mild weakness.
hyperreflexia and Babinski or associated reflexes
Early signs of MSCC.[33]
bladder or bowel dysfunction
Often a late consequence of MSCC. May present as urinary retention, urinary or faecal incontinence, or constipation.[7] Rarely the only symptom or sign of MSCC.
Other diagnostic factors
common
cauda equina syndrome
Caused by a lesion below the first lumbar vertebra. Typical symptoms and signs include bladder dysfunction (an essential component), low back pain, bilateral or unilateral sciatica, and saddle (perineal) anaesthesia. Most patients have decreased anal sphincter tone on examination. Bladder dysfunction may present as overflow incontinence, but often presents earlier as difficulty starting or stopping a stream of urine.[7] The bulbocavernosus reflex is often absent or reduced.
uncommon
Brown-Sequard syndrome
Results from a hemisection lesion of the spinal cord (due to tumour or disc herniation).
In the acute presentation, signs include unilateral spastic paralysis on the same side of the body, as well as ipsilateral loss of vibration and proprioception (position sense), with pain and temperature sensation being lost from the contralateral side beginning 1 or 2 segments below the lesion.
Risk factors
strong
tumour type and metastases
A history of prostate, lung, breast, renal, or thyroid cancer, or of soft-tissue sarcoma, neuroblastoma, non-Hodgkin's lymphoma, multiple myeloma, or high-grade meningioma, is particularly associated with MSCC. However, any systemic cancer can metastasise to the spine.[7][11][13] A high burden of metastatic disease and/or confirmed metastatic bone involvement are risk factors for MSCC.[17]
weak
immune system disorders
Most immune system disorders increase inflammation, and this can increase the risk of cancer (e.g., inflammatory bowel disease increases the risk of colorectal cancer).[22]
radiation exposure
Risk factor for malignancy and for spinal meningioma.[23] Greater exposure results in higher risk.
genotype features
Cancer genotype can provide information on the likelihood of metastasis. The MSK-IMPACT data revealed crucial roles of the TP53, KRAS, PIK3CA, and BRAF genes in metastatic tumours.[24] A whole-exome sequencing analysis of ~500 patients with metastatic tumours reported that TP53, CDKN2A, PTEN, PIK3CA, and RB1 were the most prevalent genes altered somatically in metastatic cancer.[25]
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