Laura Finucane Masqueraders course March 2012 Laura Finucane 2011 © Bony Metastases

HPC Laura Finucane 2011 © 73 yr Old female 3/12 HO bending and twisting. Aware of pain in the back and stomach Settled, 1/12 later similar incidence Worse with symptoms into ant thighs bilaterally I/M Improved with physio initially

Ache I/M 7/10 Numb constant Ache I/M 8/10 Laura Finucane 2011 ©

HPC con’t Laura Finucane 2011 © Aggravated by Walking, standing, sitting Eased by lying supine Tramadol helpful PH breast Ca 1 year ago

Physical Examination Laura Finucane 2011 © LSP movements all limited SLR positive Negative femoral nerve stretch test Neuro integrity intact Abdominal palpation TOP LLQ> RLQ

Red flags Laura Finucane 2011 © Past history Breast Ca 2006 Worsening symptoms Failed conservative treatment Bizarre symptoms Night pain Weight loss 3Kg in 3/12

Clinical Impression Laura Finucane 2011 © ? Sinister pathology Urgent MRI Bloods

Results Laura Finucane 2011 © MRI – multiple metastatic lesions involving vertebral bodies, T5, T10, L2 and L5. findings at L2 are more extensive causing posterior bulging of vertebral body into spinal canal Bloods- alkaline phosphatase 209 (35-129) CRP 46 (1-10) one month later 237

Investigations Laura Finucane 2011 © Plain Xray September NAD Bloods MRI and Bone scan 2/12 later CT abdomen and Pelvis

Laura Finucane 2011 ©

Case 5 SV Laura Finucane 2011 ©

Spinal metastases Laura Finucane 2011 © 90-95% extradural Pain most common symptom= 90% Neurologic symptoms frequently present and follows central pain Pathological fractures Cord compression

Common metastatic disease Laura Finucane 2011 © Women Breast and lung Men Prostate and lung

Common sites Laura Finucane 2011 © Vertebrae Pelvis Ribs Femur skull

Diagnostics Laura Finucane 2011 © Plain Radiographs Bone scan CT scan MRI

Winking owl sign Laura Finucane 2011 ©

Treatment Laura Finucane 2011 © Palliative NOT Curative Medical therapy Radiotherapy surgery

Surgery Laura Finucane 2011 © Neurologic compression Spinal instability Unrelenting pain Histological diagnosis needs to be established

Likelihood of developing spinal metastases Laura Finucane 2011 © 16-35% Breast 9-15% prostate 12-15% lungs 3-6% kidney 4% Thyroid

Mean survival rates Laura Finucane 2011 © Breast 19-32/12 Prostate 18-27/12 Renal 10/12 Lung 6-12/12 (Rose and Buchwoski 2011)

References Laura Finucane 2011 © van der Linden et al 2005 Prediction of Survival in Patients with Metastases in the Spinal Column Results Based on a Randomized Trial of Radiotherapy. Cancer Volume 103;2; Bradley J and Perrin R G 2001 Evaluation and treatment of spinal metastases: an overview Neurosurg Focus 11 (6) 1-7 Rose P S, Buchowski J M 2011Metastatic Disease in the Thoracic and Lumbar Spine:Evaluation and Management; Journal of the American Academy of Orthopaedic Surgeons 19;1;37-48 White et al 2006 Metastatic Disease of the Spine J Am Acad Orthop Surg 2006;14: Walker et al 2003 Axial Metastatic Bone Disease Metastatic Disease of the Spine: Evaluation and Treatment. Cinical Orthopaedics and related research 415S, pp. S165–S175