MSK

Question 1

Three most common tumours to metastasis to bone?

Answer 1

1. prostate
2. breast
3. lung

Question 2

Most common sites of bony mets (descending order)?

Answer 2

spine
pelvis
ribs
skull
long bones

Question 3

Features of boney mets?

Answer 3

bone pain
pathological fractures
hypercalcaemia
raised ALP

Question 4

What is neoplastic spinal cord compression?

Answer 4

Spinal cord compression is an oncological emergency and affects up to 5% of cancer patients.

Extradural compression accounts for the majority of cases, usually due to vertebral body metastases.

It is more common in patients with lung, breast and prostate cancer

Question 5

In which types of cancer is neoplastic cord compression more common?

Answer 5

Lung
Breast
Prostate

Question 6

What is responsible for the majority of cases of neoplastic spinal cord compression?

Answer 6

Extradural compression accounts for the majority of cases, usually due to vertebral body metastases.

Question 7

Features of neoplastic spinal cord compression?

Answer 7

back pain
- the earliest and most common symptom
- may be worse on lying down and coughing
-deep and localised

Stabbing radicular sensory disturbance at the level of the lesion

Bladder and bowel involvement

lower limb weakness

sensory changes: sensory loss and numbness
neurological signs depend on the level of the lesion. - Lesions above L1 usually result in upper motor neuron signs in the legs and a sensory level.
- Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness.
- Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion

Question 8

When might back pain from neoplastic spinal cord compression be worse?

Answer 8

Lying down
Upon coughing

Question 9

Neoplastic spinal cord compression: above what level do lesions usually result in UMN signs in the legs and a sensory level?

Answer 9

L1

Question 10

Neoplastic spinal cord compression: below what level do lesions usually result in LMN signs in the legs and perianal numbness?

Answer 10

L1

Question 11

Neoplastic spinal cord compression: tendon reflexes

Answer 11

Tendon reflexes tend to be:

Increased below the level of the lesion
Absent at the level of the lesion

Question 12

How is ?neoplastic spinal cord compression investigated?

Answer 12

MRI (within 24 hours of presentation)

Question 13

Neoplastic spinal cord compression: management?

Answer 13

high-dose oral dexamethasone (with ppi cover)

urgent oncological assessment for consideration of radiotherapy or surgery

Surgical decompression, if appropriate, should be aimed to have been done within 48 hrs

Question 14

Patients may present with spinal metastases before developing metastatic spinal cord compression.

It is, therefore, important to detect these patients early before any neurological compromise develops.

How may they present?

Answer 14

Unrelenting lumbar back pain
Any thoracic or cervical back pain

Pain is:
Worse with sneezing, coughing or straining
Nocturnal

Associated with tenderness

Question 15

Investigating spinal metastases

Answer 15

MRI

If compression is suspected (neurological features) - within 24 hours of presentation

Without neurological features, a whole spine MRI should be completed within one week.

The whole spine should be imaged as patients commonly present with multi-level disease.

Question 16

Causes of spinal cord compression?

Answer 16

Trauma

Neoplasia (seen in 5-10% of cancer patients, presenting complaint in 20% of these)

Infection (especially TB in at-risk patients)

Disc prolapse

Epidural haematoma