- Email: [email protected]
Spinal Cord Compression Secondary to Metastatic Carcinoma of the Prostate Treated by Decompressive Laminectomy
THE JOURNAL OF UnOLOGY
VoL 88, No. 5 Nm·ember 1962 Copyright © 1962 by The Williams & Wilkins Co. Printed in C.8.Ao
SPI'.\:AL CORD COMPRESSION SECONDARY TO :METASTATIC CARCI;'.fOJ\1 OF THE PROSTATE TREATED BY DECOMPRESSIVE LAl\HNECTOMY SUMNER MARSHALL, FRANK R. TAVEL
AND
JOHN W. SCHULTE
From the Department 1(/ S1ugery, Division of Urology, University of California School of 11:Iedicinc and ihe Department of Snryery, Division of Uroloyy, Veterans Administration Hospital., San Fmncisco, Cal.
With the advent of hormonal therapy for carcinoma of the prostate, an entirely new perspective has evolved in the management of the disease. Patients who had previously been destined to the early onset of severe pain secondary to metastases have now been afforded many months, and in some cases years, of relatively pain-free, productive life. In most patients with known metastases, the emphasis in the management has been palliation. Besides hormonal control, x-ray, steroids and, more recently, radioactive phosphorus have been used in the later stages of the diseasP. One of the late complications of metastatic disease is impairment of motor and sensory function secondary to impingement of tumor on the spinal cord. Bumpus in 19261 reported that of 1000 patient8 treated for carcinoma of the prostate, 11 had symptoms simulating tumor of the cord associated with some degree of paralysis pnor to death. Subsequent investigators 2• 10 Accepted for publication May 29, 1962. A summary of this paper was presented at the annual meeting of the Western Section, American Urological Association, Inc., April 23-26, 1962. Requests for reprints should be sent to Division of Urology, University of California Hospitals, San Francisco 22, Cal. 1 Bumpus, H. C., Jr.: Carcinoma of prostate. Surg., Gynec. & Obst., 43: 150-155, 1926. 2 Arduino, L. J.: Unusual metastases of carci·noma with four case reports. Amer. Surgeon, 21: 114G-1153, 1955. 3 Clarke, B. G. and Viets, H. R.: Effect of diethylstilbestrol on neurologic symptoms of carcinoma of prostate. J .A.M.A., 121: 499-501, 1943. 4 Edelman, I. S.: Paraplegia secondary to metastatic prostatic carcinoma treated with stilbestrol; report of a case. Ann. Int. Med., 31: 1098-1102, 1949. 5 Flocks, R. H.: Carcinoma. of the prostate. J.A.M.A., 163: 709-712, 1957. 6 Huggins, C.: Prostatic cancer treated by orchiectomy; the five year results. J.A.M.A., 131: 576-581, 1946. 7 Kawaichi, G. K. and Rider, R. D.: Paraplegia. due to vertebral metastasis of prostatic carcinoma; case report. J. Urol., 70: 720-723, 1953. 8 Xesbit, R. M. and Baum, W. C.: Endocrine (167
reported similar complications which to varying degrees of estrogenic hormones, castration or both. Our series includes with and without previous treatment for tlw1r prostatic carcinoma who have been subsequently subjected to de.compressive laminectomy e
CASI, REPORTS
Case 1. F. P. was a 68-year-old white prospector who, 8 years ago, was noted on open perinea] biopsy to have adenocarcinoma of the prostate with local extension. He was subsequently treated with orchiectomy and estrogens. He was admitted to the hospital because of severe low back pain which radiated into the pelvis and legs. A 5-day rnurse of intravenous stilphosterol yielded no relief. After receiving orw dose of "priming" testosterone prior to tlw administration of radioactive phosphorus, the patient experienced more severe pain, and the following morning complained of difficulty in initiating his urinary stream and bowel movements. Associated weakness of his legs prngressr'll over the next 12 hours to i5 per cent paral.rnic of the quadriceps, psoas and hamstring muscles. No sensory deficits were noted. A myelogrnm (fig. 1) showed complete blockage at IA, the vertebral body of which re\·ealed ostcobla~tic lesions. Laminectomy of Tl 2-L4 was performed and tumor was found to be compressing the r:ord at these levels. \Vithin 3 days the patient experienced a rapid return of motor power and significantly redrn:ed pain. Five months later, neurologic examination was entirely negatin, and the patient has returned to prosppe;ting for control of prostatic carcinoma ..J.A.M.A., 1.43: 1317-1320, 1950. 9 Roberts, R. R. and Kuehn, C. A.: Carcinoma of the prostate with vertebral metastasis and paraplegia. Urol. & Cutan. Rev., 55: :388-:390, l!J51 10 Toulson, W. H. and Hawkins, C. W.· Pnniplegia as a result of metastasis from carcinorn:, ol the prostate gland. Bull. School Mee!., Univ. Md. 32: 159-1G2, 1948.
668
MARSHALL, TAVEL AND SCHULTE
Case 2. E. A. was a 70-year-old white man in whom a diagnosis of prostatic carcinoma had been made 2 years previously and who had been treated with orchiectomy and estrogens. He entered the hospital with a 4-month history of low back pain which radiated down his right leg and was associated with weakness of the leg. Serial examinations revealed a decreased, then absent, right patellar reflex with associated quadriceps weakness. Roentgenographic studies showed osteoblastic lesions of the lower lumbar vertebrae (fig. 2, A). A myelogram showed an extradural mass pressing anteriorly on the cord (fig. 2, B). At the time of laminectomy of L3-L5 this mass was found to be a metastatic tumor.
FIG. 1. Case 1. Myelogram shows complete blockage at L4 vertebral body which contains osteoblastic lesions.
FIG. 2. Case 2. A, postero-anterior view of myelogram shows no significant defect. Note osteoblastic lesions of lower lumbar vertebrae. B, lateral view of myelogram shows mass pressing anteriorly on cord, demonstrating necessity of lateral views.
Postoperatively the patient had rapid return of the patellar reflex and strength of his leg. Recurrent pain, 3 months later, responded to a course of intravenous stilphosterol, and neurologic examination was negative. Case 3. B. T. was a 66-year-old white man in whom a diagnosis of prostatic carcinoma had been made 1 year previously and who had been treated palliatively with orchiectomy, estrogens and transurethral resection of the prostate. He entered the hospital with a 12-hour history of sharp chest pain. Roentgenograms revealed collapse of the body of T7 (fig. 3). Local x-ray treatments were initiated, but after two such treatments, the patient complained of numbness and weaknes~ of his lower legs. A myelogram showed a block at T7 which during operation was found to be secondary to metastatic tumoi' and a decompressive laminectomy of T7-T8 was done. Postoperatively the patient regained total motor and sensory function. Residual hip pain responded to a course of intravenous stilphosterol and he has remained relatively free of pain and neurologic deficits over the successive 7 months. Case 4. W. J., a 59-year-old white man, had had a radical perineal prostatectomy for adenocarcinoma 9 years previously. He entered the hospital with a 1-month history of severe low back pain. Two days before admission to the hospital he experienced sudden complete paralysis of his left leg and the following day the right leg became similarly affected. Physical examination revealed complete flaccid paralysis of the lower extremities; position and vibration sense were absent below the iliac crests. A myelogram showed a complete block at Ll, the body of which appeared osteoblastic on the x-ray (fig. 4). A laminectomy of Tl2-Ll was performed and the
FIG. 3. Case 3. Lateral view of thoracic spine shows collapse of body of T7 with osteoblastic lesions.
dnrnl ,sac waf found to h(: rnmpressccl at this
lencl lJ,1- overgrown hone and cxtrnclurnl tumor. \Yithin a few the patin1t hacl alrnost total sensor)- return us \\'ell as partial n,eoYery of motor J'unctimL ~\t 1n·e~c·nt, 1 :>'.i years later, the patient has regained full and 1s free of nu1rologic a hcrrntious, Case 5. H. H., a \1·hite man, had hacl a rndi,·al peri1wa1 prostatt·ctomy G :n•arn . He hacl t'xperit·11n·d clilhrnc back pain for the: past 7 months \1·hieh had partiall_1· n:to or('liied,0111_1· and estrogens. He then 1ras admjttcd to tlH' \Yith a 12-hour we~ knests. Physical exmarkl'cl mnination re\Taled atroph_1· and \\Takiwss of boU1 muscles 11·ith h_1·poactin, rcflcxe.~ fJf the lmn·r extremities. Osteoblastic ksions of Tl and Ll -L:3 l\'l'l'f' SPl'Yl on films. A. shmwcl a block at Tl -T2 (fig ..5). ,\t a tumm \\'aR sc•e11 to lie compressiug the cord at this !(•1-d, am! tl lamineetom,1· ,nlfi perfonnr:d the third po~topcrnti \'e da_1· the n:f!rxes 11en: hrcoming more pronounced, and b_1·
the ninth day the patient was fnll,1· Followup examination 2 months later rPn:al(·d that the patient 1rns ('RsentiaHy frc(: of deficits. Case U. D. a 58-n:ar-old 11 hik man, 11:1.d L week histor,1- of se1·e1T pain ill the hunbo,c;acm: area with radiation into the right which 11:1~ aggranitccl h,1· straining, awl rPlil'\'C'(l ,Yitl1 n:,,.t,. Examination 1Tn,alecl slight scolios.is \,·ith em., caYity to the right 1'liglit rn 1J1t distrilmtion of SJ 011 thl' right siclP \\'as noted, m,1-eJogram 1T1·ealed a !urge hilatrnd ddc:et. IA ,Yhich was felt to be ,,ecomlar,,~ to a herniate(: clisc (fig. G). "\t tiuw cf l:imiu<·dom,1· or L4~L,5, :, large: em·ap,,ulaterl niaR~ la1· brneath tlic: Jiftli lumbar root :\Iicroscopic t:xamination n:vc·:ilcd metastatic adenocarcinoma, probably of prostatit origin, Pro8tatic biop8y rnufirmed this ancl the patieut was subsrqm·11tl)· treatl'd ,1itl: orchiectomy and cstrogenB. Foll01n1p cxamrna, tiom; ll\'er tlie C'nsuing rear rc:\'('alcrl no cle6cits, although rnentgcnogram:, of the ~J)Jlli' ren-;akd tlic presence of nwta~tatic tumor in tlw
\'ertebrae Case '1. "\, \Y., a S9-_1·t~ar-olcl man, complu.iwxl of numlmess of both lmwr extremitiC's ,rnd progrcssi\'C clifficnlty in ,miking for tlw montlL Ph_1-sical examination re\·eakd Jos.•,
Ji'HL ,!, Case 4. j\fl'<:logrnm shows complete blockage ar Ll, body of ,i-!1ich con! a ins ostc•oblnstic lesions.
_l-i'rn. b. Case 5. l\i~,c~1ognun ;:_,:ho\,-~ block,lgP ui_, Tl-T2.
position ancl vibrntor_1- 8Pll~atiun with associatt:,1 h:qJesthesi:t 011 the ldt to Tl 2 amt on the to To. "\ m_1·elogrn.rn (fig. 7) shom,cl a block at T2 ancl the: patic·nt umlerwent thcm,ci•: spine de corn pression of TI -T3. A ma8~ \In,, founcl to he comprcs~ing the rnnl at this len,L ~\Iicroscopie examination ~hom,'d it to be ackuocarcinoma and the proLabln primm·,1· ~ite 11 tlic prostate. Biopsy of the prostate, rnnfirmcd tJi,,
}<'[(;, b. Case (L l\Iydogram lateral defect, :ct lA, beliPved to represent hernial eel discs.
sho1rn L1rgc ii,. i.11itial inspeci 1010
11t
670
MARSHALL, TA VEL AND SCHULTE
diagnosis. A bilateral orchiectomy was performed and estrogens were given. A followup examination 18 months later revealed no neurologic deficits. Case 8. J. C., a 73-year-old white man. underwent a suprapubic prostatectomy for obstructive urinary symptoms. Five months later he complained of low back pain, which radiated down his left leg, and progressive pain and numbness down the medial aspect of his right arm. Physical examination revealed hypoactive reflexes in the upper extremities with slight hypesthesia along Tl-T2 distribution. A myelogram revealed a block at T2-T3 (fig. 8). A laminectomy of Tl-T5 was subsequently performed and a large epidural mass of metastatic tumor was found. A biopsy of the residual prostate was performed and
carcinoma was found. Followup examination 3 months later revealed the patient to be almost free of pain with no evidence of neurologic deficits. Case 9. G. E., a 66-year-old white man, entered the hospital with a 9-month history of low back pain, obstructive urinary symptoms and occasional urinary incontinence. Neurologic examination was unremarkable, although the cystometrogram showed a hypo tonic bladder. Roentgenographic studies showed sclerotic areas and mottling in the lumbosacral spine (fig. 9, cl). Following a histologic diagnosis of prostatic carcinoma, the patient was treated with orchiectomy and estrogens. Since he was unable to void spontaneously, the patient was sent home with an
FIG. 7. Case 7. Myelogram blockage at T2.
T2-T3.
shows
complete
FIG. 8. Case 8. Myelogram shows blockage at
Frn. 9. Case 9. A, plain film demonstrates sclerotic areas and mottling in lumbosacral spillc. U, myelogram shows complete block at L5.
CORD COMPRESSION SECONDARY TO METASTATIC CARCINOMA
indwelling catheter in place for 5 weeks. On return to the hospital he complained of increased low back pain, intermittent loss of bowel control and weakness of his legs. Phy,,;ical examination revealed saddle anesthesia, absent bulbocavernous reflex, bilateral weakness of the gastrocnemius and soleus muscles and absent ankle jerks. A myelogram (fig. 9,B) showed a total block at L5. Exploration revealed an anterior extradural tumor compressing the cord at L5 which was subsequently shown to be a metastasis from the prostate. Total laminectomy of L4-S1 was performed. Postoperatively, the patient had only partial and temporary improvement in motor function and pain anci within a few days had lapsed into the preoperative state. Over the next 4 months, the patient's condition progressively deteriorated and he needed more and more opiates to control his pain. Postmortem examination revealed widely disseminated tumor. Case 10. P. J., a 67-year-old white man, who had been treated empirically with estrogens for 5 years for a clinical prostatic carcinoma, experienced fairly severe low back pain which radiated into both legs. During the following 2 months the patient had constipation, urinary incontinence, numbness and progressive weakness of both legs, which finally ended in total paralysis. Physical examination revealed flaccid lower extremities with hypalgesia to TS. Total laminectomy of T5-T8 was performed and metastatic tumor was seen to be compressing the cord at this level. Postoperatively, there was slight and only transient improvement of motor power and alleviation of the pain; the sensory level remained unchanged. The patient died approximately one year later from widely disseminated carcinoma (fig. 10).
Fm. 10. Case 10. Myelogram shows complete blockage at TS.
671
Case 11. A. Z., a 61-year-old white man, underwent radical perineal prostatectomy 3 years ago. He was then admitted to the hospital with a 1-year history of progressive urinary incontinence, low back pain and leg pain which had responded only partially to orchiectomy, estrogens and steroids. Examination revealed perineal hypalgesia and hypoactive tendon reflexes bilaterally. Roentgenographic studies showed complete collapse of L5 with diffuse metastatic lesions of the spine and pelvis (fig. 11). At operation, a total laminectomy of L4-S1 was performed; the vertebral column was found to be grossly involved with tumor which compressed the cord at this level. Postoperatively, the patient had almost no clinical improvement and became progressively worse. He died 3 months after the laminectomy. Case 12. B. N., a 77-year-old white man, had had a transurethral resection of the prostate 3 years previously for carcinoma, which was treated by orchiectomy and estrogen therapy. For 1 week he had progressive weakness of his legs with associated urinary incontinence. Examination revealed flaccid paralysis of the lower extremities with hypesthesia bilaterally to Ll. Osteoblastic lesions were seen in the spine and pelvis and a myelogram showed a complete block at TI1-T12 (fig. 12). At operation a large extradural mass, which proved to be metastatic tumor from the prostate, was found to be compressing the cord. Postoperatively, the patient had minimal return of function. He became progressively worse and died 2 months later.
Fm. 11. Case 11. Plain film shows collapse of L5 with diffuse metastatic lesions of spine and pelvis.
672
MARSHALL, TA VEL AND SCHULTE
Case 13. C. F., a 69-ycar-old white man, was admitted to neurosurgical service ,vith a 4-month history of lower back pain which radiated down both posterior thighs, and a 6-,veek history of progressively increasing weakness of his lower extremities, involving primarily the quadriceps, adductors and rotator groups. The prostate was palpably benign. Roentgenograms revealed extensive osteoblastic lesions of the lun1bosacral spine and pelvis with collapse of TIO and Tll. A myelogram showed a complete block at L3 (fig. 13,A ). A laminectomy of T10-L3 was performed and a tumor was seen to be compress-
FIG. 12. Case 12. Myelogram shows complete blockage at Tll-T12.
Fro. 13. Case 13. A, postero-anterior view of myelogran1 shows cord compression with block at L3. B, lateral view, osteoblastic lesions of L3 are clearly seen.
ing the cord in these areas (fig. 13,B). The patient died in the early postoperati"ve period. Postmortem examination revealed metastatic carcinoma of the prostate. DISCUSSION
Bumpus has shown that neurologic aberrations secondary to metastatic carcinoma of the prostate arc not uncommon. Yet at the University of California Hospital from 1937 to the present, decompressive lamincctomy for cord compression secondary to this lesion was performed in only 5 cases. At the Veterans Administration Hospital in San Francisco no patients were subjected to this operation until 1962. From this relatively low number of cases one might conclude that either the risks were considered to be too great and results of operation too poor to warrant the procedure, or that the neurologic deficits were not recognized as reflecting cord compression. Our first case, F. P., prompted our interest in the subject. Our index of suspicion was then raised, and within a period of 4 months, we diagnosed four more such cases in the Vcterans Administration Hospital. The lesion was demonstrated first by myelography and was then confirmed at operation. The other cases in the series \\'ere seen at various hospitals in San Francisco. As can be noted from an analysis of the case histories, the relative value of the decompressive laminectomy speaks for itself, and in cases in which the neurologic aberrations were recognized early and decomprcssive laminectomy was carried out shortly thereafter (cases 1-8), the results were gratifying. Cases 9 through 13 illustrate the results of late surgieal decompress10n. The prognosis in patients ,vith spinal cord compression depends on the severity and duration of the disturbance of function, the extent to which it can be relieved, and the part of cord that is compressed.U Tarlov, 12 in his experiments on the mechanism of paralysis by cord compression, demonstrated that the shorter the period of time it takes to produce complete paralysis, the greater the delay in recovery and the less likelihood of recovery. For example, if the cord were progressively compressed to the point of paralysis 1
11 Brain, W. R.: Disease of the Nervous System, 4th ed. London: Oxford University Press, 1951. 12 Tarlov, I. M.: Spinal Cord Compression: Mechanism of Paralysis and Treatment. Springfield: Charles C. Thomas, 1957.
CORD COMPRESSION SECONDARY TO METASTATIC CARCINOMA
over a period of 75 minutes there would be a safety period of 9 hours in which decompression would result in full recovery. Were this progressive compression to be extended to 48 hours, the safety period would be prolonged up to one week. The clinical implication,; are obvious. Unfortunately it is usually difficult to establish accurately the duration of cord compression in a patient on the basis of pain alone, for the pain might be secondary to pressure on the richly innervated periosteum or on nerve roots rather than from actual spinal cord compression. 13 Signs of slightly impaired sensory or motor function can be discovered only by careful neurologic examination. The most common signs and symptoms are low back pain with or without radiation into the lower extremities, and weakness of the lower extremities. Symptoms referable to the bowel and bladder are seen in patients with lesions affecting the sacral roots. 14 Physical examination will frequently reveal hypoactive deep tendon reflexes, demonstrable muscular atrophy with some decreased motor power and disturbed 13 Epstein, B. S.: The Spine. Philadelphia: Lea & Febiger, 1955. 14 Wechsler, I. S.: A Textbook of Clinical Neurology. Philadelphia: W. B. Saunders, Co., 1952.
673
position sense. Hypalgesia, or loss of pinprick reaction, occurs more slowly and if, in spite of total motor paralysis after the acute or gradually increasing spinal cord compression there is pain sensation, the outlook for recovery after removing the compression, is favorable. 12 Case 1 illustrates this point well. Because of aforementioned clinical difficulties in evaluating the degree and duration of cord compression, urologists should not forget the neurosurgical principle that as soon as the history and physical findings arouse suspicion of cord compression, a myelogram should be obtained to determine the level and degree of the lesion. Once the presence of the lesion is established, prompt relief of the obstruction should be carried out. In light of the varied and unpredictable course of this disease, it would seem unwise to deny a patient an ambulatory and productive life, even if just for a few months, or perhaps even years. SUMMARY
Thirteen illustrative cases of cord compression secondary to metastatic carcinoma are presented in which subsequent decompressive laminectomy was performed. The importance of early recognition of the lesion is stressed.
VoL 88, No. 5 Nm·ember 1962 Copyright © 1962 by The Williams & Wilkins Co. Printed in C.8.Ao
SPI'.\:AL CORD COMPRESSION SECONDARY TO :METASTATIC CARCI;'.fOJ\1 OF THE PROSTATE TREATED BY DECOMPRESSIVE LAl\HNECTOMY SUMNER MARSHALL, FRANK R. TAVEL
AND
JOHN W. SCHULTE
From the Department 1(/ S1ugery, Division of Urology, University of California School of 11:Iedicinc and ihe Department of Snryery, Division of Uroloyy, Veterans Administration Hospital., San Fmncisco, Cal.
With the advent of hormonal therapy for carcinoma of the prostate, an entirely new perspective has evolved in the management of the disease. Patients who had previously been destined to the early onset of severe pain secondary to metastases have now been afforded many months, and in some cases years, of relatively pain-free, productive life. In most patients with known metastases, the emphasis in the management has been palliation. Besides hormonal control, x-ray, steroids and, more recently, radioactive phosphorus have been used in the later stages of the diseasP. One of the late complications of metastatic disease is impairment of motor and sensory function secondary to impingement of tumor on the spinal cord. Bumpus in 19261 reported that of 1000 patient8 treated for carcinoma of the prostate, 11 had symptoms simulating tumor of the cord associated with some degree of paralysis pnor to death. Subsequent investigators 2• 10 Accepted for publication May 29, 1962. A summary of this paper was presented at the annual meeting of the Western Section, American Urological Association, Inc., April 23-26, 1962. Requests for reprints should be sent to Division of Urology, University of California Hospitals, San Francisco 22, Cal. 1 Bumpus, H. C., Jr.: Carcinoma of prostate. Surg., Gynec. & Obst., 43: 150-155, 1926. 2 Arduino, L. J.: Unusual metastases of carci·noma with four case reports. Amer. Surgeon, 21: 114G-1153, 1955. 3 Clarke, B. G. and Viets, H. R.: Effect of diethylstilbestrol on neurologic symptoms of carcinoma of prostate. J .A.M.A., 121: 499-501, 1943. 4 Edelman, I. S.: Paraplegia secondary to metastatic prostatic carcinoma treated with stilbestrol; report of a case. Ann. Int. Med., 31: 1098-1102, 1949. 5 Flocks, R. H.: Carcinoma. of the prostate. J.A.M.A., 163: 709-712, 1957. 6 Huggins, C.: Prostatic cancer treated by orchiectomy; the five year results. J.A.M.A., 131: 576-581, 1946. 7 Kawaichi, G. K. and Rider, R. D.: Paraplegia. due to vertebral metastasis of prostatic carcinoma; case report. J. Urol., 70: 720-723, 1953. 8 Xesbit, R. M. and Baum, W. C.: Endocrine (167
reported similar complications which to varying degrees of estrogenic hormones, castration or both. Our series includes with and without previous treatment for tlw1r prostatic carcinoma who have been subsequently subjected to de.compressive laminectomy e
CASI, REPORTS
Case 1. F. P. was a 68-year-old white prospector who, 8 years ago, was noted on open perinea] biopsy to have adenocarcinoma of the prostate with local extension. He was subsequently treated with orchiectomy and estrogens. He was admitted to the hospital because of severe low back pain which radiated into the pelvis and legs. A 5-day rnurse of intravenous stilphosterol yielded no relief. After receiving orw dose of "priming" testosterone prior to tlw administration of radioactive phosphorus, the patient experienced more severe pain, and the following morning complained of difficulty in initiating his urinary stream and bowel movements. Associated weakness of his legs prngressr'll over the next 12 hours to i5 per cent paral.rnic of the quadriceps, psoas and hamstring muscles. No sensory deficits were noted. A myelogrnm (fig. 1) showed complete blockage at IA, the vertebral body of which re\·ealed ostcobla~tic lesions. Laminectomy of Tl 2-L4 was performed and tumor was found to be compressing the r:ord at these levels. \Vithin 3 days the patient experienced a rapid return of motor power and significantly redrn:ed pain. Five months later, neurologic examination was entirely negatin, and the patient has returned to prosppe;ting for control of prostatic carcinoma ..J.A.M.A., 1.43: 1317-1320, 1950. 9 Roberts, R. R. and Kuehn, C. A.: Carcinoma of the prostate with vertebral metastasis and paraplegia. Urol. & Cutan. Rev., 55: :388-:390, l!J51 10 Toulson, W. H. and Hawkins, C. W.· Pnniplegia as a result of metastasis from carcinorn:, ol the prostate gland. Bull. School Mee!., Univ. Md. 32: 159-1G2, 1948.
668
MARSHALL, TAVEL AND SCHULTE
Case 2. E. A. was a 70-year-old white man in whom a diagnosis of prostatic carcinoma had been made 2 years previously and who had been treated with orchiectomy and estrogens. He entered the hospital with a 4-month history of low back pain which radiated down his right leg and was associated with weakness of the leg. Serial examinations revealed a decreased, then absent, right patellar reflex with associated quadriceps weakness. Roentgenographic studies showed osteoblastic lesions of the lower lumbar vertebrae (fig. 2, A). A myelogram showed an extradural mass pressing anteriorly on the cord (fig. 2, B). At the time of laminectomy of L3-L5 this mass was found to be a metastatic tumor.
FIG. 1. Case 1. Myelogram shows complete blockage at L4 vertebral body which contains osteoblastic lesions.
FIG. 2. Case 2. A, postero-anterior view of myelogram shows no significant defect. Note osteoblastic lesions of lower lumbar vertebrae. B, lateral view of myelogram shows mass pressing anteriorly on cord, demonstrating necessity of lateral views.
Postoperatively the patient had rapid return of the patellar reflex and strength of his leg. Recurrent pain, 3 months later, responded to a course of intravenous stilphosterol, and neurologic examination was negative. Case 3. B. T. was a 66-year-old white man in whom a diagnosis of prostatic carcinoma had been made 1 year previously and who had been treated palliatively with orchiectomy, estrogens and transurethral resection of the prostate. He entered the hospital with a 12-hour history of sharp chest pain. Roentgenograms revealed collapse of the body of T7 (fig. 3). Local x-ray treatments were initiated, but after two such treatments, the patient complained of numbness and weaknes~ of his lower legs. A myelogram showed a block at T7 which during operation was found to be secondary to metastatic tumoi' and a decompressive laminectomy of T7-T8 was done. Postoperatively the patient regained total motor and sensory function. Residual hip pain responded to a course of intravenous stilphosterol and he has remained relatively free of pain and neurologic deficits over the successive 7 months. Case 4. W. J., a 59-year-old white man, had had a radical perineal prostatectomy for adenocarcinoma 9 years previously. He entered the hospital with a 1-month history of severe low back pain. Two days before admission to the hospital he experienced sudden complete paralysis of his left leg and the following day the right leg became similarly affected. Physical examination revealed complete flaccid paralysis of the lower extremities; position and vibration sense were absent below the iliac crests. A myelogram showed a complete block at Ll, the body of which appeared osteoblastic on the x-ray (fig. 4). A laminectomy of Tl2-Ll was performed and the
FIG. 3. Case 3. Lateral view of thoracic spine shows collapse of body of T7 with osteoblastic lesions.
dnrnl ,sac waf found to h(: rnmpressccl at this
lencl lJ,1- overgrown hone and cxtrnclurnl tumor. \Yithin a few the patin1t hacl alrnost total sensor)- return us \\'ell as partial n,eoYery of motor J'unctimL ~\t 1n·e~c·nt, 1 :>'.i years later, the patient has regained full and 1s free of nu1rologic a hcrrntious, Case 5. H. H., a \1·hite man, had hacl a rndi,·al peri1wa1 prostatt·ctomy G :n•arn . He hacl t'xperit·11n·d clilhrnc back pain for the: past 7 months \1·hieh had partiall_1· n:to or('liied,0111_1· and estrogens. He then 1ras admjttcd to tlH' \Yith a 12-hour we~ knests. Physical exmarkl'cl mnination re\Taled atroph_1· and \\Takiwss of boU1 muscles 11·ith h_1·poactin, rcflcxe.~ fJf the lmn·r extremities. Osteoblastic ksions of Tl and Ll -L:3 l\'l'l'f' SPl'Yl on films. A. shmwcl a block at Tl -T2 (fig ..5). ,\t a tumm \\'aR sc•e11 to lie compressiug the cord at this !(•1-d, am! tl lamineetom,1· ,nlfi perfonnr:d the third po~topcrnti \'e da_1· the n:f!rxes 11en: hrcoming more pronounced, and b_1·
the ninth day the patient was fnll,1· Followup examination 2 months later rPn:al(·d that the patient 1rns ('RsentiaHy frc(: of deficits. Case U. D. a 58-n:ar-old 11 hik man, 11:1.d L week histor,1- of se1·e1T pain ill the hunbo,c;acm: area with radiation into the right which 11:1~ aggranitccl h,1· straining, awl rPlil'\'C'(l ,Yitl1 n:,,.t,. Examination 1Tn,alecl slight scolios.is \,·ith em., caYity to the right 1'liglit rn 1J1t distrilmtion of SJ 011 thl' right siclP \\'as noted, m,1-eJogram 1T1·ealed a !urge hilatrnd ddc:et. IA ,Yhich was felt to be ,,ecomlar,,~ to a herniate(: clisc (fig. G). "\t tiuw cf l:imiu<·dom,1· or L4~L,5, :, large: em·ap,,ulaterl niaR~ la1· brneath tlic: Jiftli lumbar root :\Iicroscopic t:xamination n:vc·:ilcd metastatic adenocarcinoma, probably of prostatit origin, Pro8tatic biop8y rnufirmed this ancl the patieut was subsrqm·11tl)· treatl'd ,1itl: orchiectomy and cstrogenB. Foll01n1p cxamrna, tiom; ll\'er tlie C'nsuing rear rc:\'('alcrl no cle6cits, although rnentgcnogram:, of the ~J)Jlli' ren-;akd tlic presence of nwta~tatic tumor in tlw
\'ertebrae Case '1. "\, \Y., a S9-_1·t~ar-olcl man, complu.iwxl of numlmess of both lmwr extremitiC's ,rnd progrcssi\'C clifficnlty in ,miking for tlw montlL Ph_1-sical examination re\·eakd Jos.•,
Ji'HL ,!, Case 4. j\fl'<:logrnm shows complete blockage ar Ll, body of ,i-!1ich con! a ins ostc•oblnstic lesions.
_l-i'rn. b. Case 5. l\i~,c~1ognun ;:_,:ho\,-~ block,lgP ui_, Tl-T2.
position ancl vibrntor_1- 8Pll~atiun with associatt:,1 h:qJesthesi:t 011 the ldt to Tl 2 amt on the to To. "\ m_1·elogrn.rn (fig. 7) shom,cl a block at T2 ancl the: patic·nt umlerwent thcm,ci•: spine de corn pression of TI -T3. A ma8~ \In,, founcl to he comprcs~ing the rnnl at this len,L ~\Iicroscopie examination ~hom,'d it to be ackuocarcinoma and the proLabln primm·,1· ~ite 11 tlic prostate. Biopsy of the prostate, rnnfirmcd tJi,,
}<'[(;, b. Case (L l\Iydogram lateral defect, :ct lA, beliPved to represent hernial eel discs.
sho1rn L1rgc ii,. i.11itial inspeci 1010
11t
670
MARSHALL, TA VEL AND SCHULTE
diagnosis. A bilateral orchiectomy was performed and estrogens were given. A followup examination 18 months later revealed no neurologic deficits. Case 8. J. C., a 73-year-old white man. underwent a suprapubic prostatectomy for obstructive urinary symptoms. Five months later he complained of low back pain, which radiated down his left leg, and progressive pain and numbness down the medial aspect of his right arm. Physical examination revealed hypoactive reflexes in the upper extremities with slight hypesthesia along Tl-T2 distribution. A myelogram revealed a block at T2-T3 (fig. 8). A laminectomy of Tl-T5 was subsequently performed and a large epidural mass of metastatic tumor was found. A biopsy of the residual prostate was performed and
carcinoma was found. Followup examination 3 months later revealed the patient to be almost free of pain with no evidence of neurologic deficits. Case 9. G. E., a 66-year-old white man, entered the hospital with a 9-month history of low back pain, obstructive urinary symptoms and occasional urinary incontinence. Neurologic examination was unremarkable, although the cystometrogram showed a hypo tonic bladder. Roentgenographic studies showed sclerotic areas and mottling in the lumbosacral spine (fig. 9, cl). Following a histologic diagnosis of prostatic carcinoma, the patient was treated with orchiectomy and estrogens. Since he was unable to void spontaneously, the patient was sent home with an
FIG. 7. Case 7. Myelogram blockage at T2.
T2-T3.
shows
complete
FIG. 8. Case 8. Myelogram shows blockage at
Frn. 9. Case 9. A, plain film demonstrates sclerotic areas and mottling in lumbosacral spillc. U, myelogram shows complete block at L5.
CORD COMPRESSION SECONDARY TO METASTATIC CARCINOMA
indwelling catheter in place for 5 weeks. On return to the hospital he complained of increased low back pain, intermittent loss of bowel control and weakness of his legs. Phy,,;ical examination revealed saddle anesthesia, absent bulbocavernous reflex, bilateral weakness of the gastrocnemius and soleus muscles and absent ankle jerks. A myelogram (fig. 9,B) showed a total block at L5. Exploration revealed an anterior extradural tumor compressing the cord at L5 which was subsequently shown to be a metastasis from the prostate. Total laminectomy of L4-S1 was performed. Postoperatively, the patient had only partial and temporary improvement in motor function and pain anci within a few days had lapsed into the preoperative state. Over the next 4 months, the patient's condition progressively deteriorated and he needed more and more opiates to control his pain. Postmortem examination revealed widely disseminated tumor. Case 10. P. J., a 67-year-old white man, who had been treated empirically with estrogens for 5 years for a clinical prostatic carcinoma, experienced fairly severe low back pain which radiated into both legs. During the following 2 months the patient had constipation, urinary incontinence, numbness and progressive weakness of both legs, which finally ended in total paralysis. Physical examination revealed flaccid lower extremities with hypalgesia to TS. Total laminectomy of T5-T8 was performed and metastatic tumor was seen to be compressing the cord at this level. Postoperatively, there was slight and only transient improvement of motor power and alleviation of the pain; the sensory level remained unchanged. The patient died approximately one year later from widely disseminated carcinoma (fig. 10).
Fm. 10. Case 10. Myelogram shows complete blockage at TS.
671
Case 11. A. Z., a 61-year-old white man, underwent radical perineal prostatectomy 3 years ago. He was then admitted to the hospital with a 1-year history of progressive urinary incontinence, low back pain and leg pain which had responded only partially to orchiectomy, estrogens and steroids. Examination revealed perineal hypalgesia and hypoactive tendon reflexes bilaterally. Roentgenographic studies showed complete collapse of L5 with diffuse metastatic lesions of the spine and pelvis (fig. 11). At operation, a total laminectomy of L4-S1 was performed; the vertebral column was found to be grossly involved with tumor which compressed the cord at this level. Postoperatively, the patient had almost no clinical improvement and became progressively worse. He died 3 months after the laminectomy. Case 12. B. N., a 77-year-old white man, had had a transurethral resection of the prostate 3 years previously for carcinoma, which was treated by orchiectomy and estrogen therapy. For 1 week he had progressive weakness of his legs with associated urinary incontinence. Examination revealed flaccid paralysis of the lower extremities with hypesthesia bilaterally to Ll. Osteoblastic lesions were seen in the spine and pelvis and a myelogram showed a complete block at TI1-T12 (fig. 12). At operation a large extradural mass, which proved to be metastatic tumor from the prostate, was found to be compressing the cord. Postoperatively, the patient had minimal return of function. He became progressively worse and died 2 months later.
Fm. 11. Case 11. Plain film shows collapse of L5 with diffuse metastatic lesions of spine and pelvis.
672
MARSHALL, TA VEL AND SCHULTE
Case 13. C. F., a 69-ycar-old white man, was admitted to neurosurgical service ,vith a 4-month history of lower back pain which radiated down both posterior thighs, and a 6-,veek history of progressively increasing weakness of his lower extremities, involving primarily the quadriceps, adductors and rotator groups. The prostate was palpably benign. Roentgenograms revealed extensive osteoblastic lesions of the lun1bosacral spine and pelvis with collapse of TIO and Tll. A myelogram showed a complete block at L3 (fig. 13,A ). A laminectomy of T10-L3 was performed and a tumor was seen to be compress-
FIG. 12. Case 12. Myelogram shows complete blockage at Tll-T12.
Fro. 13. Case 13. A, postero-anterior view of myelogran1 shows cord compression with block at L3. B, lateral view, osteoblastic lesions of L3 are clearly seen.
ing the cord in these areas (fig. 13,B). The patient died in the early postoperati"ve period. Postmortem examination revealed metastatic carcinoma of the prostate. DISCUSSION
Bumpus has shown that neurologic aberrations secondary to metastatic carcinoma of the prostate arc not uncommon. Yet at the University of California Hospital from 1937 to the present, decompressive lamincctomy for cord compression secondary to this lesion was performed in only 5 cases. At the Veterans Administration Hospital in San Francisco no patients were subjected to this operation until 1962. From this relatively low number of cases one might conclude that either the risks were considered to be too great and results of operation too poor to warrant the procedure, or that the neurologic deficits were not recognized as reflecting cord compression. Our first case, F. P., prompted our interest in the subject. Our index of suspicion was then raised, and within a period of 4 months, we diagnosed four more such cases in the Vcterans Administration Hospital. The lesion was demonstrated first by myelography and was then confirmed at operation. The other cases in the series \\'ere seen at various hospitals in San Francisco. As can be noted from an analysis of the case histories, the relative value of the decompressive laminectomy speaks for itself, and in cases in which the neurologic aberrations were recognized early and decomprcssive laminectomy was carried out shortly thereafter (cases 1-8), the results were gratifying. Cases 9 through 13 illustrate the results of late surgieal decompress10n. The prognosis in patients ,vith spinal cord compression depends on the severity and duration of the disturbance of function, the extent to which it can be relieved, and the part of cord that is compressed.U Tarlov, 12 in his experiments on the mechanism of paralysis by cord compression, demonstrated that the shorter the period of time it takes to produce complete paralysis, the greater the delay in recovery and the less likelihood of recovery. For example, if the cord were progressively compressed to the point of paralysis 1
11 Brain, W. R.: Disease of the Nervous System, 4th ed. London: Oxford University Press, 1951. 12 Tarlov, I. M.: Spinal Cord Compression: Mechanism of Paralysis and Treatment. Springfield: Charles C. Thomas, 1957.
CORD COMPRESSION SECONDARY TO METASTATIC CARCINOMA
over a period of 75 minutes there would be a safety period of 9 hours in which decompression would result in full recovery. Were this progressive compression to be extended to 48 hours, the safety period would be prolonged up to one week. The clinical implication,; are obvious. Unfortunately it is usually difficult to establish accurately the duration of cord compression in a patient on the basis of pain alone, for the pain might be secondary to pressure on the richly innervated periosteum or on nerve roots rather than from actual spinal cord compression. 13 Signs of slightly impaired sensory or motor function can be discovered only by careful neurologic examination. The most common signs and symptoms are low back pain with or without radiation into the lower extremities, and weakness of the lower extremities. Symptoms referable to the bowel and bladder are seen in patients with lesions affecting the sacral roots. 14 Physical examination will frequently reveal hypoactive deep tendon reflexes, demonstrable muscular atrophy with some decreased motor power and disturbed 13 Epstein, B. S.: The Spine. Philadelphia: Lea & Febiger, 1955. 14 Wechsler, I. S.: A Textbook of Clinical Neurology. Philadelphia: W. B. Saunders, Co., 1952.
673
position sense. Hypalgesia, or loss of pinprick reaction, occurs more slowly and if, in spite of total motor paralysis after the acute or gradually increasing spinal cord compression there is pain sensation, the outlook for recovery after removing the compression, is favorable. 12 Case 1 illustrates this point well. Because of aforementioned clinical difficulties in evaluating the degree and duration of cord compression, urologists should not forget the neurosurgical principle that as soon as the history and physical findings arouse suspicion of cord compression, a myelogram should be obtained to determine the level and degree of the lesion. Once the presence of the lesion is established, prompt relief of the obstruction should be carried out. In light of the varied and unpredictable course of this disease, it would seem unwise to deny a patient an ambulatory and productive life, even if just for a few months, or perhaps even years. SUMMARY
Thirteen illustrative cases of cord compression secondary to metastatic carcinoma are presented in which subsequent decompressive laminectomy was performed. The importance of early recognition of the lesion is stressed.