 |
|
Prediction of Spinal Epidural Metastases
George E. M. Kienstra, MD, PhD;
Caroline B. Terwee, MSc;
Friedo W. Dekker, PhD;
Leo R. Canta, MD;
Aernout C. W. Borstlap, MD;
Cees C. Tijssen, MD, PhD;
D. Andries Bosch, MD, PhD;
Jan G. P. Tijssen, PhD
Arch Neurol. 2000;57:690-695.
Context Early diagnosis and treatment of spinal epidural metastases (SEM) is of the utmost importance to prevent neurological deficit due to spinal cord compression. Magnetic resonance imaging (MRI) has become the final tool in that diagnostic process. However, access to MRI is still limited in the Netherlands, requiring cost-effective use. It is generally acknowledged that patients with systemic cancer who present with a radiculopathy or myelopathy should undergo an MRI. However, the diagnostic policy in patients with systemic cancer who present with recently developed back pain is still a matter of debate.
Objective To identify the patients with back pain in whom MRI can safely be omitted because of a low risk of SEM.
Methods In a prospective series of 170 consecutive patients with cancer with recently developed back pain, prediction of spinal metastatic disease (SMD) and especially SEM was studied by means of a multivariate risk analysis of the parameters of the standard neurological evaluation (medical history, neurological examination, and plain films of the whole spine). Magnetic resonance imaging was used as the criterion standard. We calculated the risk implications of omitting MRI in patients with an estimated risk below different cutoff points.
Results Spinal metastatic disease was diagnosed in 80 patients (47%); of these, 31 had SEM. A metastatic abnormality on plain films was the strongest independent predictor for SMD. Other important predictors were night pain, progressive pain, and Karnofsky score. Advanced age, exacerbation of pain during recumbency, and osteoporotic fracture imply a low risk of SMD. Night pain and the Karnofsky score proved to be the main predictors for SEM. A plain film showing an osteoporotic fracture strongly decreased the risk of SEM. The discriminating value of the multivariate analysis was too low, and too few patients can be excluded from undergoing MRI on the basis of the standard neurological checkup. To identify all the patients with SMD (P<.01), MRI would be excluded in only 7 patients. Identification of all patients with SEM (P<.001) reduced the number of MRIs by 21 at the expense of plain films of the whole spine for any patient.
Conclusions Selection of patients with cancer with back pain at risk of SEM was not possible with the standard neurological checkup. After intake by the neurologist, the next step should be MRI of the whole spine.
From the Department of Neurology, Martini Hospital, Groningen (Dr Kienstra); the Departments of Clinical Epidemiology and Biostatistics (Ms Terwee and Drs Dekker and J. G. P. Tijssen) and Neurosurgery (Dr Bosch), Academic Medical Center, University of Amsterdam, Amsterdam; the Department of Neurology, St Elisabeth Hospital and Maria Hospital, Tilburg (Drs Canta and C. C. Tijssen); and the Department of Radiology, University Hospital Maastricht, Maastricht (Dr Borstlap), the Netherlands.
RELATED ARTICLE
Archives of Neurology Reader's Choice: Continuing Medical Education
Arch Neurol. 2000;57(5):762-763.
FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Spinal Extradural Metastasis: Review of Current Treatment Options
Bartels et al.
CA Cancer J Clin 2008;58:245-259.
ABSTRACT
| FULL TEXT
Spinal Cord Compression in Patients With Advanced Metastatic Cancer: "All I Care About Is Walking and Living My Life"
Abrahm et al.
JAMA 2008;299:937-946.
ABSTRACT
| FULL TEXT
Understanding diagnostic errors in medicine: a lesson from aviation.
Singh et al.
Qual Saf Health Care 2006;15:159-164.
ABSTRACT
| FULL TEXT
|
