Cauda equina compression in metastatic prostate cancer

Abstract

A 67-year-old man presented to his general practitioner with intermittent episodes of unilateral sciatica over a 2-month period for which he was referred for an outpatient MRI of his spine. This evidenced a significant lumbar vertebral mass that showed tight canal stenosis and compression of the cauda equina. The patient was sent to the emergency department for management by orthopaedic surgeons. He was mobilising independently, pain free on arrival and without neurological deficit on assessment. Clinically, this patient presented with no red flag symptoms of cauda equina syndrome or reason to suspect malignancy. In these circumstances, National Institute for Health and Care Excellence guidelines do not support radiological investigation of the spine outside of specialist services. However, in this case, investigation helped deliver urgent care for cancer that otherwise may have been delayed. This leads to the question, do the current guidelines meet clinical requirements?

Keywords: general practice / family medicine; orthopaedic and trauma surgery; prostate; prostate cancer; spinal cord.

Figure 1

MRI spine lumbar and sacral T2 sagittal view portraying tight spinal canal stenosis at the level of L4 vertebrae caused by a space-occupying lesion (arrow) arising from the posterior aspect of the L4 vertebral body extending down to the back of L5 vertebrae. L4, lumbar 4; L5, lumbar 5.

Figure 2

MRI spine lumbar and sacral T2 axial view of L4 vertebral body (arrow) indicating a space-occupying lesion causing compression of the cauda equina nerve roots. L4, lumbar 4.

Figure 5

CT sagittal view of spine part of the staging CT series showing multilevel degenerative changes noted in spine and an ill-defined mixed lytic sclerotic bone lesion (arrow) involving L4 vertebral body with destruction of posterior cortex. L4, lumbar 4.

Figure 3

NM whole body bone scan anterior view showing an area (arrow) of increased activity within the L4 vertebral body in keeping with known metastatic deposit. L4, lumbar 4; NM, nuclear medicine.

Figure 4

NM whole body bone scan posterior view showing an area (arrow) of metastatic deposit at the L4 vertebral body. L4, lumbar 4.