Early diagnosis and treatment is crucial for neurological recovery after surgery for metastatic spinal cord compression in prostate cancer.

BACKGROUND: Spinal cord compression is an oncological and surgical emergency. Delays in referral and diagnosis may influence functional outcome. It is therefore important to identify patients who will regain or maintain the ability to walk after surgery. The aim of the present study was to examine current practice for referral and diagnosis of prostate cancer patients with spinal cord compression and to identify prognostic factors for neurological outcome after surgery. PATIENTS AND METHODS: The study includes 68 consecutive patients with prostate cancer who underwent surgery due to neurological compromise. Intervals from onset of neurological symptoms to referral, diagnosis, and treatment were analyzed in relation to functional outcome. The prognostic significance of preoperative clinical parameters on gait function one month after surgery was evaluated. RESULTS: Patients who were referred from local hospitals had longer delay to surgery than those who directly presented to the cancer center (p = 0.004). The rate of diagnosis with MRI increased through the week and peaked on Friday, with few patients being diagnosed during weekends. The ability to walk before surgery, hormone-naive prostate cancer, and/or shorter time from loss of ambulation were associated with more favorable neurological outcome. In patients with hormone-refractory disease who were unable to walk before surgery regaining ambulation was associated with: duration of paresis < 48 hours (p = 0.005), good preoperative performance status (p = 0.04), preoperative PSA serum level < 200 ng/ml (p = 0.03), and surgery with posterior decompression and stabilization (p = 0.03). CONCLUSION: Early diagnosis and rapid treatment of spinal cord compression in prostate cancer patients is crucial for neurological recovery. Raising awareness of the condition among patients at risk and among physicians is of outmost importance as well as improving local and regional guidelines for treatment.

Predicting survival for surgery of metastatic spinal cord compression in prostate cancer: a new score.

STUDY DESIGN: We retrospectively analyzed prognostic factors for survival in patients with prostate cancer operated for metastatic spinal cord compression. OBJECTIVE: The aim was to obtain a clinical score for prediction of survival after surgery. SUMMARY OF BACKGROUND DATA: Survival prognosis is important when deciding about treatment of patients with metastatic spinal cord compression. The criteria for identifying patients with prostate cancer who may benefit from surgical treatment are unclear. METHODS: The study comprised 68 consecutive patients with prostate cancer operated for metastatic spinal cord compression at Umeå University Hospital, Sweden. The indication for surgery was neurological deficit; 53 patients had hormone-refractory prostate cancer and 15 patients had previously untreated, hormone-naïve prostate cancer. In 42 patients, posterior decompression was performed and 26 patients were operated with posterior decompression and stabilization. RESULTS: A new score for prediction of survival was developed on the basis of the results of survival analyses. The score includes hormone status of prostate cancer, Karnofsky performance status, evidence of visceral metastasis, and preoperative serum prostate-specific antigen (PSA). The total scores ranged from 0 to 6. Three prognostic groups were formulated: group A (n = 32) with scores 0-1; group B (n = 23) with scores 2-4, and group C (n = 12) with scores 5-6. The median overall survival was 3 (0.3-20) months in group A, 16 (1.8-59) months in group B, and more than half (7 of 12) of patients were still alive in group C. CONCLUSION: We present a new prognostic score for predicting survival of patients with prostate cancer after surgery for metastatic spinal cord compression. The score is easy to apply in clinical practice and may be used as additional support when making decision about treatment.

Outcome after surgery for metastatic spinal cord compression in 54 patients with prostate cancer.

BACKGROUND AND PURPOSE: The criteria for selecting patients who may benefit from surgery of spinal cord compression in metastatic prostate cancer are poorly defined. We therefore studied patients operated for metastatic spinal cord compression in order to evaluate outcome of surgery and to find predictors of survival. PATIENTS AND METHODS: We reviewed the records of 54 consecutive patients with metastatic prostate cancer who were operated for spinal cord compression at Umeå University Hospital. The indication for surgery was neurological deficit due to spinal cord compression. 41 patients had hormone-refractory cancer and 13 patients had previously untreated, hormone-naïve prostate cancer. 29 patients were operated with posterior decompression only, and in 25 patients posterior decompression and stabilization was performed. RESULTS: Preoperatively, 6/54 of patients were able to walk. 1 month after surgery, 33 patients were walking, 15 were non-ambulatory, and 6 had died. Mortality rate was 11% at 1 month, 41% at 6 months, and 59% at 1 year. In the hormone-naïve group, 8/13 patients were still alive with a median postoperative follow-up of 26 months. In the hormone-refractory group, median survival was 5 months. Patients with hormone-refractory disease and Karnofsky performance status (KPS) of ≤ 60% had median survival of 2.5 months, whereas those with KPS of 70% and KPS of ≥ 80% had a median survival of 7 months and 18 months, respectively (p < 0.001). Visceral metastases were present in 12/41 patients with hormone-refractory tumor at the time of spinal surgery, and their median survival was 4 months-as compared to 10 months in patients without visceral metastases (p = 0.003). Complications within 30 days of surgery occurred in 19/54 patients. INTERPRETATION: Our results indicate that patients with hormone-naive disease, and those with hormone-refractory disease with good performance status and lacking visceral metastases, may be helped by surgery for metastatic spinal cord compression.

Gender differences in lumbar disc herniation surgery.

BACKGROUND AND PURPOSE: Although there have been numerous publications on lumbar disc herniation (LDH) treated surgically, there has been little interest in sex differences. It has been shown in many studies that sex differences may be important in certain diseases. We therefore reviewed consecutive register material from one institution for possible gender differences in pre- and postoperative parameters in patients operated for lumbar disc herniation. PATIENTS AND METHODS: Pre- and postoperative parameters for all patients operated on at the Department of Orthopedics, Lund University Hospital over 6 years (2000-2005 inclusive) (301 patients, 165 males) were analyzed regarding sex differences. RESULTS: Statistically significant and clinically relevant sex differences were found. Preoperatively, females had more pronounced back pain and disability, and also lower quality of life in some respects. At 1-year followup, females reported a higher rate of consumption of analgesics, a higher degree of postoperative back and leg pain, and less improvement regarding disability and some aspects of quality of life. Relative improvement, rate of return to work, and satisfaction with the outcome of surgery were not, however, statistically significantly different between females and males. INTERPRETATION: There are statistically significant differences between the sexes in lumbar disc herniation surgery regarding basic demographic status and postoperative status, whereas the surgical effect is similar. Further investigations should focus on whether there is a true sex difference or whether these differences are due to selection for surgery, differences in proneness to seek medical advice or to accept/choose surgery, or other unknown factors.

Low back pain, lifestyle factors and physical activity: a population based-study.

OBJECTIVE AND DESIGN: The prevalence of low back pain was assessed in relation to physical activity, for both work and leisure activities, in a randomly selected population in the northern part of Sweden. Additionally, the associations between age, sex, level of education, lifestyle factors, demographic characteristics, and low back pain were evaluated. SUBJECTS: A total of 5798 subjects aged 25-79 years were selected randomly from a geographically well-defined area in northern Sweden. METHODS: Additional questions concerning people's experience of low back pain were added to the questionnaire of the World Health Organization MONICA (MONItoring of trends and determinants in CArdiovascular disease) health survey with the aim of investigating prevalence rates and factors associated with low back pain. RESULTS: Forty-one percent of the participants reported having low back pain (of these 55% were women and 45% men). The prevalence rate was highest in the age group 55-64 years. Chronic low back pain was the most frequent occurring problem. Of those with low back pain, 43% of the women and 37% of the men reported having continuous low back pain for more than 6 months. Individuals with low back pain often experienced a more physically heavy workload at work and lower physical activity during leisure time, and they were also more likely to have been smokers, have had higher body mass index, lived in smaller communities, and were less educated than people without low back pain. CONCLUSION: Low back pain seems to be associated with physical activity at work and in leisure time, certain lifestyle factors and demographic characteristics.

Altered cerebral blood flow in chronic neck pain patients but not in whiplash patients: a 99mTc-HMPAO rCBF study.

A cross-sectional study to investigate regional cerebral blood flow (rCBF) in patients with chronic whiplash syndrome and chronic neck pain patients without previous history of trauma along with a healthy control group. Chronic neck pain is a common disorder and a history of cervical spine injury including whiplash trauma constitute a risk factor for persistent neck pain. The aetiology of the late whiplash syndrome is unknown with no specific diagnostic criteria based on imaging, physiological, or psychological examination. Earlier studies indicate a parieto-occipital hypoperfusion but it is unclear if the hypoperfusion represents a response to chronic pain. The rCBF was monitored in 45 patients with chronic neck pain: 27 cases with chronic whiplash syndrome and 18 age and gender matched cases with non-traumatic chronic neck pain. The rCBF was estimated with single-photon emission computed tomography (SPECT) using technetium-99m hexamethylpropylene amine oxime (HMPAO). The non-traumatic patients displayed rCBF changes in comparison with the whiplash group and the healthy control group. These changes included rCBF decreases in a right temporal region close to hippocampus, and increased rCBF in left insula. The whiplash group displayed no significant differences in rCBF in comparison with the healthy controls. The present study suggests different pain mechanisms in patients with chronic neck pain of non-traumatic origin compared to those with chronic neck pain due to a whiplash trauma.

Chronic low back pain in individuals with chronic neck pain of traumatic and non-traumatic origin: a population-based study.

BACKGROUND: It is unclear whether the prevalence of chronic low back pain is higher in chronic whiplash patients than in the general population. In a population-based study, we evaluated the prevalence of chronic low back pain in individuals with chronic neck pain of traumatic and non-traumatic origin, with special emphasis on whiplash injury. SUBJECTS AND METHODS: Additional questions concerning the patient's experience of neck and low back pain were added to the questionnaire of the MONICA health survey. 4,415 subjects aged 25-64 years were randomly selected from a geographically well-defined area in northern Sweden. RESULTS: The prevalences of chronic low back pain and chronic neck pain were 16% and 17%, respectively. 51% of subjects had both back and neck pain. Of the patients with neck pain, one quarter had a history of neck injury, which was related to whiplash injury in almost one-half of the cases. The prevalence of chronic low back pain in individuals with chronic non-traumatic neck pain was 53%, and it was 48% in those with chronic neck pain and a history of neck trauma. There was no difference in the prevalence of chronic low back pain between whiplash injury and other types of neck trauma. Confounding factors such as sex, age, marital status, BMI, smoking status and level of education were not significantly different between traumatic and non-traumatic groups. INTERPRETATION: Independently of traumatic or non-traumatic origin of the symptoms, the prevalence of chronic low back pain is 3 times higher in individuals with chronic neck pain than in the general population. Causes other than a history of neck trauma, such as chronic muskuloskeletal pain syndromes, may be important in evaluation of these cases.

Neuropsychological functioning and MMPI-2 profiles in chronic neck pain: a comparison of whiplash and non-traumatic groups.

We measured the neuropsychological functioning in 42 patients with chronic neck pain, 21 with a whiplash trauma and 21 without previous trauma. Subjectively, the whiplash group was more forgetful and had more concentration difficulties compared with the non-traumatic group. The neuropsychological tests did not reveal any differences between the two groups and a reference group of healthy individuals. Thus, chronic neck pain did not seem to interfere with neuropsychological functioning. The personality traits assessed with MMPI-2 in our 42 patients with chronic neck pain differed significantly from the normals on several scales. We also found that the whiplash group had more divergent test results than the non-traumatic group on the MMPI-2 test. Thus, it seems that the health status in those with chronic neck pain is closely linked to separate personality traits. It is concluded that the subjective complaints and poor performance in patients with chronic neck pain may be associated to somatization and inadequate coping, especially in chronic whiplash patients.

Temperament and character: prognostic factors in whiplash patients?

We studied the relationship between whiplash injury and personality in 40 whiplash patients who admitted the hospital within 8 h from the car accident and 80 age- and gender-matched controls. For this purpose we used the Temperament and Character Inventory (TCI). We found that personality dimensions in whiplash patients both in the acute phase and at follow-up 2 years later showed the same results, i.e., significantly less Harm Avoidant (less anxious; low HA) than controls, but when dividing patients into groups depending on severity of outcome from whiplash injury 2 years after, no differences were found. According to our results personality symptoms related to whiplash injury is probably not a secondary phenomenon. Whiplash patients were normally developed in character, i.e., self-directedness (SD), and CO (cooperativeness) and therefore in general are capable of coping with their somatic problems.

Chronic neck pain of traumatic and non-traumatic origin: a population-based study.

Chronic neck pain is a common cause of disability. The effect of neck trauma on the development of chronic neck pain has been debated. In this population-based study, 8,356 persons (25-79 years) were randomly selected from a geographically well-defined area in northern Sweden. 6000 answered a self-administered questionnaire. We evaluated the data from all participants in the age range 25-64 years, a total of 4,392 persons. 18% reported chronic neck pain, defined as continuous pain of more than 6 months duration. 5% had a history of neck trauma and 13% had no such history. Of all patients with chronic neck pain, 30% had a history of neck injury. We divided all subjects with a chronic neck pain into two groups: those with or without a history of neck trauma. When studying the effect of sociodemographic data, self-perceived health and working conditions, multiple regression analysis showed that the trauma group consisted of significantly more younger men, who were more frequently on sick-leave and that their perceived health was worse than those without a neck injury. We found no significant differences concerning BMI, marital status, educational level, smoking habits, psychosocial work situation on the Karasek questionnaire or physical activity during leisure time or at work.

Nervous tissue damage markers in cerebrospinal fluid after cervical spine injuries and whiplash trauma.

Clinical examination is the only tool available to assess the extent of the nerve tissue damage after a spinal cord injury, and it is well known that the reliability of classification based on clinical examination is not satisfactory, especially in cases with incomplete motor injuries. There is a need to evaluate new methods in order to improve the possibilities of classifying and prognosticating spinal cord injuries. Methods for assessing central nervous system (CNS) damage using markers in cerebrospinal fluid (CSF) have recently been developed. Previous studies have reported glial fibrillary acidic protein (GFAp) and neurofilament protein (NFL) levels in non-traumatic diseases in the central nervous system. The present study is the first report of GFAp and NFL levels in CSF after trauma to the cervical spine. Six cases with cord damage and pronounced neurological deficit showed significantly increased concentrations of both GFAp and NFL in the CSF. Patients with tetrapareses showed higher values than those with incomplete injuries. Three of the 17 whiplash cases had increased levels of NFL, but normal GFAp. Assessment of nervous tissue markers in CSF will probably improve possibilities to classify and prognosticate spinal cord injuries and also to evaluate pharmacological intervention. The increased levels of NFL in three whiplash cases indicate neural damage in a proportion of the cases with neurological deficit. Neurological examinations are presently the only tools for grading and prognostication of spinal cord injuries. Assessment of nervous tissue markers in CSF makes it possible to quantify the degree of nerve cell damage after different types of cervical spine injury ranging from spinal cord lesions to whiplash injuries.

The incidence of whiplash trauma and the effects of different factors on recovery.

We performed a prospective study of patients with a whiplash trauma to the cervical spine to describe the incidence of these injuries and to evaluate prognostic factors for disability and recovery. A total of 356 patients were enrolled in the study. All the patients received a comprehensive questionnaire after the injury, and 296 cases responded to the follow-up protocol more than 1 year after the accident. Disability related to the whiplash trauma was used as the outcome variable for the assessment of prognostic factors. The annual incidence of acute whiplash trauma in the catchment area was 4.2 per 1,000 inhabitants and 3.2 per 1,000 for whiplash-associated disorder grades 1-3. Thirty-two percent reported persisting disability at follow-up. The following factors were significantly associated with a poor prognosis: pretraumatic neck pain, low educational level, female gender, and whiplash-associated disorder grades 2-3.

The prevalence of neck pain: a population-based study from northern Sweden.

The two northernmost counties in Sweden form together 1 of the 39 collaborating centers in the World Health Organization (WHO) MONICA (MONItoring of trends and determinants in CArdiovascular disease) project. At the last survey in 1999, we added some questions about cervical spine complaints. Persons randomly selected from the population in a geographically well-defined area completed a self-administered questionnaire. The sample included 8,356 subjects and 6,000 (72%) of them answered. 43% of the population reported neck pain, more women (48%) than men (38%). Women of working age had more neck pain than older ones, a phenomenon not seen among men. Chronic neck pain, defined as continuous pain of more than 6 months' duration, was commoner in women (22%) than men (16%). More than one fourth of the cases with chronic symptoms had a history of neck or head trauma and one third of these had sustained a whiplash type of injury. Thus, all types of neck trauma seem to be associated with chronic neck pain.