By Tedler D. Depaynos, MD
The 57 years old male patient came from a low land municipality. He was admitted because of weakness of both lower extremities with pain from both lumbar areas radiating to his legs. It started as a gradual weakness 2 or 3 months ago which he tried to ignore but with time it worsened with the appearance of the radiating pain two weeks before consultation. Actually it was the pain which was becoming more severe which made him consent to see an MD.
Initial impression was partial compression of his spinal cord with the probable cause still unknown.
The patient was first brought to a clinic in their Poblacion where x-rays of his spine were done. The results they brought with them reveal no abnormalities. Hence they came up to the city hospital which is apparently more equipped for further work-up.
After a repeat spinal x-rays were done, the 3rd lumbar vertebra seems to have “collapsed” due to an “old fracture”. Probably this is the site of the spinal cord compression.
On further interview, his daughter could recalled that around 17 years ago while doing carpentry work at the wall of their farm house, her father slipped and fell from the stairs that he was using and lost consciousness. A “hilot” from their barangay made him regain consciousness with extensive “massage”. A “swelling” and “hematoma” was later noticed at his back and righit shoulder which made them conclude that he landed on these areas. Except for the pain which later disappeared and enabled him to return to work in their farm, he never complained of pain similar to what he was experiencing that caused him to seek consultation. Probably, he incurred the fracture during the accident.
An old fracture making the spinal vertebrae eventually collapsing is a strong possibility. It may have weakened the bones together with age and stress since the patient being a farmer must have been carrying heavy loads.
Although it is rare, cases like these are encountered from time to time where the spinal column may have “weakened” because of “trauma” and with time the weakened vertebra may “collapse” even in individuals with plain office work.
As a rule when “collapsing” vertebrae are encountered without acute trauma, various etiologies are considered like Tuberculosis (TB) of the bones , Osteoporosis which is more common in menopausal women , Infection or Osteomyelitis and Cancer or Malignancy which is most of the time metastatic. Hence to confirm the initial impression of “old fracture” and to rule out other probable causes a routine Magnetic Resonance Imaging (MRI) which is very specific in visualizing the pathologic lesion was requested. When the results came out, the cause of the collapse vertebra was due to a “malignant metastatic lesion”! It was very unfortunate since metastatic lesions imply a 4th stage malignancy. When this was mentioned by the attending Orthopedic Surgeon to the relatives watching the patient, they all shed uncontrollable tears.
A further work up of the patient to search for the primary lesion was explained to the relatives especially if palliative treatment would be given. If it would be negative, the Orthopedic Surgeon suggested that the lesion would be opened and be biopsied. The collapsed vertebra may also be supported by placing “titanium” bar supports.
The relatives conducted a conference among themselves and they concluded that since the lesion is a metastatic one, the possibility that other sites of metastasis are also present. Knowing that a 4th stage malignancy is incurable they decided to be “practical” and brought home the patient against medical advice with his consent and prepare for the sad eventuality. **
