Other / General Medicine
Stephen G. Zak, MD
Resident
Westchester Medical Center
Upper Saddle River, New Jersey, United States
Jordan Stumph, MD
Attending physician
Westchester Medical Center
Valhalla, New York, United States
Stephen G. Zak, MD
Resident
Westchester Medical Center
Upper Saddle River, New Jersey, United States
Bone metastasis
Case Description:
A 57-year-old woman with a history of tobacco use in good health was admitted with new-onset left foot drop and weight loss. Imaging revealed a lung mass and multiple enhancing brain lesions. She underwent craniotomy for brain metastasis resection and was discharged to acute rehabilitation to improve left lower-extremity(LLE) strength and regain independence in ADLs impacted by her cancer and surgery.
During rehabilitation, she developed acute, severe right ankle pain. Radiographs revealed a lytic lesion of the distal tibial metaphysis with cortical erosion, consistent with metastatic disease. Orthopedics deemed the lesion non-operative, and patient was made non–weightbearing(NWB) on the right lower-extremity(RLE). Pain initially managed with acetaminophen and low-dose oxycodone eventually required increased opioid use. With the RLE NWB and significant LLE paresis, goals shifted to wheelchair-level mobility/self-care and pain control. Despite improved pain control, she required discharge to her sister’s home for wheelchair access and assistance with ADLs and transfers.
Discussions:
Metastatic bone pain is one of the most common and debilitating symptoms of advanced cancer and represents a major barrier to participation in rehabilitation. Pain can be tonic, movement-related, or episodic, and is often poorly responsive to conservative analgesia. In patients with new acute pain, bone metastasis must be considered even when pain may also stem from primary cancer or its treatments. While our patient met Mirel’s criteria for prophylactic fixation, orthopedic surgery deemed the risks outweighed the benefits therefore restricting her weight-bearing status and thus her functional ability and rehabilitation goals. Early recognition and medical optimization are essential to enable timely treatment and maximize rehabilitation participation.
Conclusions:
Prompt recognition and workup of acute pain secondary to bone metastases in advanced cancer patients is essential to maintaining rehabilitation participation and optimizing outcomes.
