Critical Care Medicine-Neurologic Disorders>>>>>Neuro Oncology
Question 3#

A 72-year-old man with past medical history of hypertension and prostate cancer status post radiation therapy is brought to ED after sustaining a witnessed mechanical fall. He denies loss of consciousness and reports that his head did not hit the floor. He reports a 3-week history of progressive lower back pain radiating down his left leg. The day before he experienced two episodes of fecal incontinence. A head CT is negative for any acute abnormalities. MRI spine shows collapsed L2 -L4 lumbar vertebrae and a mass invading the spinal cord with surrounding vasogenic edema.

What is the most appropriate next step in management?

a. Stat consult to spine surgery for emergent surgery
b. Stat consult to radiation oncologist for emergent radiation therapy
c. Administer IV steroids
d. Consult interventional radiology to obtain a biopsy

Correct Answer is C

Comment:

Correct Answer: C

The patient described in the scenario above has spinal cord compression due to metastatic disease and should receive steroids. In addition, analgesics should be administered and the patient should undergo rest and appropriate immobilization to protect vulnerable spine segments from further damage.

Vertebral metastases occur in up to 3% to 5% of patients with a diagnosis of cancer and can be the presenting symptom. Back pain is the most common feature and occurs in up to 95% of the patients with metastatic spinal cord compression syndrome. It is more commonly radicular in nature but can be localized, particularly to mid- and high thoracic spinal areas. While radiation therapy and/or surgical resection are considered definitive treatment, randomized trials support the use of steroids as beneficial adjunctive therapy in patients with myelopathy from spinal cord compression while planning for definitive therapy. Steroids are contraindicated in patients who are suspected to have lymphoma as the underlying cause of spinal cord compression.

References:

  1. Al-Qurainy R, Collis E. Metastatic spinal cord compression: diagnosis and management. BMJ. 2016;353:i2539
  2. Levack P, Graham J, Collie D, et al. A prospective audit of diagnosis, management and outcome of malignant spinal cord compression. Clin Resour Audit Group. 2001.