Critical Care Medicine-Hematologic and Oncologic Disorders>>>>>Oncological Syndromes
Question 4#

A 57-year-old woman with a history of breast cancer treated with mastectomy and radiation therapy is admitted with a 4-week history of progressive low back pain. She reports decreased sensation over her buttocks, perineal region, and posterior superior thighs and occasional difficulty with voiding. Her physical examination is noticeable for decreased anal sphincter tone.

What is the most appropriate next step in management?

A. Emergent decompressive surgery
B. CT scan of the spine with and without contrast
C. MRI of full spine
D. Intravenous dexamethasone

Correct Answer is C

Comment:

Correct Answer: C

Malignant spinal cord compression (MSCC) is a devastating complication of cancer. Cancers of prostate, breast, and lung account for most cases of vertebral metastases; however cancer of any origin can metastasize to the spine.

Back pain occurs in 95% of patients for up to 2 months before signs related to MSCC appear. Pain can be localized or radicular in nature and the severity of pain often increases over time. A higher index of suspicion is required in patients with a known history of cancer and those presenting with unremitting pain or pain localized to middle or upper spine. Motor deficits (eg, weakness, unsteady gait, difficulty walking or standing, etc.) that has progressed over days or few weeks is the second most common symptom in patients with MSCC. Sensory symptoms (eg, parasthesias, numbness, decreased sensation) are less common than motor deficits. Autonomic dysfunction (bowel or bladder incontinence) is a late complication of MSCC. Cauda equina syndrome, characterized by low back pain, unilateral or bilateral radicular pain, saddle anesthesia, erectile dysfunction, loss of bladder or bowel continence, and lower extremity weakness, may be the first presentation of MSCC in patients with metastasis to lumbar spine.

An MRI of full spine within 24 hours of presentation is the imaging study of choice in patients presenting with pain and autonomic dysfunction (bowel/bladder incontinence). CT scan is used for surgery or radiation therapy planning. Definitive therapy for MSCC includes decompressive surgery and radiation therapy. In absence of contraindications, all patients with MSCC should receive corticosteroids as adjunctive therapy.

References:

  1. Al-Qurainy R, Collis E. Metastatic spinal cord compression: diagnosis and management. BMJ. 2016;353:i2539.
  2. Quaile A. Cauda equina syndrome – the questions. Int Orthop. 2018; [Epub ahead of print].
  3. McCurdy MT, Shanholtz CB. Oncologic emergencies. Crit Care Med. 2012;40:2212-2222.