By Schon Roberts MD PGY-3
61yo M with h/o of metastatic adenocarcinoma p/w numbness, tingling, and weakness in B/L UE and LE X 3 weeks. This has worsened in the past 3 days. He is now unable to walk or feed himself. He denies bowel/bladder incontinence, HA, fevers, chills, N/V/D, abdominal pain. He denies any IVD. He was 3 weeks ago able to work full time as an electrician. He complains also of chronic neck and back pain.
Vital Signs are unremarkable. Back is normal appearance. Pt has 4/5 strength in B/L UE and LE. He has rigidity of R arm with spasm. Decreased sensation B/L UE and LE R>L. What is the best treatment option for this pt?
A. Discharge home. This is chronic back pain.
B. Refer patient to both pain management and a spinal surgeon to evaluate for disc herniation
C. Obtain consults from nuclear medicine, spinal surgery, and admit pt. Give steroids
D. Place pt in a TLSO brace and admit to the hospital
E. Start broad spectrum antibiotics: pt has an epidural abscess
C. Obtain consults from nuclear medicine, spinal surgery, and admit pt. Give steroids.
· Suspect spinal cord compression in a pt with H/O of CA and cauda equine symptoms.
· Dx is made by MRI showing cord compression
· Treatment should involve steroids.
· Most recent data shows similar rates of relapse/improvement between radiation and surgery.
Sørensen S, Helweg-Larsen S, Mouridsen H, Hansen HH. Effect of high-dose dexamethasone in carcinomatous metastatic spinal cord compression treated with radiotherapy: a randomized trial. Eur J Cancer 1994; 30A:22.
Vecht CJ, Haaxma-Reiche H, van Putten WL, et al. Initial bolus of conventional versus high-dose dexamethasone in metastatic spinal cord compression. Neurology 1989; 39:1255.
Graham PH, Capp A, Delaney G, et al. A pilot randomized comparison of dexamethasone 96 mg vs. 16 mg per day for malignant spinal-cord compression treated by radiotherapy: TROG 01.05 Superdex study. Clin Oncol (R Coll Radiol) 2006; 18:70.
Findlay GF. Adverse effects of the management of malignant spinal cord compression. J Neurol Neurosurg Psychiatry 1984; 47:761.
Young RF, Post EM, King GA. Treatment of spinal epidural metastases. Randomized prospective comparison of laminectomy and radiotherapy. J Neurosurg 1980; 53:741.
VegasFOAM is dedicated to sharing cutting edge learning with anyone, anywhere, anytime. We hope to inspire discussion, challenge dogma, and keep readers up to date on the latest in emergency medicine. This site is managed by the residents of Las Vegas’ Emergency Medicine Residency program and we are committed to promoting the FOAMed movement.