A 55-year-old woman comes to the emergency department with progressively worsening severe back pain and difficulty walking for the last 2 weeks. The pain is at the mid-thoracic level and wraps around her upper abdomen in a band-like fashion. She also has weakness, numbness, and tingling in both lower extremities. No bowel or bladder dysfunction is reported. The patient completed treatment for non-Hodgkin's lymphoma 8 months ago with chemotherapy and radiation therapy. On physical examination, her temperature is 36.7 C (98 F), blood pressure is 110/80 mm Hg, and pulse is 94/min. Neurological examination shows motor strength of 3/5 in both lower extremities. The patellar and Achilles reflexes are brisk and Babinski reflex is upgoing bilaterally. Which of the following are the most appropriate next steps in management of this patient?

Question

A 55-year-old woman comes to the emergency department with progressively worsening severe back pain and difficulty walking for the last 2 weeks.  The pain is at the mid-thoracic level and wraps around her upper abdomen in a band-like fashion.  She also has weakness, numbness, and tingling in both lower extremities.  No bowel or bladder dysfunction is reported.  The patient completed treatment for non-Hodgkin's lymphoma 8 months ago with chemotherapy and radiation therapy.  On physical examination, her temperature is 36.7 C (98 F), blood pressure is 110/80 mm Hg, and pulse is 94/min.  Neurological examination shows motor strength of 3/5 in both lower extremities.  The patellar and Achilles reflexes are brisk and Babinski reflex is upgoing bilaterally.  Which of the following are the most appropriate next steps in management of this patient?

Quizplus · Accepted Answer

Explanation: Cancers that commonly metastasize to the spinal column include prostate, breast, lung, non-Hodgkin's lymphoma, and renal cell carcinoma. This patient with recent history of non-Hodgkin's lymphoma has classic thoracic radicular pain (wraps around the abdomen) accompanied by weakness and sensory changes in the lower extremities consistent with epidural spinal cord compression (ESCC). Bowel or bladder dysfunction usually develops late in the disease but may present early in those with compression at the level of conus medullaris. epidural spinal cord compression Cord compression is a medical emergency as long-term prognosis is determined by pretreatment neurologic status. High-dose corticosteroids (especially dexamethasone) should be administered immediately to decrease edema and swelling around tumor tissue. Early steroid administration has shown better neurologic outcomes. MRI of the spine should be obtained to confirm the diagnosis. It is also needed to assess spinal stability and plan definitive therapy. Generally, patients with an unstable spine and radioresistant tumors should undergo urgent surgical evaluation for decompression. Patients with a stable spine and minimal neurologic symptoms or those with highly radiosensitive tumors, such as lymphoma, may be treated with radiotherapy alone. (Choice A) Cerebrospinal fluid evaluation may be needed in patients with myelopathy of undetermined etiology. An MRI is required to diagnose structural abnormalities before a lumbar puncture is performed, particularly in patients with a history of malignancy. (Choices C, D, and E) Steroids are crucial in the early management of ESCC and should be given empirically. Intravenous antibiotics would be indicated for infection, such as an epidural abscess, that may produce similar symptoms. However, in the setting of malignancy and no signs of infection, neoplastic ESCC is more likely. The need for surgical evaluation is determined by findings on MRI and radioresistance of the tumor. Educational objective: Suspected epidural spinal cord compression should be treated as an emergency with empiric high-dose corticosteroids. An MRI should be ordered to confirm the diagnosis and assess spine stability. Patients with highly radiosensitive tumors may be treated with radiation. Patients with radioresistant tumors and those with an unstable spine should undergo surgical evaluation. References: Neoplastic myelopathy. (http://www.ncbi.nlm.nih.gov/pubmed/22961188) A 2011 updated systematic review and clinical practice guideline for the management of malignant extradural spinal cord compression. (http://www.ncbi.nlm.nih.gov/pubmed/22420969) Direct decompressive surgery followed by radiotherapy versus radiotherapy alone for metastatic epidural spinal cord compression: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24503688)

A 55-Year-Old Woman Comes to the Emergency Department with Progressively