An 82-year-old man is brought to the emergency department after multiple falls. He has had severe back pain over the last month, for which he has been taking over-the-counter pain medication without significant relief. Over the last week, the patient has noted weakness in his legs bilaterally, and his gait has become unstable. Medical history is significant for hypertension, hyperlipidemia, coronary artery disease, and gout. The patient has lost 6.8 kg (15 lb) in the last month due to poor appetite. Rectal examination reveals an enlarged, firm, nodular prostate. Which of the following is the most likely cause of this patient's current symptoms?

Question

An 82-year-old man is brought to the emergency department after multiple falls.  He has had severe back pain over the last month, for which he has been taking over-the-counter pain medication without significant relief.  Over the last week, the patient has noted weakness in his legs bilaterally, and his gait has become unstable.  Medical history is significant for hypertension, hyperlipidemia, coronary artery disease, and gout.  The patient has lost 6.8 kg (15 lb) in the last month due to poor appetite.  Rectal examination reveals an enlarged, firm, nodular prostate.  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

11ec160b_39dc_1a35_9249_7787bf54398a_MD0001_00 This elderly patient with severe back pain developed lower extremity weakness and gait instability. In association with his weight loss and enlarged nodular prostate, this presentation is concerning for neoplastic cord compression. Spinal cord compression is a frequent complication of advanced malignancy, especially breast, lung, and prostate cancers. Neoplastic cord compression most commonly results from local extension of vertebral metastases (neoplastic cells) into the epidural space. The tumors can encase the thecal sac and cause venous obstruction, leading to vasogenic edema, cord ischemia, and infarction. Presenting symptoms depend on the level of cord involvement but typically include severe back pain (often worse at night) that progresses to include motor weakness and/or sensory deficits. Urinary and fecal retention or incontinence are common late-stage findings. MRI is diagnostic. (Choice A) Intramedullary metastases (malignant cells within the intramedullary spinal cord) are very rare and usually associated with lung cancer. Because of the tumor location within the spinal cord, as opposed to an adjacent structure, Brown-Séquard syndrome (ie, ipsilateral hemiplegia, contralateral sensory loss) is a common presentation. (Choice B) Compression fractures are common in elderly patients, particularly those with osteoporosis, and can cause severe back pain. Although pathologic fractures can occur due to vertebral metastases, subsequent cord compression due to retropulsed bone fragments occurs only rarely and is a less common cause of cord compression than direct epidural invasion by the tumor mass. (Choice D) Intervertebral disc herniation can cause back pain and spinal cord compression but more commonly causes focal radiculopathy due to nerve root compression (eg, sciatica). In addition, this patient's weight loss and abnormal prostate examination are more suggestive of neoplastic cord compression. (Choice E) Spondylosis (age-related degeneration of the spinal column) can cause spinal stenosis (narrowing of the spinal canal) with cord compression, typically due to osteophyte formation or thickening of the ligamentum flavum. However, symptoms are typically slowly progressive rather than of rapid onset, as seen in this patient. Educational objective: Neoplastic spinal cord compression most commonly results from local extension of vertebral metastases into the epidural space. Presenting symptoms typically include severe back pain (often worse at night), motor weakness, and/or sensory deficits. Urinary and fecal retention or incontinence are common late-stage findings.

An 82-Year-Old Man Is Brought to the Emergency Department After