A 75-year-old man is brought to the emergency department with severe back pain that began 3 weeks ago. The pain has been significantly worse for the last 12 hours. This morning, the patient also noticed difficulty walking and urinating. He has a history of advanced prostate cancer initially treated with local radiation therapy. Temperature is 37 C (98.6 F), blood pressure is 122/83 mm Hg, and pulse is 104/min. The patient appears uncomfortable. He has point tenderness over the midline spine near T10 and T11. Upper extremity strength and reflexes are normal. Muscle strength in the lower extremities is 3/5 and deep-tendon reflexes are 3+ bilaterally. Bilateral plantar reflexes are upgoing. Straight urinary catheterization produces 800 mL of urine. Which of the following is the best initial step in management of this patient?

Question

A 75-year-old man is brought to the emergency department with severe back pain that began 3 weeks ago.  The pain has been significantly worse for the last 12 hours.  This morning, the patient also noticed difficulty walking and urinating.  He has a history of advanced prostate cancer initially treated with local radiation therapy.  Temperature is 37 C (98.6 F), blood pressure is 122/83 mm Hg, and pulse is 104/min.  The patient appears uncomfortable.  He has point tenderness over the midline spine near T10 and T11.  Upper extremity strength and reflexes are normal.  Muscle strength in the lower extremities is 3/5 and deep-tendon reflexes are 3+ bilaterally.  Bilateral plantar reflexes are upgoing.  Straight urinary catheterization produces 800 mL of urine.  Which of the following is the best initial step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d54d_9134_bc81_0df3c429e2de_MD0003_00 This patient with advanced prostate cancer presents with subacute back pain that has now profoundly changed in severity. Examination shows lower extremity motor weakness, hyperreflexia, and bladder dysfunction, raising concern for epidural spinal cord compression (ESCC). The thoracic (60%) and lumbosacral (30%) spine are the most common locations for ESCC. Cancers that often metastasize to the spine include lung, breast, and prostate, as well as multiple myeloma. Early diagnosis of ESCC is crucial in preserving neurologic function; in fact, the primary determinant of outcome is the degree of neurologic involvement at the time of intervention. Pain is typically the first symptom, often present for 1-2 months before additional symptoms appear. Motor findings (bilateral weakness) and ataxia are common as the disease progresses. Bowel and bladder dysfunction are late findings. Although imaging (MRI) plays an important role in the diagnosis of ESCC, intravenous glucocorticoids should be given without delay in a patient with suspected neoplastic ESCC. Glucocorticoids decrease vasogenic edema (caused by obstructed epidural venous plexus), help alleviate pain, and may restore neurologic function. Once imaging confirms ESCC, neurosurgery and/or radiation oncology consultation is typically required. (Choice A) Analgesics and baclofen are used for muscular spasm. Alpha blockers may help relieve bladder obstruction from an enlarged prostate. This patient is manifesting signs of significant bilateral motor nerve involvement, making a muscular cause much less likely than a critical neurologic cause. (Choice C) Radiation to the spine is a useful intervention for painful spinal metastases. It may play a role in this patient's treatment but requires imaging and scheduling. Glucocorticoids should not be delayed. (Choices D and E) A radionuclide bone scan and skeletal survey (x-rays of major bones) can detect metastatic bone disease but do not provide useful information about compression of the thecal sac; therefore, they are not recommended for diagnosis of ESCC. In general, glucocorticoids should not be delayed for imaging in this patient as the pretest probability of ESCC is quite high (given patient's neurologic findings, history of prostate cancer, and symptoms). Educational objective: Epidural spinal cord compression must be suspected in any patient with a history of malignancy who develops back pain with motor and sensory abnormalities. Bowel and bladder dysfunction are late neurologic findings. Intravenous glucocorticoids should be given without delay. MRI is then recommended. References: Spinal cord compression. (http://www.ncbi.nlm.nih.gov/pubmed/22547256)

A 75-Year-Old Man Is Brought to the Emergency Department with Severe