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Difficulty: MediumNeurosurgery

A 68-year-old man is brought to the emergency department due to a rapid decline in his ability to walk over the past 24 hours. He has a 3-week history of progressively worsening mid-back pain that awakens him from sleep. His medical history is significant for castration-resistant prostate cancer. Upon arrival, his temperature is 37.0°C (98.6°F), blood pressure is 142/88 mmHg, pulse is 88/min, and respiratory rate is 16/min. His Glasgow Coma Scale score is 15. Neurologic examination of the upper extremities is unremarkable. In the lower extremities, motor strength is 2/5 bilaterally. There is hyperreflexia at the patellar and Achilles tendons, and plantar reflexes are upgoing bilaterally. Sensation to pinprick is decreased below the level of the umbilicus. Bladder ultrasound demonstrates 550 mL of retained urine.

Which of the following is the most appropriate initial step in the management of this patient?

  1. Administration of intravenous dexamethasoneAnswer
  2. B
    Magnetic resonance imaging of the entire spine
  3. C
    Emergent surgical decompression
  4. D
    Administration of empiric broad-spectrum intravenous antibiotics
  5. E
    Bladder catheterization and careful observation

Answer

Administration of intravenous dexamethasone
The correct response is the administration of intravenous dexamethasone. This patient presents with a classic triad of neoplastic epidural spinal cord compression (ESCC): severe back pain (often worse at night), progressing to motor weakness, and autonomic dysfunction (evidenced by urinary retention). Upper motor neuron signs, including hyperreflexia and upgoing plantar reflexes, confirm a central nervous system lesion. Given his history of castration-resistant prostate cancer, a spinal metastasis is the most likely cause. In suspected ESCC, the very first step in management is to immediately administer high-dose intravenous glucocorticoids (such as dexamethasone). Corticosteroids work rapidly to decrease peritumoral vasogenic edema, thereby relieving pressure on the spinal cord and preventing irreversible ischemia and permanent paralysis. This must be done without delay, even before confirming the diagnosis with imaging.

Step-by-Step Solution

1
Analyze the clinical presentation.
The patient has progressively worsening back pain, acute bilateral lower extremity weakness, a sensory level at T10, upper motor neuron signs (hyperreflexia, upgoing plantar reflexes), and urinary retention.
Identifying this constellation of symptoms localizes the lesion precisely to the spinal cord.
2
Synthesize the presentation with the patient's medical history.
The history of advanced prostate cancer combined with acute spinal cord signs strongly points to epidural spinal cord compression from bone metastasis.
Establishing the most likely etiology dictates the specific emergency management pathway.
3
Determine the most appropriate initial step in management.
Intravenous dexamethasone must be administered immediately.
Glucocorticoids rapidly decrease peritumoral edema, lowering pressure on the spinal cord and preserving neurologic function while awaiting definitive imaging and therapy.

Key Concept

In patients with suspected neoplastic epidural spinal cord compression, the most critical initial step is the immediate administration of high-dose intravenous corticosteroids (e.g., dexamethasone) to reduce edema and preserve neurologic function, even before confirmatory imaging is obtained.
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Neurosurgery

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