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Difficulty: MediumNeurosurgery

A 68-year-old man presents to the emergency department with a 5-day history of progressively worsening mid-back pain. He reports that over the past 24 hours, his legs have felt "heavy" and he has had difficulty walking. He also mentions not having a bowel movement in 3 days and experiencing difficulty initiating urination. His medical history is significant for advanced prostate cancer diagnosed 2 years ago. His temperature is 37.1°C (98.8°F), blood pressure is 145/90 mm Hg, and pulse is 82/min. Neurologic examination reveals 3/5 strength in the bilateral lower extremities. Muscle tone is increased in the lower limbs, and deep tendon reflexes are 3+ at the knees and ankles. Plantar reflexes are upgoing bilaterally. Perianal sensation is decreased. Which of the following is the most appropriate next step in management?

  1. Administration of intravenous dexamethasoneAnswer
  2. B
    Magnetic resonance imaging of the spine
  3. C
    Administration of broad-spectrum intravenous antibiotics
  4. D
    Urethral catheterization and observation
  5. E
    Noncontrast computed tomography of the abdomen and pelvis

Answer

Administration of intravenous dexamethasone
The correct answer is the administration of intravenous dexamethasone. This patient's clinical picture is classic for malignant epidural spinal cord compression (MESCC), a neurosurgical and oncologic emergency. The history of advanced prostate cancer combined with progressive back pain, bilateral lower extremity weakness, sensory deficits, and bowel/bladder dysfunction strongly points to spinal metastasis. The presence of hyperreflexia, increased tone, and bilateral Babinski signs localizes the lesion to the upper motor neurons in the spinal cord. When MESCC is clinically suspected, the absolute most important next step is to administer high-dose intravenous glucocorticoids (such as dexamethasone) immediately. Glucocorticoids reduce the vasogenic edema surrounding the epidural tumor, which relieves pressure on the cord, preserves neurologic function, and buys time. Only after steroids have been administered should the patient be sent for definitive imaging (MRI of the spine) to guide subsequent surgical decompression or radiation therapy.

Step-by-Step Solution

1
Analyze the patient's presentation and medical history.
The patient has known prostate cancer, worsening back pain, lower extremity weakness, bowel/bladder dysfunction, and upper motor neuron signs (hyperreflexia, upgoing plantar reflexes).
Identifying these signs helps localize the lesion to the spinal cord, highly suspicious for malignant epidural spinal cord compression (MESCC).
2
Determine the priority of interventions.
Medical stabilization to protect the spinal cord takes precedence over diagnostic confirmation.
MESCC causes permanent neurologic damage through direct compression and vasogenic edema. High-dose corticosteroids reduce this edema rapidly.
3
Select the correct sequence of care.
Intravenous dexamethasone must be given immediately, followed by an urgent MRI of the entire spine.
Ordering the MRI first without giving steroids delays critical, potentially paralysis-preventing treatment.

Key Concept

Patients with suspected malignant epidural spinal cord compression must receive high-dose intravenous glucocorticoids immediately, prior to obtaining diagnostic imaging.
Estimated Time:1m 0s
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Topics

Neurosurgery

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