During a weekend shift at the acute care clinic, a 69-year-old male with a history of cast… — USMLE Step 2 CK

During a weekend shift at the acute care clinic, a $69$ -year-old male with a history of castration-resistant prostate cancer is evaluated for escalating mid-thoracic back pain over the past three days. He describes a new sensation of heaviness in both legs that has progressively impaired his ability to walk unassisted. Additionally, he reports an episode of involuntary urinary dribbling earlier this morning. Current medications include leuprolide and denosumab. Vital signs are temperature $37.1^{\circ}\text{C}$ ( $98.8^{\circ}\text{F}$ ), blood pressure $142/86 \text{ mm Hg}$ , pulse $88/\text{min}$ , and respiratory rate $14/\text{min}$ . Physical examination reveals exquisite tenderness to percussion over the $T10$ spinous process. Neurologic evaluation demonstrates $3/5$ muscle strength in bilateral lower extremities, symmetrically hyperactive patellar reflexes, and diminished pinprick sensation below the umbilicus. Digital rectal examination reveals decreased anal sphincter tone. Which of the following is the most appropriate initial step in the management of this patient?

Administer intravenous dexamethasoneAnswer
B
Obtain urgent magnetic resonance imaging of the entire spine
C
Consult radiation oncology for emergency spinal irradiation
D
Consult neurosurgery for immediate operative decompression
E
Administer broad-spectrum intravenous antibiotics

Answer

Administer intravenous dexamethasone

The correct answer is to administer intravenous dexamethasone. This patient's presentation of escalating back pain, lower extremity weakness, sensory level deficit, upper motor neuron signs (hyperreflexia), and bowel/bladder dysfunction in the setting of advanced prostate cancer is highly indicative of malignant epidural spinal cord compression (MESCC). MESCC is a true oncologic emergency. The absolute most critical initial step in management is the immediate administration of high-dose intravenous corticosteroids (such as dexamethasone). Corticosteroids rapidly reduce the vasogenic edema surrounding the epidural tumor, thereby decreasing pressure on the spinal cord, restoring blood flow, and preserving neurologic function. This empirical therapy must be initiated instantly upon clinical suspicion, even before diagnostic imaging is performed, to prevent irreversible paralysis.

Step-by-Step Solution

Identify the clinical syndrome

The patient has progressive back pain, lower extremity weakness, sensory level at

T10

, upper motor neuron signs, and autonomic dysfunction (urinary retention).

These are the classic neurologic findings of a spinal cord compression.

Determine the most likely etiology

Given the established history of advanced prostate cancer and lack of infectious signs, this presentation is highly suspicious for malignant epidural spinal cord compression (MESCC).

Prostate cancer frequently metastasizes to the axial skeleton, placing the patient at high risk for epidural space invasion.

Select the most urgent initial intervention

Intravenous glucocorticoids (such as dexamethasone) must be administered immediately.

Corticosteroids decrease peritumoral vasogenic edema, relieving mechanical pressure on the spinal cord and preventing irreversible ischemic injury. This life-saving medical therapy must precede all diagnostic imaging.

Key Concept

Empirical management of Malignant Epidural Spinal Cord Compression (MESCC)

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