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Case History

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Image not available. A 65-year-old man presents with thoracic back pain, tiredness and a 24-hour history of leg weakness (Medical Research Council Scale muscle power 4). His back pain has been present for three months. An urgent whole-spine MRI reveals a single-level lesion at T5 causing cord compression (Figure 31.1). There is no significant past medical history and examination reveals no other abnormality.

What underlying malignancies would you consider in your differential diagnosis?

What is the immediate management?

What are the options for treatment and how do you assess which is the most appropriate?

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Figure 31.1

Axial T2-weighted (fluid white) magnetic resonance image showing soft tissue metastasis causing cord compression at the mid-thoracic level.

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Background

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What underlying malignancies would you consider in your differential diagnosis?

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Image not available. Prostate cancer is the most likely diagnosis in men of this age group. It frequently presents at diagnosis with signs and symptoms of metastatic disease, and may present with metastatic spinal cord compression (MSCC). The diagnosis of prostate cancer would usually be confirmed by clinical examination of the prostate and elevated PSA level. Other common primary sites would include lung cancer and myeloma, with renal and thyroid cancer being less common. In women, the breast would be the most common site of origin.

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Although it would be uncommon for lymphoma to present in this way it must always be considered in the differential diagnosis. If lymphoma is suspected then a biopsy must be undertaken prior to commencement of any steroids. Treatment with corticosteroids prior to biopsy may prevent a diagnosis being made.

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What is the immediate management?

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Any patient presenting with signs or symptoms suggesting MSCC should be treated as outlined in the National Institute for Health and Care Excellence (NICE) guidance CG75 (see also Figure 31.2).1 They should be laid flat to avoid further damage from a potentially unstable spine and to improve perfusion of the spinal cord. High-dose steroids are recommended (16 mg dexamethasone daily with proton pump inhibitor cover) to reduce oedema and inhibit prostaglandin synthesis. These should be used unless contraindicated, or if there is a high clinical suspicion of lymphoma. Clinical trials have shown no statistical benefit and increased side effects with very high-dose steroids (100 mg) and their use is therefore not recommended.2 Appropriate analgesia should be given to the patient.

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Figure 31.2

Flow chart for diagnosis and treatment of MSCC. PPI, proton pump inhibitor.

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MSCC is an oncological emergency and should be diagnosed from an MRI scan of the whole spine done within 24 hours of neurological signs/symptoms developing.1,3 Following diagnosis, rapid treatment is required as extrinsic compression of the ...

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