Hematology Oncology · Year 2 · from Hematology Oncology

Case 3: Malignant Spinal Cord Compression

Patient Presentation

Demographics: 65-year-old female

Chief Complaint: Progressive back pain with leg weakness

History of Present Illness: The patient has metastatic breast cancer with known bone metastases. She developed new mid-back pain 2 weeks ago, initially attributed to muscle strain. The pain has progressively worsened and is now severe, worse at night, and radiates around her chest "like a band." Over the past 3 days, she has developed progressive leg weakness and difficulty walking. Today she noticed she cannot feel when she needs to urinate.

Past Medical History:

  • Metastatic breast cancer (ER+, HER2-)
  • Bone metastases (spine, pelvis)
  • On hormonal therapy

Physical Examination:

  • Back: Point tenderness at T8
  • Motor: Bilateral lower extremity weakness (3/5)
  • Sensory: Sensory level at T10 (decreased sensation below)
  • Reflexes: Hyperreflexia in lower extremities, upgoing plantar responses
  • Bladder: Palpable bladder (urinary retention)

Workup and Results

MRI Spine (Emergent):

  • Epidural tumor at T8 with severe spinal cord compression
  • Near-complete obliteration of thecal sac
  • Cord signal changes (edema)

Labs:

  • CBC: Normal
  • Calcium: 10.8 mg/dL (normal)

Clinical Image

MRI demonstrating malignant spinal cord compression from metastatic tumor causing epidural mass effect with compression of the spinal cord (arrow) and signal changes indicating cord edema.

Diagnosis

Malignant Spinal Cord Compression - Oncologic Emergency

Clinical features:

  • Progressive back pain (worse at night, positional)
  • Neurological deficits (weakness, sensory level)
  • Bowel/bladder dysfunction (late sign)
  • Known malignancy with bone metastases

Discussion

This case illustrates spinal cord compression:

  • Warning Signs: The lecture emphasizes that back pain with neurologic symptoms in a cancer patient should prompt urgent evaluation. Pain worse at night or with recumbency is a red flag.
  • Presenting Symptom: The lecture notes that back pain is the most common presenting symptom, often preceding neurological deficits by weeks. The pain is often described as band-like at the level of compression.
  • Bowel/Bladder Dysfunction: The lecture identifies bowel/bladder dysfunction as a late finding indicating more severe compression. Urinary retention is more common than incontinence initially.
  • Prognosis: The lecture states that ambulatory status at diagnosis is the most important predictor of outcome. Patients who are walking when treated usually remain ambulatory; those who are paraplegic rarely recover.

Treatment Plan

  1. High-Dose Steroids (Immediate):
  • Dexamethasone 10 mg IV bolus
  • Then 4-16 mg IV every 6 hours
  • Reduces vasogenic edema
  1. Urgent Imaging:
  • MRI of entire spine (other levels may be involved)
  • CT if MRI contraindicated
  1. Definitive Treatment (within 24-48 hours):
  • Surgical decompression if:
  • Single level, spinal instability, unknown primary, rapidly progressive
  • Radiation therapy:
  • For radiosensitive tumors (lymphoma, myeloma, breast, prostate)
  • When surgery not feasible
  1. Supportive Care:
  • Foley catheter for retention
  • DVT prophylaxis (immobility)
  • Pain management
  • Bowel regimen (opioids + immobility)
  1. Oncology/Spine Surgery/Radiation Oncology:
  • Multidisciplinary urgent consultation

Teaching Points

  1. Back pain in cancer patient = spinal cord compression until proven otherwise
  2. High-dose steroids immediately upon suspicion
  3. MRI entire spine (25% have multiple levels)
  4. Ambulatory status at diagnosis predicts outcome
  5. Bowel/bladder dysfunction is a late sign - don't wait for it

Image Reference

For visual reference of oncology emergency concepts, see:

Learning Points

  1. Febrile Neutropenia: ANC <500 + fever = immediate broad-spectrum antibiotics within 60 minutes
  1. TLS Electrolytes: High K, high phos, high uric acid, LOW calcium
  1. TLS Prevention: Aggressive hydration + allopurinol/rasburicase in high-risk patients
  1. Spinal Cord Compression: High-dose steroids immediately; MRI entire spine
  1. Prognostic Factor: Ambulatory status at diagnosis predicts cord compression outcome

All cases for this lecture as Markdown