Neurology · Year 3 · from Neurology

Case 1: Acute Spinal Cord Compression from Metastatic Disease

Patient Demographics

  • Age: 67 years
  • Sex: Male
  • Occupation: Retired construction foreman

Chief Complaint

"I can't walk and I'm having trouble urinating."

History of Present Illness

The patient presents to the emergency department with progressive weakness in both legs over 5 days and new-onset urinary retention. He has had mid-back pain for 6 weeks, which he attributed to "old age" and prior work injuries. The back pain is constant, worse at night when lying down (red flag), and not relieved by rest. Over the past week, he noticed his legs felt "heavy" and he was stumbling. Yesterday, he could barely walk and needed his wife's help to get to the bathroom. This morning, he was unable to urinate despite feeling the urge. He has also noticed numbness from his belly button down. He has a history of prostate cancer diagnosed 4 years ago, treated with radical prostatectomy and radiation, with rising PSA over the past 6 months (not yet worked up).

Neurological Examination Findings

Mental Status:

  • Alert, oriented, anxious
  • GCS: 15

Cranial Nerves:

  • Intact II-XII

Motor Examination:

Muscle GroupRightLeft
Hip flexion (L1-L2)3/53/5
Knee extension (L3-L4)3/52/5
Ankle dorsiflexion (L4-L5)2/52/5
Ankle plantarflexion (S1-S2)2/51/5
Toe extension (L5)1/51/5
  • Upper extremities: 5/5 throughout
  • Increased tone in both legs (spasticity)

Sensory Examination:

  • Sensory level at T10 - decreased sensation below umbilicus
  • All modalities affected (light touch, pinprick, temperature)
  • Decreased proprioception in both feet
  • Saddle area: Decreased sensation

Reflexes:

  • Upper extremities: 2+
  • Patellar: 4+ bilateral (hyperreflexia)
  • Achilles: 4+ bilateral
  • Bilateral Babinski signs: Extensor (upgoing toes)
  • Clonus at ankles (>5 beats)
  • Absent bulbocavernosus reflex (sacral dysfunction)

Rectal Examination:

  • Decreased anal sphincter tone
  • Absent voluntary contraction
  • Diminished perianal sensation

Bladder:

  • Bladder scan: 800 mL residual (urinary retention)

Localization

  • Spinal cord lesion at approximately T10 level
  • Upper motor neuron pattern in legs (hyperreflexia, Babinski, spasticity)
  • Bladder and bowel dysfunction (conus involvement or bilateral cord compression)
  • Sensory level at T10

Neuro Workup - URGENT

MRI Entire Spine with Contrast (EMERGENT):

  • T9-T10: Pathological compression fracture of T9 vertebral body
  • Epidural soft tissue mass extending posteriorly from T9 vertebra
  • Severe spinal cord compression with cord signal change (T2 hyperintensity)
  • Additional lesions at T4, L2 vertebral bodies (no cord compression)
  • Findings consistent with metastatic disease

CT Chest/Abdomen/Pelvis:

  • Sclerotic bone lesions throughout axial skeleton
  • Enlarged pelvic lymph nodes
  • Consistent with metastatic prostate cancer

Laboratory Studies:

  • PSA: 285 ng/mL (markedly elevated)
  • Alkaline phosphatase: 342 U/L (elevated - bone involvement)
  • CBC, CMP: Normal
  • Coagulation: Normal

Diagnosis

Metastatic Epidural Spinal Cord Compression (MESCC) from prostate adenocarcinoma

Management - NEUROLOGICAL EMERGENCY

Immediate Interventions (within 1 hour of presentation):

  1. High-dose Dexamethasone:
  • 10 mg IV bolus immediately
  • Followed by 4 mg IV every 6 hours
  • Reduces peritumoral edema
  1. Urgent Consultations:
  • Neurosurgery: For surgical decompression consideration
  • Radiation Oncology: For emergent radiation therapy
  • Medical Oncology: For systemic therapy planning
  1. Bladder Care:
  • Foley catheter placement for urinary retention
  • Monitor output

Treatment Decision:

  • Given moderate neurological deficits (still ambulatory with assistance), both surgery and radiation are options
  • Decision: Surgical decompression followed by radiation therapy
  • Surgery indicated because: Unknown histology (though likely known prostate), moderate deficits, single level of symptomatic compression, good performance status

Surgical Treatment:

  • T9 corpectomy with anterior reconstruction
  • Posterior decompressive laminectomy T8-T10
  • Pedicle screw fixation T7-T11 for stabilization
  • Histopathology: Metastatic prostatic adenocarcinoma

Post-operative Radiation:

  • External beam radiation therapy: 30 Gy in 10 fractions to T9 region
  • Started 2 weeks post-operatively after wound healing

Systemic Therapy:

  • Androgen deprivation therapy (ADT): Leuprolide + abiraterone
  • Bone-targeting agent: Denosumab or zoledronic acid

Rehabilitation:

  • Acute inpatient rehabilitation
  • Physical therapy: Strengthening, mobility training
  • Occupational therapy: ADL training
  • Bladder training (intermittent catheterization vs indwelling)
  • Bowel program

Outcome

  • Post-operative improvement in leg strength (4/5 bilateral)
  • Resumed ambulation with walker at 2 weeks
  • Urinary function: Intermittent self-catheterization
  • Continued systemic therapy with good PSA response

Clinical Image

Image Description: Sagittal MRI of the thoracic spine showing vertebral body collapse with epidural extension causing severe spinal cord compression and cord signal abnormality (T2 hyperintensity indicating cord edema/injury).

Attribution: Image from Wikimedia Commons. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:SCIWORA_MRI.jpg

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