This is the ninth in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed alternates publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).
BJ, a 65 yo woman with known non-small cell lung cancer, metastatic to her mediastinum, contralateral lung, and supraclavicular lymph nodes, returns to your clinic for follow-up for her cancer-related pain. She is getting chemotherapy, and has always expressed a desire for ‘the most aggressive’ treatments available for her cancer.
She complains of 2 weeks of worsening, midline low back pain. She has noticed difficulty in rising from chairs/toilet, and needed a wheelchair to make it into the clinic area today from the parking garage due to weakness. Examination is notable for an unremarkable back/spine exam, and 4/5 strength bilaterally in her lower extremities both proximally and distally.
You obtain a stat MRI which shows a T12 vertebral metastasis and cord compression.
In addition to administering glucocorticoids, then next best step is to:
a) Arrange an urgent radiation oncology consultation for the next day
b) Admit her to the hospital, and arrange a stat radiation oncology consultation
c) Admit her to the hospital, and arrange a stat spine surgery consultation
d) Adjust her pain medications appropriately, and instruct her to contact you immediately if her pain or disability worsens
Correct answer is (c)
This is a medical emergency.
Vertebral metastases, putting a patient at risk for cord compression, should be considered in any patient with new back pain and cancer. New or otherwise suspicious back-pain can be evaluated urgently with a non-contrast MRI of the entire spine.
If patients have neurologic symptoms of LE weakness and/or bladder, bowel dysfunction, it is a medical emergency and patients needs stat imaging, steroids, and intervention. Neurologic deficits, once present, can rapidly progress to permanent paraplegia within 24h.
The role of steroids + XRT vs steroids + surgery is unclear. A recent trial indicated better outcomes with immediate surgery, especially for patients who came in with severe weakness. 84% of patients vs 54% were ambulatory after treatment course with surgery vs radiation without surgery. Actual practice has not necessarily caught up with this, and will depend on local, institutional resources.
http://www.pallimed.org/2005/08/surgery-better-than-radiation-steroids.html http://www.pallimed.org/2008/03/spinal-cord-compression-copd-prognosis.html http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_237.htm http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_238.htm
(For email readers - click here for the answer and discussion)