A 72-year-old man with prostate cancer and spinal metastases presents to the emergency department with 12 hours of painful urinary retention, 3 days of worsening lower limb weakness, and a flare of his chronic back pain. 
A urinary catheter is inserted, which drains 1200mL of clear urine.


Neurological exam shows normal tone, reduced power (4/5) in both legs, reduced knee and ankle reflexes, upgoing plantars, and normal coordination. He has saddle anaesthesia and decreased anal tone on rectal examination.

MRI spine shows severe metastatic spinal cord compression from L1 to L3.

The neurosurgery team opts for conservative management, and 16mg dexamethasone is prescribed.

Which of the following is the best next step in the management of this patient?

Options:
explanation: Spinal braces are useful in immobilising the spine and provide support and stability. They are used in unstable spinal fractures to promote healing and reduce further instability. In this patient, however, there is no mention of spinal instability
name: Attach a spinal brace
label: c
answer: no
explanation: This will almost certainly be done while an inpatient to determine the progression of this patient's prostate cancer. However given this patient's new neurology findings, he requires urgent therapy to relieve his spinal cord compression to prevent permanent neurological damage
name: Staging CT scan to identify extra-spinal metastases
label: e
answer: no
explanation: Given this patient's new neurology findings he should have urgent radiotherapy within 24hrs to prevent permanent neurological damage. While dexamethasone is a crucial part of management of MSCC and cauda equina syndrome, we should not wait for a trial of dexamethasone as there is a risk of permanent neurological damage if the cord is not decompressed
name: Review neurology twice daily for 48hrs to asses response to dexamethasone, and then consider radiotherapy if abnormal neurology persists beyond 48 hours
label: b
answer: no
explanation: Given this patient's new neurology findings he should have urgent radiotherapy within 24hrs to prevent permanent neurological damage. While dexamethasone is a crucial part of management of MSCC and cauda equina syndrome, we should not wait for a trial of dexamethasone as there is a risk of permanent neurological damage if the cord is not decompressed
name: Urgent physiotherapy to prevent further deconditioning
label: d
answer: no
explanation: This patient has metastatic spinal cord compression (MSCC) and cauda equina syndrome secondary to a metastatic deposit in the lumbar spine which is impinging on the spinal cord. High dose dexamethasone is given to reduce inflammation around the tumour. Given this patient's new neurology findings, however, he should have urgent radiotherapy within 24hrs to prevent permanent neurological damage. Radiotherapy to the tumour can reduce pressure on the cord through tumour shrinkage and can achieve local tumour control
name: Urgent radiotherapy
label: a
answer: yes

Correct answer: a

Urgent radiotherapy

Learning point: Metastatic spinal cord compression requires urgent radiotherapy to prevent permanent neurological damage and alleviate symptoms caused by spinal cord compression.