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The most likely diagnosis is cauda equina syndrome and steroids should be started prior to MRI
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16/22
The most likely diagnosis is cauda equina syndrome and steroids should be started after to MRI
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The most likely diagnosis is cauda equina syndrome and the patient should be rushed to radiation
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The most likely diagnosis is conus medullaris syndrome and steroids should be started prior to MRI
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The most likely diagnosis is conus medullaris syndrome and steroids should be started after to MRI
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The patient presents with signs and symptoms of cauda equina syndrome due to metastatic prostate cancer to the spine. The appropriate next step in management is to start IV steroids immediately and then to confirm the diagnosis on MRI. Cauda equina syndrome affects the spinal nerve rootlets. Patients present with asymmetric motor weakness, saddle anesthesia, hyporeflexia, and late-onset bowel and bladder dysfunction. Conus medullaris syndrome is marked by sudden-onset severe back pain with perianal anesthesia, symmetric motor weakness, hyperreflexia, and early onset bowel and bladder dysfunction. Once there is clinical suspicion of either of these entities steroids should be started immediately. Providers should not wait to start steroids until imaging has confirmed the diagnosis because the risk of the delay in steroid treatment is significant. Subsequent treatment involves either radiation or surgery and requires a neurological surgery evaluation. Casazza reviews diagnosis and treatment of acute lower back pain. This complaint is very common especially for family physicians. Red flags that should prompt aggressive treatment or referral to a spine specialists include trauma, major or progressive sensory deficit, new-onset bowel and bladder incontinence or urinary retention, loss of anal sphincter tone, saddle anesthesia, a history of cancer (especially metastases), and a history of a spinal infection or risk factors for spinal abscesses such as IV drug use and diabetes or immunodeficiency. Lefresne et al. discuss cauda equina syndrome from metastatic prostate cancer. The classic presentation includes severe back pain, bilateral lower extremity paresthesias, leg weakness, and urinary retention. Another cancer that may metastasize to the bone is breast cancer. However, in any patient with cancer, back pain should be a red flag. Illustration A depicts a classic MRI of cauda equina syndrome. Incorrect Answers: Answers 2-5: The patients symptoms are more consistent with cauda equina syndrome than conus medullaris syndrome, especially since he denies early bowel or bladder dysfunction. In any spinal compression emergency, steroids should be started prior to obtaining imaging since the delay in beginning steroids could be detrimental to neurological recovery.
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