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Chemotherapy
0%
0/7
Dexamethasone
29%
2/7
Palliative pain management
14%
1/7
Radiation therapy
Surgical decompression
43%
3/7
Select Answer to see Preferred Response
This patient with acute onset back pain, saddle anesthesia, bilateral lower extremity weakness, spinal cord edema, and history of breast cancer is concerning for epidural spinal cord compression (ESCC) secondary to metastatic breast cancer. The most appropriate next step in management is high-dose corticosteroids (e.g., dexamethasone). Neoplastic ESCC is a common complication from metastatic cancer and can result in permanent loss of neurologic function if not promptly identified and treated. When cancer (e.g., breast and prostate cancer) metastasize to the vertebral bodies, invades the epidural space, and compresses the spinal cord, leading to vasogenic edema. Initial management of ESCC is with high-dose corticosteroids, which can improve neurological symptoms, and serves as a bridge to definitive treatment with surgical decompression and/or radiation therapy. Figure/Illustration A demonstrates spinal cord compression (red arrow) leading to spinal cord edema (blue arrow). Incorrect Answers: Answer 1: Chemotherapy is indicated in managing her systemic malignancy, but would not be appropriate in the acute setting of ESCC as the patient is at significant risk of permanent loss of neurologic function. Answer 3: Palliative pain management is useful in managing the pain associated with ESCC. Pain management can make the patient more comfortable participating in a neurological examination, however, this will delay prompt administration of corticosteroids and definitive treatment. Answer 4: Radiation therapy to the spine is a definitive treatment option for ESCC after prompt steroid administration and is indicated in radiosensitive metastatic lesions (e.g., breast, lymphoma, and small cell lung cancer) with a stable spine (e.g., vertebral body collapse and junctional spine involvement such as T11-L1) Answer 5: Surgical decompression is a definitive treatment option for ESCC after prompt steroid administration is in indicated in an unstable spine with boney fragment retropulsion into the spinal cord, or high-grade ESCC with radioresistant metastatic lesions. Bullet Summary: The first step in management in a patient with epidural spinal cord compression is with high-dose corticosteroids.
4.8
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