A 65-year-old man presents to the emergency department with severe back pain and weakness in his legs. He reports that the pain started a few weeks ago and has progressively worsened. He also mentions difficulty urinating and numbness in his lower extremities. He has a history of prostate cancer that is currently being treated with leuprolide. Vital signs are within normal limits. On physical examination, there is tenderness over the thoracic spine, decreased strength in the lower extremities, and hyperreflexia.
A) Administer corticosteroids
In the setting of suspected spinal cord compression due to metastatic cancer, the next best step in management is to administer corticosteroids. Corticosteroids help reduce inflammation and edema around the spinal cord, potentially preventing further neurologic deterioration while awaiting definitive treatment, such as surgery or radiation therapy.
Answer choice B: Initiate physical therapy, is incorrect. Physical therapy is not appropriate in the acute setting of suspected spinal cord compression and could potentially worsen the patient's condition.
Answer choice C: Order a lumbar puncture, is incorrect. A lumbar puncture is not indicated in this scenario and could be harmful if there is increased intracranial pressure or spinal cord compression.
Answer choice D: Prescribe oral analgesics, is incorrect. While analgesics may help with pain, they do not address the underlying cause of spinal cord compression and are not the next best step in management.
Answer choice E: Schedule an outpatient MRI, is incorrect. An MRI is essential for diagnosing spinal cord compression, but it should be done urgently, not on an outpatient basis. Immediate administration of corticosteroids is the priority.
Key Learning Point
Spinal cord compression due to metastatic cancer causes local spinal pain and neurologic symptoms such as weakness, sensory loss, paralysis, incontinence, urinary retention, and reflex changes. The next best step in management is to administer high-dose corticosteroids to reduce inflammation and prevent further neurologic damage and order a magnetic resonance imaging (MRI) scan.
