blurring of vision. She has weakness of her legs, minimal knee and absent ankle tendon reflexes,
a palpable bladder, a power of 2/5 at the hip, 3/5 at the knee and ankle, and tenderness over
the 2nd lumbar vertebra. There is reduced sensation in the perineum. She has been started on
dexamethasone 16mg daily.What is the single most likely cause of her weakness?
a. Paraneoplastic neuropathy
b. Progression of brain tumor
c. PID at L2/L3
d. Spinal cord compression
e. Steroid induced myopathy
answer: D
Local spine tenderness
Weakness and sensory loss all below L2
Bladder wall gets relaxing impulses from above L2 and contracting (emptying) impulses from below L2, so here there is urinary retention(it is palpable) as it is filling up but not emptying
N.b paraneoplastic neuropathy has patchy or asymmetric motor/sensory loss and also autonomic dysfunction e.g. heart rate, blood pressure, pupillary responses
National Institute for Health and Care Excellence (NICE) recommendations for the diagnosis and management of patients at risk of or with metastatic spinal cord compression
- The aims of the NICE guidelines are to accelerate the diagnosis of spinal cord compression and to ensure that appropriate specialist management, usually surgery and/or radiotherapy, is available within 24 hours of presentation. The goal is to prevent paralysis from metastatic spinal cord compression.
- The following symptoms suggest possible spinal metastases in those with cancer:
- Pain in the thoracic or cervical spine.
- Severe unremitting or progressive lumbar spinal pain.
- Spinal pain aggravated by straining (eg, coughing, sneezing, passing stool).
- Nocturnal spinal pain preventing sleep.
- Localised spinal tenderness.
- The
following symptoms suggest metastatic spinal cord compression in
patients with cancer and pain suggestive of spinal metastases:
- Radicular pain.
- Limb weakness.
- Difficulty in walking.
- Sensory loss, or bladder or bowel dysfunction.
- Neurological signs of spinal cord or cauda equina compression.
- MRI of the whole spine (not plain X-rays) should be carried out so that definitive treatment can be planned. This should be:
- Within one week if clinical features suggest spinal metastases.
- Within 24 hours if clinical features suggest spinal cord compression.
- Sooner (including out of hours) if emergency treatment is needed.
Management
- Nurse the patient flat with the spine in neutral alignment (eg, using logrolling or turning beds) until spinal and neurological stability are ensured.
- Give a course of dexamethasone unless contra-indicated until a definitive treatment plan is made.
- Manage postural hypotension with positioning and devices to improve venous return; avoid overhydration.
- Insert a catheter to manage bladder dysfunction.
- Use breathing exercises, assisted coughing, and suctioning to clear airway secretions.
- Follow the NICE guidance for the prophylaxis of venous thromboembolism, the prevention and treatment of pressure ulcers, and the management of bowel dysfunction.
- Offer and provide psychological and spiritual support as needed (including after discharge).
- Analgesia, palliative radiotherapy, spinal orthoses, vertebroplasty or kyphoplasty, or spine stabilisation surgery may be required for pain control.
- Bisphosphonates should be offered to all patients with vertebral involvement from myeloma and breast cancer and to patients with prostate cancer in whom conventional analgesia is inadequate.
- Specialist pain control procedures may be needed for intractable pain (eg, epidural analgesia).
- If definitive treatment of the cord compression is appropriate, it should be started before patients lose the ability to walk or other neurological deterioration occurs, and ideally within 24 hours.
- Definitive treatment may be using surgery (eg, laminectomy, posterior decompression ± internal fixation) or using radiotherapy.
- Discharge should be fully planned and community-based rehabilitation and support should be available when the patient returns home. This includes support and any necessary training of carers and families.
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