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Suspected metastatic spinal cord compression — MSRA MCQ

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HardProstate CancerSuspected metastatic spinal cord compressionMSRA

A 72-year-old man with locally advanced prostate cancer is receiving leuprorelin after radical radiotherapy. He has type 2 diabetes treated with metformin and gliclazide. He reports 10 days of progressive mid-thoracic pain that wakes him at night and is markedly worse on standing, coughing and turning. Since this morning, both legs have felt heavy and he has become unsteady. Examination shows localised thoracic tenderness, a broad-based gait, symmetrically brisk knee reflexes, extensor plantar responses and reduced pinprick sensation below the umbilicus. Lower-limb power is 4+/5. He has no bladder or bowel dysfunction and is haemodynamically stable. Which is the most appropriate immediate management?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Contact the MSCC coordinator immediately, immobilise him for transfer, give dexamethasone 16 mg, and arrange whole-spine MRI within 24 hours

Explanation lettering: D = shown as A · E = shown as B · B = shown as C · C = shown as D · A = shown as E

This is suspected metastatic spinal cord compression (MSCC): he has cancer, progressive mechanical and nocturnal spinal pain, gait disturbance, limb weakness, a sensory level and upper motor neurone signs. Bladder or bowel dysfunction is not required. MSCC with neurological features is an oncological emergency requiring immediate contact with the MSCC coordinator and whole-spine MRI as soon as possible, always within 24 hours. His movement-related pain and neurological signs raise concern about spinal instability, so immobilisation should begin without delay, including during transfer. Dexamethasone 16 mg should be given as soon as possible and continued daily while definitive surgery or radiotherapy is awaited. Diabetes does not justify withholding urgently indicated corticosteroids; blood glucose should instead be monitored and treatment adjusted, with proton-pump inhibitor gastroprotection. A is incorrect because MRI, rather than CT, is the definitive emergency investigation, mobilisation may worsen an unstable lesion, and corticosteroids should not await imaging. B uses an inappropriate referral pathway and timeframe. C resembles management of pain suggesting spinal metastases without neurological findings, for which advice within 24 hours and MRI within 1 week may apply; this patient has cord-compression signs. E correctly recognises the emergency and imaging timeframe but omits necessary immobilisation and incorrectly treats diabetes as a contraindication to dexamethasone.

Reference: Spinal metastases and metastatic spinal cord compression: recommendations (6 September 2023) — https://www.nice.org.uk/guidance/ng234/chapter/recommendations Spinal metastases and metastatic spinal cord compression: immobilisation and corticosteroid therapy (6 September 2023) — https://www.nice.org.uk/guidance/ng234/chapter/recommendations