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Suspected metastatic spinal cord compression due to prostate cancer — MSRA MCQ

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HardProstate CancerSuspected metastatic spinal cord compression due to prostate cancerMSRA

A 70-year-old man with metastatic hormone-sensitive prostate adenocarcinoma and known thoracic vertebral metastases contacts his GP out of hours. He has developed progressively severe mid-thoracic pain over 5 days, which is worse on coughing and now wakes him at night. Since this morning, he has had a band-like shooting pain around the left chest wall. He has normal lower-limb power and gait, no sensory loss, and no bladder or bowel symptoms. He has type 2 diabetes treated with metformin. What is the most appropriate immediate management?

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

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Correct answer: E — Immediately contact the MSCC coordinator, arrange spinal MRI as soon as possible and within 24 hours, and give dexamethasone 16 mg orally now with glucose monitoring and proton-pump inhibitor cover

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

This is suspected metastatic spinal cord compression (MSCC), not uncomplicated metastatic bone pain. In a person with cancer, progressive severe thoracic pain, pain aggravated by straining and night pain suggest spinal metastases; new radicular pain is specifically a symptom suggesting cord compression. The absence of weakness, gait disturbance and sphincter dysfunction does not reduce this to a routine referral pathway. NICE advises immediate contact with the MSCC coordinator and treatment as an oncological emergency when symptoms or signs of cord compression occur. MRI should be performed as soon as possible, always within 24 hours. Dexamethasone 16 mg orally, or an equivalent parenteral dose, should be given immediately and continued daily while awaiting definitive surgery or radiotherapy. Because he has diabetes, glucose monitoring is required; NICE also advises proton-pump inhibitor acid suppression during corticosteroid treatment. A incorrectly uses the pathway for suspected spinal metastases without features of cord compression. B wrongly delays dexamethasone despite radicular pain. C uses an inappropriate corticosteroid regimen. E may become relevant to systemic cancer management but neither CT nor initiation of a GnRH agonist replaces the emergency MSCC pathway; treatment decisions should follow urgent specialist assessment.

Reference: Spinal metastases and metastatic spinal cord compression (NG234): Recommendations (2023) — https://www.nice.org.uk/guidance/ng234/chapter/recommendations Spinal metastases and metastatic spinal cord compression (NG234): Recommendations (2023) — https://www.nice.org.uk/guidance/ng234/chapter/recommendations Spinal metastases and metastatic spinal cord compression (NG234): Recommendations (2023) — https://www.nice.org.uk/guidance/ng234/chapter/recommendations