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This is the ninth in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed alternates publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).  


Question 9

BJ, a 65 yo woman with known non-small cell lung cancer, metastatic to her mediastinum,
contralateral lung, and supraclavicular lymph nodes, returns to your clinic for follow-up for her
cancer-related pain. She is getting chemotherapy, and has always expressed a desire for ‘the
most aggressive’ treatments available for her cancer.

She complains of 2 weeks of worsening, midline low back pain. She has noticed difficulty in
rising from chairs/toilet, and needed a wheelchair to make it into the clinic area today from the
parking garage due to weakness. Examination is notable for an unremarkable back/spine exam,
and 4/5 strength bilaterally in her lower extremities both proximally and distally.

You obtain a stat MRI which shows a T12 vertebral metastasis and cord compression.

In addition to administering glucocorticoids, then next best step is to:

a) Arrange an urgent radiation oncology consultation for the next day

b) Admit her to the hospital, and arrange a stat radiation oncology consultation

c) Admit her to the hospital, and arrange a stat spine surgery consultation

d) Adjust her pain medications appropriately, and instruct her to contact you immediately
if her pain or disability worsens

Discussion:

Correct answer is (c)

This is a medical emergency.

Vertebral metastases, putting a patient at risk for cord compression, should be
considered in any patient with new back pain and cancer. New or otherwise suspicious
back-pain can be evaluated urgently with a non-contrast MRI of the entire spine.

If patients have neurologic symptoms of LE weakness and/or bladder, bowel
dysfunction, it is a medical emergency and patients needs stat imaging, steroids, and
intervention. Neurologic deficits, once present, can rapidly progress to permanent
paraplegia within 24h.

The role of steroids + XRT vs steroids + surgery is unclear. A recent trial indicated
better outcomes with immediate surgery, especially for patients who came in with
severe weakness. 84% of patients vs 54% were ambulatory after treatment course with
surgery vs radiation without surgery. Actual practice has not necessarily caught up
with this, and will depend on local, institutional resources.

References

http://www.pallimed.org/2005/08/surgery-better-than-radiation-steroids.html
http://www.pallimed.org/2008/03/spinal-cord-compression-copd-prognosis.html
http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_237.htm
http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_238.htm

(For email readers – click here for the answer and discussion)

This Post Has One Comment

  1. This is absolutely a medical emergency, and stat surgical evaluation is necessary.

    I wonder about the rationale for including in the question the idea that patient "always expressed a desire for 'the most aggressive' treatments available for her cancer".

    This would be a case where I think you should be arguing for emergent surgical consultation even with a patient with much more comfort-based goals. Even in a patient who had decided against further chemotherapy, you'd still be advocating the stat consult (unless goals of care were strongly against surgery–but you'd better make sure the decision-maker is well-informed).

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