CIM Case: Spinal Cord Compression - Oncology
Clinical Scenario
Patient: 68-year-old man
Presentation: 2-week history of progressive back pain, 3-day history of bilateral leg weakness, urinary hesitancy since yesterday
Relevant history: Metastatic prostate carcinoma diagnosed 3 years ago (hormone-sensitive initially, now castration-resistant), known bone metastases (ribs, pelvis), recent PSA rise from 4 to 85 ng/mL, back pain worsening despite analgesia, weight loss 6kg over 2 months
Examination findings:
Pain score 8/10, pain with percussion over T8-T10
Bilateral lower limb weakness (MRC grade 3/5 hip flexion, 4/5 knee extension)
Brisk knee and ankle reflexes bilaterally
Upgoing plantars bilaterally (Babinski positive)
Sensory level at T10 (reduced pinprick and light touch below)
Distended bladder (1200mL on catheterisation)
Anal tone reduced
Upper limb neurologically normal
Mild hypotension (BP 105/65)
Investigations Provided
Laboratory Results
Test Result Normal Range Interpretation Hb 102 g/L 130-170 g/L ↓ Anaemia of chronic disease WCC 8.5 ×10⁹/L 4-11 ×10⁹/L Normal Platelets 195 ×10⁹/L 150-400 ×10⁹/L Normal CRP 45 mg/L <5 mg/L ↑ Elevated ESR 65 mm/hr <20 mm/hr ↑ Elevated PSA 85 ng/mL <4 ng/mL ↑↑ Markedly elevated ALP 380 U/L 30-120 U/L ↑ Elevated (bone turnover) Calcium 2.65 mmol/L 2.2-2.6 mmol/L ↑ Mildly elevated Albumin 32 g/L 35-50 g/L ↓ Low Creatinine 118 μmol/L 60-110 μmol/L ↑ Mildly elevated
Imaging
Image 1: MRI Whole Spine with Contrast
Findings:
T9 vertebral body: near-complete replacement with tumour
Posterior cortex breached with epidural extension
Spinal cord compression at T9 level (>50% canal compromise)
Cord signal change (oedema visible on T2)
Additional vertebral body metastases at T4, L2, L4 (no cord compression)
Paraspinal soft tissue mass at T9
No intraspinal haematoma
Image 2: CT Thorax/Abdomen/Pelvis
Findings:
Multiple blastic and mixed bone metastases (typical prostate pattern)
No visceral metastases
Moderate prostatic enlargement
No lymphadenopathy
No lung metastases
Questions & Model Answers
Q1
What is the diagnosis and what is the urgency?
Reveal Answer Q2
What scoring systems guide management and prognosis?
Reveal Answer Q3
What is your immediate management?
Reveal Answer Q4
What are the treatment options for MSCC?
Reveal Answer Q5
Describe the surgical technique for posterior decompression and stabilisation.
Reveal Answer Q6
What factors predict neurological outcome in MSCC?
Reveal Answer Key Teaching Points
Pattern Recognition
This pattern suggests Metastatic Spinal Cord Compression:
Known malignancy + progressive back pain
Bilateral lower limb weakness (upper motor neuron pattern)
Sensory level on examination
Bladder/bowel dysfunction (late sign, poor prognostic)
Pain worse at night or with recumbency
Progressive over days to weeks
Red Flags for Spinal Metastases (CES-M):
Red Flag Significance Known cancer High pre-test probability Age >50 with new back pain Increased malignancy risk Night pain Suggests malignancy Weight loss Constitutional symptom Progressive neurological deficit EMERGENCY Bladder/bowel dysfunction EMERGENCY
Critical Management Points
Dexamethasone 16mg STAT - reduce cord oedema immediatelyMRI whole spine - multiple levels in 30% of casesTreat within 24-48 hours - neurological outcome depends on timingMDT discussion - oncology, spine surgery, radiation oncologySINS for stability - guides surgical decisionTokuhashi for prognosis - guides extent of interventionGoals of care - maintain/restore function, not necessarily cure
Common Examiner Follow-ups
Q: "What tumours are radiosensitive vs radioresistant?"
Radiosensitive Radioresistant Prostate carcinoma Renal cell carcinoma Breast carcinoma Melanoma Multiple myeloma Sarcoma Lymphoma Non-small cell lung cancer Small cell lung cancer Colorectal cancer Seminoma Thyroid carcinoma
Radiosensitive tumours may be treated with RT alone. Radioresistant tumours often require surgery for local control.
Q: "What is separation surgery?"
Separation surgery is a modern concept combining:
Surgical decompression to create space between tumour and spinal cord (2-3mm gap)
Stabilisation with instrumentation
Post-operative stereotactic radiosurgery (SBRT) to the tumour
Advantages:
Allows high-dose RT to tumour while protecting cord
Less extensive surgery than en bloc resection
Suitable for radioresistant tumours
Q: "When would you consider palliative care only?"
Indications for best supportive care:
Complete paraplegia for >48-72 hours
Expected survival <3 months
Multiple levels with extensive disease
Patient preference (after informed discussion)
Severe medical comorbidities precluding intervention
Haemodynamic instability
Palliative care includes:
High-dose steroids (for symptom relief)
Optimal analgesia
Nursing care (pressure areas, catheter, bowels)
Psychological support
End-of-life planning
Q: "What is the role of bisphosphonates or denosumab?"
Bone-modifying agents in metastatic bone disease:
Reduce skeletal-related events (fractures, MSCC)
Zoledronic acid 4mg IV monthly OR Denosumab 120mg SC monthly
Start after acute management of MSCC
Monitor renal function (zoledronic acid)
Risk of osteonecrosis of jaw (dental review before starting)
Spinal Instability Neoplastic Score (SINS)
Tokuhashi Score
Metastatic Bone Disease
Prostate Cancer Bone Metastases
Spinal Instrumentation Techniques
Palliative Orthopaedics