Spinal Cord Compression: An Obstructive Oncologic Emergency

Maryjo Osowski, RN, MSN, AOCN

Disclosures

Topics in Advanced Practice Nursing eJournal. 2002;2(4) 

In This Article

Case Study

Mr. B, 68 years old, comes to the oncology clinic for his scheduled appointment. The APN notices that he seems uncomfortable and walks much slower than usual. When asked about the presence of pain, Mr. B states: "The low back pain that I have had on and off for years is acting up again." He rates his pain as 3 to 4 (on a scale of 1 to 10) during the day but 7 to 8 at night, when he is in bed. Mr. B took several doses of oxycodone, but the drug only took the edge off his pain.

Mr. B's wife says she noticed that he had trouble getting up from the chair last night. On further questioning, Mr. B admits to some leg weakness and complains that his legs are cold and his feet are numb. He denies constipation and urinary retention. At the time of his diagnosis, Mr. B's cancer was confined to his prostate. He underwent a prostatectomy 9 months before presentation, and has done well since his surgery until the advent of these present complaints.

When asked to walk, Mr. B does so unsteadily, and he is unable to stand without holding on to a stationary object. He has bilateral leg weakness and some loss of pinprick sensation and cannot feel the vibration of the tuning fork in either leg. Muscle strength and sensory function are normal in the upper extremities. There is some percussion tenderness over his lumbar spine. His pain increases when he is asked to cough. A digital rectal examination reveals good sphincter tone. His mental status is normal, with memory and cognition intact.

Emergency MRI shows the vertebrae at L5 to be compressed by a tumor mass. The patient is admitted to the hospital and is immediately given a 100-mg bolus dexamethasone by slow IV push, as well as IV morphine. Fortunately, the hospital has a radiation therapy department, and although it is now 6 PM, on-call staff are able to administer the first dose of radiation therapy.

Mr. B receives 3 more 100-mg doses of dexamethasone, followed by 24 mg/d in divided doses. This dose is tapered gradually, reduced by one third every 3 days (from 24 to 20 to 16 mg and so on) over the 10-day course of radiation therapy. He requires morphine by patient-controlled analgesia pump for the first week of therapy, after which he administers fewer bolus dosesof morphine and is switched to oral long-acting morphine. Mr. B does not lose bladder or bowel control. He still has some muscle weakness and some numbness at discharge, but he rates his pain as 2 and states that he feels much better.

This case demonstrates the importance of early recognition of SCC. The patient was fortunate that it was time for his regularly scheduled appointment. Otherwise, he probably would have put off calling the clinic until his pain and weakness had progressed significantly, when it might have been too late to prevent bladder and bowel incontinence or paralysis. As it was, emergency radiation and steroid therapy ensured maintenance of function and good pain control. The APN obtained a thorough history, despite the fact that the patient minimized the condition as back pain he had experienced in the past. The APN also conducted a thorough physical examination and found some motor and sensory deficits in his legs. This case demonstrates the multidisciplinary nature of diagnosis and treatment of SCC and the necessity of having immediate radiation therapy available.

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