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Ecase # 16-C Dena Kennedy, M.D. August 5-9, 2002 CC: KW is a 55 YO woman with mid-back and chest pain, numbness in the legs, weakness, jerkiness, heavy sensation and "feeling like body is melting away." HPI: While on recent 2 week trip to Washington, DC she developed aching in the upper back, cramping and jerking sensations in her legs exacerbated by stretching or pointing her toes down. She also noted a sensation in both legs, as if her "nerves were on fire". She complained of a heavy sensation in the thighs, more noticeable when standing. When she walked she noted weakness and insecurity as though she might fall. Also there was a sense of numbness of both side of rib cage and sensation "like body is melting away." PMH: stage III non-small cell lung CA on R, S/P radiation Rx, chemotherapy, RU Lobectomy and excision of chest wall and ribs 2-4, 8/98. No known recurrence but recent Sx of parasympathetic nervous system asymmetry of face/neck and UE's; DM II; Obesity; Anemia; Asthma/COPD, hydrosalpinx. FH: Epilepsy, Parkinson's Dz; Brain tumor; metastatic CA of unknown primary Rx: Zocor; Vioxx PE: Unremarkable VS. Assistance needed to transfer from chair to exam table. HEENT, Neck, Cor and lungs neg. Back without localized spinal or paraspinal tenderness. Neuro: alert and oriented. DTR's 2+ UE, 3+ RLE, 4+ LLE. Babinski's positive. Sensory exam intact to light touch. Weakness distal greater than proximal. Lab previous wk: Normal CMP except CO2 19. FBS 108. Lipids excellent. CPK and aldolase nl. Hct 36.7. Discussion She has acute thoracic spinal cord compression until proven otherwise, most likely from epidural extension of newly recurrent lung CA (unlikely presentation of expanding hydrosalpinx with relatively acute and rapidly progressive symptoms) ; diabetic myelopathy a reasonable consideration as well. Other possibilities (such as spinal stenosis and cord compression from disc disease, viral transverse myelitis, multiple sclerosis of spinal cord, etc.) are much less likely. Emergent evaluation with MRI and emergent treatment with Decadron and radiation therapy is essential to preserve and improve nerve function and prevent paraplegia. Time is of the essence when evaluating and treating patients with this presentation. MRI confirmed large epidural tumor in the thoracic canal from T1 through T5 levels with tumor extending to the R T2-T3 foramen into the paraspinal soft tissues. This tumor showed marked homogenous enhancement with severe mass effect and edema of the cord. Cervical MRI revealed spondylosis with degenerative discs and small protrusions. Chest and abdominal CT scans 1 month previously showed old scarring and post-surgical changes plus minor incidental/non-contributory findings. This patient responded to emergent radiation and Decadron, with prompt improvement of symptoms, and was able to maintain ambulatory status. Further staging evaluation was planned with the hope that treatment might allow for extended survival, assuming the relapse was limited to the spine, and would respond to XRT. References could not be posted, but are available by FAX. Here is one of the abstracts: Unique Identifier
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