Department: ACTION STAT
Lucas, Stephanie M. MSN, RN, OCN
Adjunct Faculty Duquesne University School of Nursing Pittsburgh, Pa.
The author has disclosed that she has no financial relationships related to this article.
What's the situation?
MS. L, 63, ARRIVES in the outpatient chemotherapy clinic for her scheduled treatment. During your assessment, she tells you her back has been aching for the last 2 days. She's been taking acetaminophen at home with no relief. Ms. L was diagnosed with multiple myeloma 10 months ago and a recent bone scan revealed several new lesions. She's been coming to the clinic once a month for chemotherapy.
What's your assessment?
Ms. L says her back pain woke her up during the night about 2 days ago. She denies any recent falls or trauma. The back pain originates in the lower thoracic region of her spine. She describes it as a constant ache that radiates to both legs and is exacerbated by ambulation or other movement. Ms. L also reports decreased sensation and tingling in both feet. Her gait appears ataxic. On exam, she has 3/5 muscle strength and decreased deep tendon reflexes in both legs. She denies any recent changes in bowel or bladder function.
Multiple myeloma can cause skeletal destruction from the formation of osteolytic lesions. These lesions can invade the epidural space or cause a pathologic fracture. Either of these complications will compress the spinal cord.
Based on the history and physical assessment findings, Ms. L is likely experiencing malignant spinal cord compression (MSCC). Notify the healthcare provider at once; a delay in diagnosis or treatment can lead to severe neurologic impairment such as paraplegia.
What must be done immediately?
Ms. L is transferred to the ED for further evaluation. She's sent for an emergency magnetic resonance imaging of the spine for a definitive diagnosis of MSCC. If spinal cord compression is identified, she'll receive dexamethasone to reduce spinal cord edema and help control pain. Initial pain management with an I.V. or oral opioid is also a high priority to alleviate discomfort associated with cord compression. She's immediately sent to radiation oncology for external beam radiation therapy (EBRT) to control the spinal cord lesion and preserve neurologic function.
What should be done later?
Monitor Ms. L's pain intensity level and neurologic status including motor, sensory, and bowel and bladder function every 4 hours to detect changes suggesting complications from MSCC, including paresis. Depending on her response to EBRT, a neurosurgeon may be consulted for a laminectomy.
Permanent neurologic and sensory deficits may remain as a result of spinal cord damage. Collaboration with physical and occupational therapy can help Ms. L with residual motor deficits. Ensure that fall prevention strategies are in place. Teach her to promptly report any episodes of back pain, numbness or tingling, or changes in bowel or bladder function. When she's discharged home, refer her to social services or local support groups and ensure that family members or neighbors will be able to assist her in the event of another cord compression or other emergency.
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