Should I start a patient with steroids if the CT scan of the lumbar spine shows an L5 collection and the CT scan of the thoracic spine shows a probable T9 mass?

Management of Spinal Masses and Collections

Steroids should not be started for a patient with an L5 collection and probable T9 mass until a definitive diagnosis is established through appropriate imaging and possibly biopsy, as steroid administration may interfere with diagnostic accuracy and potentially worsen outcomes depending on the underlying pathology.

Diagnostic Considerations

• CT scans showing an L5 collection and probable T9 mass require further evaluation before initiating steroid therapy, as these findings could represent various pathologies including infection, tumor, or other inflammatory processes 1
• MRI is the preferred imaging modality for spinal lesions and should be performed as soon as possible to reach a final diagnosis, especially when neurological deficits are present 1
• When possible, MRI should be performed before any surgical intervention to better guide the surgical approach and improve outcomes 1

Steroid Considerations in Spinal Pathology

Potential Risks of Premature Steroid Administration:

• Steroids can mask infections, potentially leading to delayed diagnosis and treatment of spinal infections 1
• Administration of steroids can cause secondary adrenal insufficiency and altered immune response that may last up to 4 weeks with methylprednisolone, and up to 2 months in some patients 1
• Steroids may interfere with diagnostic procedures, particularly if spinal infection is suspected 1
• In patients with spinal tumors, steroid use may impact the efficacy of subsequent immunotherapy if that becomes necessary 1

Evidence Against Routine Steroid Use:

• After post-traumatic spinal cord injury, early administration of steroids is not recommended to improve neurological prognosis (Grade 1 recommendation) 1
• For chronic low-back pain without radiculopathy, trigger point injections with steroids are not recommended as they don't provide long-lasting benefit (Level II evidence) 1

Appropriate Indications for Steroid Use:

• Steroids are indicated in cases of symptomatic tumor-associated brain edema, with dexamethasone being the drug of choice (4-16 mg/day) 1
• In cases of spinal cord compression from metastatic cancer, high-dose dexamethasone (96 mg/day) has shown improved ambulation outcomes, though with significant toxicity (11-29%) 1
• For patients with significant mass effect from brain tumors, steroids should be administered for at least 24 hours before radiation therapy 1

Management Algorithm

1. Complete diagnostic workup first:

   • Obtain MRI of the thoracic and lumbar spine to better characterize the L5 collection and T9 mass 1
   • Consider biopsy of the lesions if the diagnosis remains unclear after imaging 1

2. Initiate steroids only for specific indications:

   • If spinal cord compression with neurological deficits is confirmed: Consider dexamethasone 1
   • If metastatic tumor with symptomatic edema: Dexamethasone 4-16 mg/day 1
   • If infection is suspected: Avoid steroids and pursue appropriate antimicrobial therapy 1

3. Monitor for steroid-related complications if initiated:

   • Increased risk of infections, particularly pneumocystis jiroveci pneumonia with treatment >4 weeks 1
   • Potential for hyperglycemia, hypertension, myopathy, and psychiatric effects 2
   • Consider prophylaxis against gastrointestinal complications with H2 blockers or proton pump inhibitors 1

Common Pitfalls to Avoid

• Starting steroids before establishing a diagnosis can mask symptoms and complicate the diagnostic process 1
• Failing to recognize that steroids can worsen outcomes in certain conditions like infections 1
• Using high-dose steroids without clear indications increases the risk of serious side effects 1
• Not monitoring patients closely for steroid-related complications once therapy is initiated 2

Conclusion

The decision to start steroids in a patient with spinal lesions should be based on a definitive diagnosis. For the patient with an L5 collection and probable T9 mass, complete the diagnostic workup with MRI and possible biopsy before considering steroid therapy, as premature administration may interfere with diagnosis and potentially worsen outcomes.