What's the next step for a 65-year-old female with a history of breast cancer, recent lung biopsy showing metastases, and now presenting with left-sided back pain?

Urgent MRI of the Entire Spine Within 12 Hours

This patient requires an urgent MRI of the entire spine within 12 hours to evaluate for spinal metastases with potential epidural spinal cord compression (MESCC), given her metastatic breast cancer and new-onset back pain. 1

Immediate Diagnostic Workup

Primary Imaging

• Obtain sagittal T1-weighted MRI of the entire spine immediately (within 12 hours maximum) as this is the gold standard for diagnosing spinal metastases and detecting epidural compression 1
• Both T1- and T2-weighted sequences are essential to demonstrate spinal metastases and epidural involvement 1
• Plain radiographs, CT scans, and bone scintigraphy cannot exclude spinal metastases and should not be used as screening tools 1

Clinical Assessment Priority

• Perform focused neurological examination immediately to assess for:
  • Motor weakness in lower extremities 1
  • Sensory deficits or radicular symptoms 1
  • Sphincter dysfunction (bowel/bladder control) 1
  • Gait abnormalities 1

Risk Stratification Based on Symptoms

The urgency of imaging depends on the clinical presentation 1:

• Local back pain only: MRI within 2 weeks
• Unilateral radicular pain: MRI within 1 week
• Progressive radicular deficit developing over >7 days: MRI within 48 hours
• Progressive radicular deficit developing within 7 days: MRI within 24 hours
• Clinical suspicion of MESCC (any neurological symptoms): MRI within 12 hours 1

Given this patient's recent lung metastases diagnosis (9 days ago) and new back pain, she falls into the high-risk category requiring urgent evaluation. 1

Immediate Management Pending MRI Results

If MESCC is Suspected or Confirmed

• Start high-dose dexamethasone 16 mg/day immediately if there is any clinical suspicion of cord compression, even before MRI confirmation 1
• Obtain urgent neurosurgical or orthopedic spine consultation (within hours, not days) 1
• Treatment must begin within 24 hours of MESCC diagnosis to prevent irreversible paralysis 1

Treatment Algorithm Based on MRI Findings

If spinal metastases WITHOUT cord compression:

• Radiotherapy is first-line treatment for symptomatic spinal metastases 1
• Single fraction of 8 Gy is equally effective and more cost-effective than fractionated doses 1
• Add bisphosphonates for pain relief in addition to radiation 1

If MESCC WITH neurological symptoms and good performance status:

• Immediate neurosurgical decompression followed by radiotherapy is recommended 1
• Surgery and radiotherapy are equivalent options for MESCC-induced deficits; choice should be made via urgent multidisciplinary discussion 1
• If surgery is not feasible, emergency radiotherapy is the treatment of choice 1

If spinal instability is present:

• Surgery is the preferred treatment regardless of neurological status 1
• Patient must have life expectancy ≥3 months to be eligible for surgery 1

Critical Pitfalls to Avoid

• Do not wait for plain X-rays or bone scan results - these cannot exclude spinal metastases and will delay appropriate imaging 1
• Do not delay MRI to obtain other staging studies - spinal cord compression is a medical emergency with a narrow window for intervention 1
• Do not assume pain is musculoskeletal - in a patient with known metastatic cancer, back pain is metastatic disease until proven otherwise 2, 3
• Do not delay starting dexamethasone if there is any suspicion of neurological involvement while awaiting MRI 1

Additional Considerations

• The recent CT-guided lung biopsy (9 days ago) makes post-procedural complications (pneumothorax, bleeding) less likely as the cause of back pain, but these should still be briefly considered 2
• Breast cancer has high propensity for bone metastases, with bone being the most common metastatic site 3
• The natural history of untreated spinal cord compression is relentless progression to complete and irreversible paralysis 2
• Time is critical: delays in diagnosis and treatment are the primary cause of poor neurological outcomes 1