CAPÍTULO 2: CARACTERÍSTICAS DEL TREN DE ATERRIZAJE PARA LA
2.4 ESFUERZOS CORTANTES
so, is the neurological deficit typical of spinal cord compression? Look for bilateral weakness and increased tone with extensor plantar
responses. Look for a sensory level consistent with the description of girdle-type pain. Remember to check perianal sensation at the same time as you perform rectal examination. Look at the back for obvious spinal deformity. The patient may also have pain on palpation consistent with vertebral collapse secondary to metastatic tumour.
Investigation
The priority is obviously to obtain imaging of the spine: plain radiographs may reveal obvious vertebral collapse or associated vertebral disease (Fig. 2). However, the definitive test, required urgently, is an MRI scan of the spinal axis to define the presence and level(s) of
spinal cord compression (Fig. 3a). Gadolinium contrast enhancement helps to delineate between
leptomeningeal disease and intramedullary metastases. It will also be appropriate to check FBC, creatinine, electrolytes, bone and liver function tests and a CXR.
Fig. 2 (a) Plain pelvic radiograph and (b) technetium-99 pyrophosphate bone scan of the corresponding
area from a patient with sclerotic bone metastases of prostate cancer. (a)
Management
Other aspects that require attention include pain relief (see Pain Relief and Palliative Care, Section 2.1), bladder catheterisation (if the patient is suffering from urinary retention) and nursing care to avoid pressure area damage (if he has severe paresis and/or sensory loss).Further comments
Fig. 3 (a) MRI demonstrating cord compression at T11 due to vertebral metastasis with soft-tissue extension and (b) plain radiograph following surgical
decompression and stabilisation.
Spinal cord compression is a medical emergency: treatment should be started immediately on clinical suspicion.
Preservation of gait and continence requires prompt diagnosis and treatment.
High-dose intravenous
corticosteroids should be initiated on clinical suspicion alone to prevent further evolution of any neurological deficit: give dexamethasone 10 mg iv stat, then 4 mg po qds.
If the overall condition of the patient makes it appropriate, a neurosurgical opinion should be obtained about the potential for surgical decompression, especially if there is vertebral instability (Fig. 3) or if the level of the compression has been previously irradiated. Otherwise, the definitive treatment is urgent local radiotherapy.
If the patient can walk at presentation with malignant cord compression, there is an 80% chance that his ability to walk can be preserved with appropriate treatment. A multidisciplinary team approach with active rehabilitation following treatment is required to optimise neurological recovery.
1.4.3 Breathless, hoarse, dizzy
and swollen
Scenario
You are asked to see and assess a 65-year-old woman who has been sent for assessment as a medical emergency. She had been booked an appointment for the chest clinic in 2 week’s time, but has deteriorated over the last 2 days with worsening shortness of breath and dizziness.
She is a heavy smoker (50 pack-years) and has been complaining of a persistent but worsening productive cough with occasional streaks of blood in the sputum for some months. In the last few days she has noted that she is becoming more short of breath when she walks to the shops for her cigarettes; also
The first priority must be to assess the patient’s airway because airway compromise is an emergency. She has a hoarse voice, but is she short of breath at rest, does she speak in broken sentences and is she cyanosed? In particular, does she have inspiratory and/or expiratory stridor? Elicit this (if it is not obvious when she breathes normally) by asking her to open her mouth and take a deep breath in and out as fast as she can.
Given the clinical suspicion in this case, look carefully for oedema and discoloration of the face and arms, and also for collateral veins. Check for lymphadenopathy in the neck. The most important clinical sign in making the diagnosis of SVCO is loss of pulsation in the veins of the neck.
In the chest itself, look for the likely signs of chronic obstructive
pulmonary disease, as well as for evidence of a pleural effusion. Palpate the breasts carefully and note if the liver is palpable in the abdomen and, if so, whether it is likely to contain secondaries.
Investigation
The combination of symptoms and signs of SVCO are unmistakable. The priority is to obtain imaging to confirm this and indicate the likely cause. A plain CXR will demonstrate superior mediastinal widening, perhaps with the presence of a pleural effusion. A CT scan of the thorax will provide more detailed information regarding the superior vena cava and the bronchi.
Sputum cytology may establish the diagnosis of SCLC in up to 50% of cases, because most patients with SVCO (65%) have lung cancer and SCLC is the main histological type that presents in this way.
Airway compromise is an emergency.
Elicit stridor by asking the patient to open his or her mouth and take a deep breath in and out as fast as possible.
General examination will obviously include noting if there is evidence of weight loss or even cachexia. Also check the following: • pulse rate (for tachycardia); • BP (for pulsus paradoxus – a fall
in systolic pressure on inspiration
Beware the patient with a respiratory problem who has a normal respiratory rate but looks exhausted – they may be about to die.
she feels dizzy when bending forward.
She says that her friends have noticed that her voice has deepened and become hoarser over the past few weeks. She also feels she has been putting on weight, as her fingers are swollen and she can no longer wear her rings. She sleeps poorly at night and often wakes in the morning with ‘puffy bags’ under her eyes.
Introduction
The diagnosis of superior vena cava obstruction (SVCO) depends on recognising the clinical features that arise from obstruction of the venous drainage of the upper body: headaches, oedema of the arms and face, distended neck and arm veins, and a dusky skin coloration over the chest, arms and face. Collateral venous circulation may develop over a period of weeks, with the direction of blood flow – towards the drainage territory of the inferior vena cava – helping to confirm the diagnosis. The most frequent malignant causes of SVCO are:
• small-cell lung cancer (SCLC); • non-small-cell lung cancer; • lymphoma;
• germ-cell tumours; • breast cancer.
The severity of symptoms relates to the rate of onset, degree of obstruction and development of compensatory collateral venous return. The symptoms may worsen on lying flat or bending as this further stresses the obstructed venous return, hence this woman’s dizziness.