# Situation: A 72-year-old man with prostate cancer that has spread to the spine and pelvis is admitted to the oncology ward for pain control. Three days later, he reports new back pain that is worse when lying down and difficulty starting urination. His findings are: Morphine: extended-release dose increased 2 days ago Legs: strength 3/5 in both legs; reduced sensation below the level of the umbilicus Bladder scan: 620 mL after an attempt to void Serum calcium: 11.0 mg/dL (8.5–10.5); he is alert and oriented Which complication do these findings MOST likely indicate?

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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 72-year-old man with prostate cancer that has spread to the spine and pelvis is admitted to the oncology ward for pain control.

Three days later, he reports new back pain that is worse when lying down and difficulty starting urination. His findings are:
Morphine: extended-release dose increased 2 days ago
Legs: strength 3/5 in both legs; reduced sensation below the level of the umbilicus
Bladder scan: 620 mL after an attempt to void
Serum calcium: 11.0 mg/dL (8.5–10.5); he is alert and oriented
Which complication do these findings MOST likely indicate?

## 보기

1. Spinal cord compression **✔ 정답**
2. Opioid-induced urinary retention
3. Fecal impaction from opioid use
4. Hypercalcemia of malignancy

**정답: 1**

## 해설

Several findings fit more than one problem, so the deciding clues are those that only one condition explains. Weakness of both legs with a sensory level at the umbilicus, new back pain worse lying down, and urinary retention in a client with spinal metastases indicate metastatic spinal cord compression, an emergency needing corticosteroids and urgent MRI. The recent opioid increase and the mildly raised calcium do not explain a motor and sensory level.

## 심화 해설

Clinical picture

A 72-year-old man with prostate cancer metastatic to the spine and pelvis is admitted for pain control. Three days later he develops new back pain that is worse when lying down, difficulty initiating urination, bilateral leg weakness (3/5), reduced sensation below the umbilicus, and a post-void residual of 620 mL. Serum calcium is mildly elevated at 11.0 mg/dL (normal 8.5–10.5) and he remains alert.

Why this is metastatic spinal cord compression

The key is that only one condition explains the combination of a sensory level at the umbilicus and bilateral leg weakness. The umbilicus corresponds to the T10 dermatome, so a sensory loss below this point localizes the lesion to the spinal cord at approximately T10. When prostate cancer spreads to the vertebral column, tumor commonly reaches the extradural space and compresses the cord from outside [3]. As the cord is compressed, motor and sensory tracts below that level are disrupted, producing upper motor neuron-type weakness and a defined sensory level. New back pain that worsens when lying down is a classic early symptom of malignant spinal cord compression because the supine position increases epidural venous pressure around the tumor, further narrowing the space around the cord.

Urinary retention here is not simply an opioid side effect. The bladder is innervated by S2–S4 through the pelvic parasympathetic nerves, and coordination of voiding also involves descending pathways in the spinal cord. A compressive lesion at T10 interrupts these descending pathways, causing neurogenic bladder with a large post-void residual. The bladder scan of 620 mL after voiding indicates the bladder is not emptying, which fits cord compression far better than opioid-induced retention alone. The recent increase in extended-release morphine could contribute to urinary hesitancy, but it cannot produce a sensory level at the umbilicus or bilateral leg weakness.

Why the other options are less likely

| Option | What it explains | What it does not explain |
| --- | --- | --- |
| Opioid-induced urinary retention | Difficulty starting urination and a large post-void residual can occur with opioids, especially after a dose increase. | Does not cause a T10 sensory level, bilateral leg weakness, or back pain that worsens when supine. |
| Fecal impaction | Constipation from opioids can mechanically obstruct the bladder outlet and cause urinary retention. | No bowel findings are reported, and impaction does not produce a sensory level or leg weakness. |
| Hypercalcemia of malignancy | Mildly elevated calcium (11.0 mg/dL) can cause fatigue, constipation, and polyuria. | The patient is alert and oriented; hypercalcemia does not cause a defined sensory level or focal leg weakness. |

Clinical priority and exam perspective

Watch out! In a patient with known spinal metastases, any new back pain with neurologic symptoms is spinal cord compression until proven otherwise. Do not wait for complete paralysis to develop. Key point! The sensory level is the single most localizing finding: a level at the umbilicus points to T10, and any motor or sensory level in a cancer patient with back pain is an emergency.

Malignant spinal cord compression is a medical emergency because the window for preserving neurologic function is narrow. Once axons are destroyed, deficits may become irreversible [1]. Diagnosis is best made with urgent MRI of the entire spine, and initial management includes corticosteroids to reduce vasogenic edema around the tumor while definitive treatment with radiation or surgery is arranged [2]. In men, prostate cancer is the leading cause of metastatic spinal cord disease, and the thoracic spine is the most frequently involved region [3]. The priority nursing action is to recognize the neurologic emergency, keep the patient on bed rest with spinal precautions, notify the provider immediately, and prepare for urgent imaging and corticosteroid administration.References (research sources)

- [1]Malignant spinal cord compression.Research articleMacdonald AG, Lynch D, Garbett I, Nazeer N (2019) · DOI: 10.4997/JRCPE.2019.217

- [2]Metastatic epidural spinal cord compression.Research articleCole JS, Patchell RA (2008) · DOI: 10.1016/S1474-4422(08)70089-9

- [3]Symptomatic spinal cord involvement in prostate cancer.Research articleEke N (2001) · DOI: 10.4314/cajm.v47i2.8594

## 임상 시나리오

Malignant Spinal Cord Compression RecognitionWhen back pain plus a sensory level means emergency imaging
In a patient with known vertebral metastases, new back pain worse when lying down, bilateral leg weakness, and a sensory level at the umbilicus (T10) indicate metastatic spinal cord compression until proven otherwise. Only cord compression explains the combination of a motor and sensory level with urinary retention.

A post-void residual of 620 mL reflects neurogenic bladder from disrupted descending spinal pathways, not simply opioid effect. Mild hypercalcemia (11.0 mg/dL) in an alert patient does not cause focal neurologic deficits.

CautionTreat as an oncologic emergency: notify the provider immediately, give corticosteroids as ordered, and arrange urgent MRI. Do not attribute new weakness or sensory loss to opioids or calcium without excluding cord compression.

## 핵심 개념

- **Spinal cord compression** — Extradural tumor mass compressing the spinal cord, causing pain, weakness, sensory level, and autonomic dysfunction below the lesion
- **Sensory level** — A dermatomal boundary below which sensation is reduced, localizing the spinal cord lesion (umbilicus = T10)
- **Post-void residual** — Urine volume remaining in the bladder after voiding attempt; elevated in neurogenic bladder from cord compression
- **T10 dermatome** — Skin area at the level of the umbilicus, corresponding to the 10th thoracic spinal cord segment
- **Malignant spinal cord compression** — Oncologic emergency requiring urgent corticosteroids and MRI to prevent permanent neurologic deficit

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