12/04/2026
🧠 Spinal Metastasis – Case #7: Rapid neurological decline at T6/7 despite ongoing oncologic treatment
72-year-old woman with newly diagnosed metastatic NSCLC, known thoracic spinal involvement at T6/7, presented via the ED with rapidly progressive left leg weakness. PET-CT in 01/2026 had already shown metastatic disease at this level. She had meanwhile received palliative radiotherapy to T6/7 and was on systemic oncologic treatment. According to the treating pulmonology team, expected survival was still meaningful. Relevant history: Clopidogrel.
A few days before admission, she had fallen. Since then, progressive paresis of the left leg, markedly worsening over 48 hours. On admission: severe monoparesis left leg, proximally 1–2/5, distally around 2/5, sensory level from about Th7, urinary catheter in place. Before this, she had still been mobile with a walker.
What I found notable: almost no relevant back pain. Main complaint was rib pain.
MRI showed a tumor-associated, high-grade, left-dominant epidural spinal cord compression at T6/7 with severe canal compromise.
This is exactly the kind of case where the discussion should not revolve primarily around mechanical scores. The dominant issue here was not instability, but metastatic epidural spinal cord compression with progressive neurological deficit.
Questions:
At this stage, would you still continue non-operative treatment because radiotherapy had already been initiated?
How do you weigh ongoing neurological deterioration against systemic disease burden and expected prognosis?
Would you proceed directly to decompression, or first escalate steroids and reassess?
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What we did:
Because of the rapid neurological decline, the marked cord compression, and the still relevant oncologic perspective, we proceeded with urgent surgical decompression.
Postoperatively, the patient came to ICU intubated, was extubated during the night, and already showed a clear motor improvement, with strength improving to about 3+/4-/5.
My takeaway:
In metastatic spine disease, absence of pain can be misleading. The key decision point is not always spinal instability. Sometimes the central problem is epidural tumor causing cord compromise, and then timing of decompression becomes the decisive factor for function.
