Lead the emergency response to a child with a suspected cord compression — OSCE

Candidate brief and communication tasks

The candidate enters the resuscitation bay to find an anxious nine-year-old, a palpable distended bladder, and frightened parents holding a phone. The task is to lead the structured emergency response over eight minutes: recognise the cord emergency, secure the emergency whole-spine MRI without delay, separate the compressive from the inflammatory fork, begin the matched corticosteroid, and make the neurosurgical and oncological referrals in parallel, while counselling the parents about urgency and prognosis without false reassurance. The communication skill is to convey urgency without alarm and to share the decision-making honestly while the cause is still being identified. [1] [2]

The first clinical task is to recognise the cord emergency at the bedside. The candidate states that new back pain plus a neurological deficit - a weak leg, a sensory level at T10, and urinary retention - is a spinal cord syndrome until an emergency whole-spine MRI proves otherwise, and that the symptom sequence of pain then weakness then a sensory level then sphincter loss indicates an established lesion. The candidate performs the focused examination - ambulation, motor power and tone and reflexes in the legs, a mapped sensory level, anal tone, and a post-void bladder scan - and records the ambulatory status, because ambulation at presentation is the single strongest predictor of outcome. [1] [2]

The second task is to secure the single most important investigation without delay. The candidate orders the emergency whole-spine MRI with gadolinium within hours and explains why it is not deferred for bloods or a lumbar puncture: it resolves the fork between a compressive structural lesion needing dexamethasone and surgery, and an inflammatory transverse myelitis needing methylprednisolone, and a lumbar puncture below a complete cord block risks deterioration. The candidate catheterises the bladder for retention, provides analgesia, attends to pressure areas and thromboprophylaxis, and takes bloods in parallel rather than in sequence with the imaging. [1] [3]

The third task is to begin the matched corticosteroid and make the parallel referrals. Because nocturnal back pain worse lying flat raises a malignancy, the candidate starts dexamethasone at once - in children weight-based per the local paediatric-oncology and neurosurgery protocol, with the adult National Institute for Health and Care Excellence benchmark of 16 mg loading then 16 mg per day in divided doses - and refers to neurosurgery and oncology in parallel, planning a decompression within twenty-four to forty-eight hours if a compressive mass is confirmed. The candidate states that the definitive treatment (surgery plus radiotherapy or chemotherapy for a radiosensitive tumour) is matched to the imaging and the histology. [2] [3]

Marking domains

• Recognition of the emergency and the emergency-MRI principle - the candidate states that new back pain with a deficit is a cord syndrome until excluded, orders the whole-spine MRI within hours, and never delays it for bloods or a lumbar puncture. [1]
• The compression-versus-inflammation fork and the matched corticosteroid - the candidate separates a compressive lesion (dexamethasone and surgery) from an inflammatory transverse myelitis (methylprednisolone) and starts the corticosteroid matched to the suspected cause before the final diagnosis. [2]
• The decompression window and the ambulation principle - the candidate plans a decompression within twenty-four to forty-eight hours of the loss of ambulation and states that ambulation at presentation is the strongest predictor of outcome. [2] [3]
• Parallel team referral and resuscitation - the candidate catheterises the bladder, provides analgesia, attends to pressure areas and thromboprophylaxis, and refers to neurosurgery and oncology in parallel with the imaging. [3]
• Communication with the parents - the candidate names the event in plain language, conveys urgency without alarm, sets realistic expectations grounded in the ambulation principle, and shares the decision-making honestly while the cause is identified. [1]