This patient with spinal cord compression should receive immediate administration of intravenous high-dose glucocorticoids to prevent permanent neurologic deficits. This patient has MRI-confirmed spinal cord compression characterized by mid back pain and physical findings of lower extremity hyperreflexia and weakness. His known multiple myeloma with corresponding anemia and hypercalcemia suggest progression of his disease with a plasma cell tumor as the cause of his spinal cord compression. Glucocorticoid therapy is the initial treatment in most cases of malignant spinal cord compression as they decrease inflammation and reduce the mass effect due to edema associated with many tumors. In this case, glucocorticoid therapy has the added benefit of directly treating the hypercalcemia and plasma cell myeloma. Glucocorticoid treatment is then followed with more definitive therapy, often radiation and possible neurosurgical intervention in some cases.

Biopsy of the epidural mass is not necessary because of the patient's known likely causative disease and could delay initiation of glucocorticoids and radiation therapy and increase the risk of permanent nerve damage.

Although neurosurgical intervention consisting of decompressive surgery might be necessary in some patients with spinal cord compression, it would not be appropriate before administration of immediate glucocorticoids.

Definitive treatment with chemotherapy or an immunomodulator may be appropriate but would not have the required immediate effect of glucocorticoids in preventing progressive neurologic damage.

Radiation therapy alone would not address the swelling associated with spinal cord compression nor the hypercalcemia or underlying systemic plasma cell myeloma. However, radiation therapy is often a useful therapy for treating bulky disease.