This patient should undergo external beam radiation therapy for his epidural plasmacytoma in addition to continued high-dose glucocorticoid treatment. Skeletal lesions that occur as a result of plasmacytoma or myeloma are exquisitely radiosensitive; therefore, radiation therapy is the most appropriate specific and definitive treatment for this tumor type. Patients with compressive myelopathy due to very radiosensitive tumors who have a stable spine and minimal neurologic deficits may respond to this therapy, with recovery or improvement of their neurologic deficits.

Although radiation therapy is the preferred acute treatment for compressive myelopathy in patients with plasmacytomas because of their high level of radiosensitivity and rapid response to treatment, chemotherapy may be a reasonable second-line therapy for selected patients with compressive myelopathy due to myeloma.

High-dose intravenous glucocorticoids administered within the first 8 hours of traumatic spinal cord injury can be useful in the short term to reduce the effect of edema within the spinal cord caused by a compressive injury. However, these drugs will not treat the underlying neoplastic disease and thus are inappropriate as monotherapy in this patient.

Immediate surgical decompression is indicated with evidence of spinal instability or with severe neurologic deficits that require removal of the bulk of the tumor to prevent continued injury to the spinal cord. This intervention is usually followed by definitive radiation therapy for treatment of the local tumor.