When Cancer Clouds the Picture of Arterial Embolism Masquerading as Spinal Cord Compression in a Man With Metastatic Prostate Cancer

Acute limb pain, weakness, and sensory loss in patients with metastatic cancer often raise suspicion of spinal cord or nerve root compression; however, vascular pathologies may mimic neurological deficits, particularly in hypercoagulable malignancies. We describe a 65-year-old man with metastatic prostate cancer on full-dose Rivaroxaban who presented with a five-day history of progressive left foot pain, numbness, and weakness. Examination revealed reduced sensation over the dorsum of the foot, loss of great toe extension, weak ankle dorsiflexion, and absent distal pulses with a cold, pale foot. MRI of the lumbar spine confirmed no evidence of metastatic disease or vertebral collapse, showing only multilevel degenerative spondylosis with disc protrusions and moderate-to-severe canal stenosis. Persistent severe pain and absent pulses prompted further assessment; Doppler ultrasound demonstrated no flow below the popliteal level, and CT angiography revealed an abrupt cutoff of the left superficial femoral artery (SFA) at mid-thigh with no distal reconstitution or collateral flow, consistent with acute arterial embolism. The patient was urgently transferred to a regional vascular centre for surgical management. This case highlights the diagnostic challenge of limb symptoms in oncology patients, where neurological and vascular disorders may coexist. In metastatic prostate cancer, tumour-related hypercoagulability can cause both venous and arterial thromboses despite therapeutic anticoagulation. Awareness of this overlap, careful limb examination, and timely multimodal imaging are essential to avoid diagnostic delay and reduce morbidity.