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Aetiology

  • Neoplasm’s of the lung, prostate, breast and thyroid account for half of all cases of malignant spinal cord compression (MSCC)4.
  • The most common primary tumours are lymphomas, multiple myeloma, plasmacytomas and osteosarcomas3 4
  • The thoracic spine is the most commonly affected site for boney metastasis, accounting for 70% of all cases.  The lumbosacral and cervical sites are less commonly affected, representing 20% and 10% of cases respectively.

Diagnosis

  • Early diagnosis of MSCC whilst the patient is still ambulant is crucial in optimising patient outcomes5
  • Awareness of the non-specialist is very important in making a diagnosis of serious spinal pathology, particularly in patients with spinal cord compression. 
  • Identification of RED FLAG symptoms and signs in the initial clinical assessment is key to identifying those patients who may have serious underlying pathology6  (Table 1).
  • For twenty percent of patients presenting with MSCC this will be their first time they will have been diagnosed with having cancer.

 

Table 1:  Red flags for serious spinal pathology


1)                   Onset of pain <20 or >55 years old
2)                   History of trauma
3)                   Thoracic pain
4)                   Non-mechanical pain
5)                   Previous history of:
6)                   Constitutional symptoms:
7)                   Prolonged restriction of lumbar spine flexion
8)                   Structural spinal deformity
9)                   Evidence of neurological signs
10)                 Investigations (if indicated):


 

 

(i.e:  Malignancy / Steroid use / Drug abuse / HIV)


(i.e:  Weight loss)


  (i.e:  ESR > 25mm / Plain X-ray abnormality)

 

  • Pain is the usual first presenting symptom and may have been present for some time before any symptoms or signs of MSCC are present.
  • Pain may be new or have changed in character from previous longstanding pain. 
  • The pain is constant and unremitting.
  • Night pain is a predominant symptom.
  • Pain is usually in the back, typically in the thoracic spine.
  • It may present with radicular symptoms.
  • Due to the frequent involvement of the thoracic spine the discomfort may be described as a tight band around the chest or abdomen.
  • Sensory and motor deficits are later presenting symptoms and signs.
  • Autonomic dysfunction, such as bladder or bowel problems should always be asked specifically in the history.

 

  • A significant proportion, approximately 30%, of patients do not have any symptoms. 

 

  • Neurologic symptoms may be present but are only present in 5-20% of patients.  Those patients with thoracic metastasis have a higher rate of neurological symptoms owing to the fact the spinal canal has less room to accommodate the mass lesion.

 

Clinical Examination

Clinical examination findings will depend on:

Anatomical level of the compression
Degree of spinal cord compression
Duration of the compression

 

Look

  • Swelling and clinical deformity of the back may be present but are uncommon findings and tend to be a result of complications such as fracture or subluxation of the vertebrae.
  • If the person is ambulant observe their gait.  This will indicate any weakness in the lower limbs and also in the truck muscles.  Again this depends on the level of spinal involvement.

 

Feel

  • Pain on palpation over bony prominences is a common finding in spinal malignancy.

 

Move

  • All patients should have a through neurological examination of the lower limbs and perineum.
  • The examination findings should be clearly documented as this will aid in the later management decisions if there is progression of symptoms or signs.
  • Again this will depend on the level and degree and degree of compression.  (Figure 1).

 

Figure 1:  Level of malignant cord compression and likely clinical findings.

 

NEED MRI AND XRAY

 

  • The vertebral body is most commonly affected but ant part of the vertebrae may be involved.  For example, if the vertebral body is involved and the mass lesion extends posterior into the spinal canal the anterior tracts will be effected first (if the anterior corticospinal tract is compressed descending motor neurones that conduct voluntary motor impulses will be compromised) (Figure 2).

Figure 2:  Axial cross-section of spinal cord – at mid thoracic spine level.

 

 NEED MRI


 

  • A full detailed central and peripheral neurological examination should be completed on all patients to identify the level and degree of compromise and to document any regression or progression of signs.

 

Referral

  • Here in the West of Scotland there are established guidelines developed by the West of Scotland Cancer Network for the referral of patients with confirmed or suspected MSCC1.  These are summarized and detailed below:
     

Urgent Referral and Initial Management

1.        A patient presenting with a known cancer diagnosis and early presentation triggers.

·         Commence patient on Dexamethasone 16 milligrams/day (16mg/day)

·         Suggest patient lies flat.

·         Arrange emergency admission to the patient’s local hospital.

·         Urgent MRI of whole spine to confirm diagnosis

·         Using the criteria below, on completion of a full clinical and radiological assessment, telephone the on-call Oncology Registrar at The Beatson West of Scotland Cancer Centre or the on-call Neurosurgical Registrar at the Southern General Hospital to discuss appropriate management.

 


Neurosurgery 


Oncology 



One area of compression



Multiple levels of cord compression



Radio-resistant tumours (e.g. renal)



Radio-sensitive tumours (e.g. breast)



Ambulant



Preferably ambulant or with an established paralysis of < 72 hours



Life expectancy minimum of 6 months



Life expectancy of > 4 weeks

 

 

 

 

 

 

 

 

 

 

 

 

2.        Patients without a cancer diagnosis.

 

·         Commence patient on Dexamethasone 16mg/day.

·         Suggest patient lies flat.

·         Arrange emergency admission to the patient’s local hospital.

·         Urgent MRI of whole spine to confirm diagnosis

·         Once full clinical and radiological assessment has been performed, telephone the on-call Neurosurgical Registrar at the Southern General Hospital, and discuss appropriateness for surgical intervention.

 

Non-urgent Referral and Initial Management  (Only relevant for patients with a known cancer diagnosis)

1.  Patients with a cancer diagnosis and late presentation.

 

·         A collaborative decision on the most appropriate palliative approach and place of care should be agreed by the GP and the patient’s known Oncologist or Palliative Medicine Consultant.  This decision should include the expressed wishes of the patient and family.

·         If agreed, a combined multidisciplinary and multiagency package of care should be co-ordinated following discussion with the patient and their family support network.

·         Where the level and type of support is not available at home, admission to hospital or hospice may be necessary.

·         A trial of steroids may be suggested, but if no improvement identified within five days these should be discontinued.

 

 

Figure 3:  Algorithm for Referral of Suspected & Actual MSCC or CECS in the West of Scotland

 

NEED DIAGRAM FROM WOSSCC

 

 

Investigation

  • Following admission to a local hospital, the investigation of choice for suspected cord compression is a MRI of the whole spine.
     

 

Treatment

  • Following admission to a local hospital, the investigation of choice for suspected cord compression is a MRI of the whole spine
  • Steroid Therapy
  • Radiotherapy
  • Surgical decompression +/- stabilization
  • Paliative care

 

Summary points

  • Malignant Spinal Cord Compression (MSCC) is a major cause of morbidity in cancer patients in the United kingdom1.
  • It occurs in approximately 5% of all patients diagnosed with cancer.

 

 References:

 1.  West of Scotland Cancer Network.  Guidelines for Malignant Spinal Cord Compression.  NHS Scotland.  2008.