Edinburgh Cancer Centre malignant spinal cord compression (MSCC) guidance

Metastatic spinal cord compression (MSCC) is defined by NICE as spinal cord or cauda equina compression by direct pressure and/or induction of vertebral collapse or instability by metastatic spread or direct extension of malignancy that threatens or causes neurological disability. 

Malignant spinal cord compression (MSCC) is believed to occur in approximately 5-10% of patients with cancer. Affecting not only quality of life but also prognosis. Studies have highlighted that delays in diagnosis and referral are common and that the strongest predictor of response to treatment is the functional status of the patient at time of diagnosis. MSCC is a complication of cancer which is often diagnosed when there is irreversible neurological damage.

A prospective Scottish audit by the Clinical Research Audit Group (CRAG) of the diagnosis, management and outcome of MSCC reported that there were three key reasons for delay in diagnosis:

1. A lack of recognition in acute and primary care of the early symptoms of MSCC.
2. The absence of an efficient referral pathway for patients who are considered to be at risk of developing, or have developed, signs and symptoms suggestive of compression. 
3. A lack of awareness of the most appropriate method of investigation.

The report recommended the development of a guideline for the early diagnosis of MSCC. In response to CRAG’s recommendations Macmillan Cancer Support funded a project in the South East of Scotland Cancer Network (SCAN). The project strategy aimed to diagnose MSCC earlier, hypothesising that earlier diagnosis would ensure patients are placed on the correct treatment pathway sooner, therefore enhancing quality of life and reducing service costs. The strategy included:  

1. MSCC education for acute and primary care staff.
2. Effective referral guidelines and management guidance.
3. A minimum data set and development of quality standards.

The project used a collaborative multidisciplinary approach to ensure consistency and quality of care across SCAN where cancer services are provided for a population of approximately 1.4 million (NHS Borders, NHS Dumfries and Galloway, NHS Fife and NHS Lothian). 

Patients who have cancer or whom there is a suspicion of cancer who have one of the following should be assessed for MRI investigation: 

• Severe intractable vertebral pain (especially thoracic) 
• New spinal nerve root pain (burning, numb, shooting) 
• New difficulty walking. 
• Reduced power/altered sensation in limbs. 
• Bowel/bladder disturbance. 

Note: MRI should be carried out locally and not referred to oncology until reported positive. See Appendix 1-5 of the full guidance for SCAN local pathways. NHS Lothian have a protected early slot for suspected MSCC see Appendix 6.

The following information must be recorded during admission assessment:

• Duration of symptoms (as exactly as possible)
• Presence of above symptoms and relevant systemic enquiry (including back pain, sensory loss, limb weakness, bowel/bladder function)  
• Neurological examination  
• Previous and current functional status (including previous and current mobility)

• MRI within 24 hours of suspected MSCC– use TRAK system to order and ensure priority “URGENT”. Ensure bleep number of ST who will be responsible is on order form. (See Appendix 7 of main guidance – MRI Guidance) 
• Routine admission bloods- including glucose, FBC/clotting if biopsy/surgery being considered. 
• Review most recent staging CT, if considering surgical intervention may need up to date CT CAP.  Consider time delay introduced with additional imaging requests. 
• For diagnostic purposes if spinal biopsy required please discuss with on call Consultant for Neuroradiology.  Of note biopsies performed at RIE as Neurosurgical support is on site.

• Prescribe dexamethasone 16mg daily (preferably AM) unless contra-indicated initially then reducing dose as per guidance (See Appendix 8 of main guidance) 
• Consider PPI cover for duration of steroid use and review any NSAID prescription. 
• All patients should be assessed for venous thromboembolism (VTE) risk and prescribed appropriate prophylaxis (see guidance of OOQS), unless contraindicated. 
• Prescribe appropriate aperients (at least PRN) and re-assess daily. 
• Stop aspirin /clopidogrel if biopsy/surgery being considered. 

• Observations/NEWS2 score (Temp,BP,P,R,SaO2) with escalation as appropriate.  
• Blood glucose monitoring if on steroids as per OOQS guidance. 
• Daily neurological examination.  
• Documented mobility advice (Appendix 11 of main guidance) 
• Patient information – MacMillan MSCC leaflet can help support verbal explanation Daily pain score and analgesia review (Appendix 12) 
• Monitoring bowel/bladder function. 
• Referral to physiotherapy ASAP following admission. 
• Reduction of steroid dose according to treatment plan, GP and patient letter available  (appendix 9/10) 

• If neurosurgical felt appropriate please discuss with parent oncology team and follow “Neurosurgical Guidance” Appendix 12. 
• Single 8 Gy Fraction appropriate in many patients (SCORAD trial). 
• Weekday service: complete RT booking form and highlighted to RT Superintentant (Bleep 8416),  Ensure it is clear who will be planning RT.  
• Weekday Med Onc Consultant On-Call: it is the Consultant Clin Onc for the upcoming weekend who will be responsible for providing radiotherapy cover. If they are off site, they will have arranged cover ensuring the on call team (consultant, registrar and telephone triage team) is aware of arrangements. 
• Weekend service: Oncall Clin Onc team should be made aware of any potential MSCC that may require input over weekend.  Imaging as per MRI Guidance.
• Weekend handover: Due to no Sunday RT service currently, ensure any outstanding cases are communicated from weekend team to parent team and Monday On Call Team. Weekend team to leave RT booking form in tray at RT Reception to make use of the protected Monday 9am MSCC slots which are supported by prescribing radiographers.

• In general patients who benefit from neurosurgical intervention have limited number of vertebrae involved and a good cancer prognosis. 
• Information with regards to cancer, expected survival can be useful when using  tools such as the Tokuhashi. However one need to understand their limitations – especially as established prior to TKI/immunotherapy. See Appendix 13 of main guidance.   
• Urgent “CT CAP” to assess systemic cancer burden and to assess spine integrity. 
• Via switchboard facilitate discussions with Neurosurgical team based at RIE.  Document discussion and names of clinicians involved, if accepted please ensure Consultant name is clearly documented. 
• If patient accepted by Neurosurgical team, then arrange transfer to DCN, RIE under care of on-call consultant.  Recommend If following their assessment that decision not to pursue surgery then they urgently discuss with on-call oncology team to facilitate transfer back to ECC for emergency RT.