Malignant spinal cord compression

Malignant spinal cord compression (MSCC) occurs when the dural sac and its contents are compressed at the level of the cord or cauda equina. This may be a result of direct pressure, vertebral collapse or instability caused by metastatic spread or by direct extension of malignancy.

Overview

• Rapid assessment, investigation and treatment may prevent or limit irreversible neurological damage.
• Consider cord compression in any patient with cancer who develops new or worsening back pain.
• A full neurological examination should be performed; normal examination does not exclude MSCC.

• MSCC should be considered in any malignancy, especially those with bone involvement.
• MSCC is most common in people with myeloma, lung, breast and prostate cancers.
• Cord compression can be the initial presentation of cancer.
• Thoracic cord compression is most common, but any part of the spine or multiple sites can be affected.

Severe unremitting or progressive back pain occurs in almost all patients who present with MSCC.

Pain characteristics suggesting spinal metastases:

• sites of pain and level of compression do not always correlate
• band-like, radicular pain around trunk or abdomen
• neuropathic back pain radiating into buttocks or limb
• mechanical pain (aggravated by standing, sitting, lying or moving)
• back pain aggravated by straining (for example, coughing, sneezing or bowel movements)
• night-time back pain disturbing sleep
• localised tenderness
• claudication (muscle pain or cramping in the legs when walking or exercising) may occur but is unlikely to occur in isolation.

Other key symptoms or signs of spinal cord compression:

• bladder or bowel dysfunction (urinary or fecal incontinence, constipation or urinary retention)
• gait disturbance or difficulty walking
• weakness, numbness, paraesthesia or sensory loss
• erectile dysfunction.

Neurological signs of cauda equina compression:

• new, severe root pain affecting low back, buttocks, perineum, thighs, legs
• loss of sensation often with tingling or numbness in the saddle area
• leg weakness, often asymmetrical
• bladder, bowel and sexual dysfunction; occur earlier than in cord compression
• loss of anal reflex.

Immediately after assessment, initiate the following management (unless contraindicated):

• High-dose dexamethasone (16 mg daily, given as 8 mg in the morning and 8 mg at lunchtime, ideally no later than 2pm to minimise sleep disturbance but do not delay administration of first dose).
  o Steroids should be under regular review with downward titration after radiotherapy according to local protocol.
  o Carry out routine blood glucose monitoring while on high-dose steroids at minimum daily at the afternoon meal.
  o Provide gastroprotection with proton pump inhibitor (PPI) or famotidine.
• Thromboprophylaxis with low molecular weight heparin according to local protocol.
• Nursing in bed, as pain allows, with log rolling initially, if required.
• Catheterisation if there is urinary retention or incontinence.
• Care of pressure areas, bowel and bladder according to local guidance.
• Consider the administration of opioid analgesia 15-30 minutes prior to care interventions that may cause incident pain.
• Consider daily neurological examination.
• Refer for assessment and early intervention from occupational therapy, physiotherapy and social work.

Key points:

Immobilising the spine may reduce the risk of extension of compression and associated pain and neurology while awaiting definitive treatment, such as neurosurgical intervention, radiotherapy or SACT.

Individualised conversations to decide on an acceptable plan for each patient should include risks associated with mobilising and be clearly documented.

If opting to mobilise, the patient should be encouraged to only mobilise within the limits of their pain.

The plan should be included in any transfer documentation.

Before requesting a magnetic resonance imaging (MRI) scan (or computer tomography (CT) scan if MRI is contraindicated), it is essential to consider:

• What matters to the patient? This includes tolerability of imaging, taking account of pain control and wishes regarding further treatment.
• Is the patient fit for further investigation and management?
• Does the patient have treatment options available to them? Particularly if they have already had spinal radiotherapy in the past.
• If there is complete paraplegia and loss of sphincter control, radiotherapy may improve pain control but is unlikely to restore function.
• If there is uncertainty, discuss with the metastatic spinal cord co-ordinator, acute oncology or the patient's own oncology team, or a specialist in palliative care to consider if MRI is appropriate.

Ensure discussion with oncology if the patient may have already received spinal radiotherapy as the details of areas and dosing may be held in specialist oncology radiotherapy notes.

An urgent MRI should be performed, ideally within 24 hours, at a local hospital or local cancer centre according to local protocols.

If available, discuss the patient with the metastatic spinal cord co-ordinator.

Emergency referral is essential. Check the protocol and contacts for your local NHS board.

1. Spinal instability

Once the MRI (or CT) report is available consider assessing risk of instability using a validated tool, such as the Spinal Instability Score (SINS). Online calculators such as the ones below are available to support this:
Scoring-systems-in-MSCC-SINS.pdf (oxfordmedicaleducation.com)
Spinal Instability Neoplastic Scale (SINS) Score (mdcalc.com)

SINS can guide onward management approaches, including consideration of neurosurgical intervention or a trial of orthotic braces as an adjunct to pain management approaches.

Instability should be assessed clinically following imaging. Consider neurosurgical discussion if the SINS score is 7 or greater.

If the SINS score suggests a high risk of instability, but surgery is not felt to be appropriate:
1. Use a shared decision-making approach to discuss mobility, considering the risks and benefits. Acknowledge the risk of worsening pain or paralysis with movement versus the risks of ongoing bed rest. Even if immobilised, progressive pain and neurological symptoms may occur as a result of disease progression. Individualised conversations should be clearly documented.
2. If opting to mobilise, the patient should only mobilise within the limits of their pain.
3. Orthotic supports may be a helpful adjunct in treating pain and may reduce the risk of paralysis in the short term, but this cannot be guaranteed.

2. Possible neurosurgical intervention

A person-centred multidisciplinary approach should be taken when considering if discussion with neurosurgery is appropriate.

Where appropriate, refer urgently to on-call neurosurgeon for discussion, following local protocols.

3. Possible oncological interventions

Liaise urgently with the local cancer centre (via malignant spinal cord co-ordinator where available) according to local protocols.

They may advise on urgent transfer for treatment such as radiotherapy.

4. Ongoing management

• Ensure adequate pain relief. Pain may be bony, neuropathic or mixed. Identifying the pain type may help guide the choice of analgesia. Consider bisphosphonates or denosumab. Please see the Pain guidelines for further information.
• Monitor bowels. Constipation is common and a bowel regimen may be required.
• Assess and monitor skin and pressure areas with interventions as required.
• Give opportunities to the person and their family or carers to discuss issues such as what their diagnosis means, and risks and benefits of treatment options.
• Carry out a holistic needs assessment.
• Provide advice on accessing support with psychological, emotional, spiritual and financial needs.
• Offer opportunities to discuss future care planning.
• Develop a personalised care plan with the person, taking advice from the multidisciplinary team (MDT) and other relevant clinicians.
• Offer support and rehabilitation based on ongoing review of the management plan and holistic needs.
• Start planning for discharge and ongoing care on admission to hospital.
• Offer supportive care to prevent and manage complications.

Consider referral to Specialist Palliative Care Services.