Malignant spinal cord compression (Guidelines)

A MSCC is an oncological emergency that occurs when the dural sac and its content are compressed at the level of the spinal cord or cauda equina.  They can result from direct pressure, vertebral collapse or instability caused by metastatic spread or by direct extension of a malignancy.  

MSCC affects 5 to 10% of patients with a diagnosis of cancer but can also be the first presentation of malignancy.  MSCC should be considered in malignancy especially if there is bone involvement.  

Late diagnosis due to delays in recognition can result in significant pain, permanent loss of function and significant morbidity.  

Early recognition of a MSCC may prevent or limit irreversible neurological damage.  

If you suspect a patient has symptoms of a MSCC then contact the MSCC coordinator urgently, ideally within 24hrs of symptom development. 

Does the patient have:

• a history of cancer and/or suspicion of metastatic cancer 
• new onset back pain 
• new difficulty walking 

Do not discount the MSCC pathway if there are only 2 indicators.  

Early signs 

• New onset difficulty walking 
• Use of walking aids 
• Unexplained falls 
• Lack of proprioception 
• Intermittent weakness that is unilateral or bilateral 
• Severe pain in neck or back - radicular in nature 
• New progressive intractable pain often described as band link pain around chest and down legs 

Late signs

• Sensory disturbance 
• Bladder / bowel disturbance 
• Paralysis 

Contacting your local MSCC Coordinator will ensure rapid assessment, investigation and treatment of a patient with suspicion of a MSCC.

At NHS Highland, therapeutic radiographers within the radiotherapy department at Raigmore Hospital are the MSCC coordinators.  They are supported by the on-call oncologist.  

How to contact the MSCC Coordinator at NHS Highland:

Monday-Friday 09.00-17.00:

• MSCC Coordinator via bleep: 2134.
• Raigmore switchboard (01463 704000) and ask for the malignant or metastatic spinal cord coordinator.

Out of Hours: 

• On-call oncologist via Raigmore switchboard (01463 704000).
• If there is no local oncologist available please contact the on-call oncologist in Aberdeen Royal Infirmary.

The MSCC Coordinator will: 

• Act as a single point of contact for the triage and discussion of patient symptoms.
• Seek advice from the on-call oncologist on a patients eligibility for the MSCC pathway. 

If a patient is eligible for the pathway, they will organise a MRI scan and ward admission if applicable.  

Dexamethasone

• Administer 16mg dexamethasone daily unless contraindicated. 
• Consider gastro-protective cover if patient is high risk. 

If MRI scan negative: 

• stop any additionally prescribed dexamethasone. 

If MRI scan positive: 

• Continue on dexamethasone 16mg once daily until treatment is completed.  
• Then follow a stepwise reduction of dexamethasone reducing to a minimum as soon as possible as guided by clinical condition of the patient.  

Analgesia administered as required.

Radiotherapy 

• Radiotherapy is the most common treatment option for patients with MSCC. If the patient is positive for MSCC then the on-call oncologist will make the decision on whether they will receive urgent radiotherapy.  

If mobile at presentation: 

• Local agreement in NHS Highland is to keep a mobile patient mobile.
• Advise not to carry anything.
• Seek assistance on transfer and climbing stairs.
• Refrain from driving.

If severe pain on movement: 

• May indicate spinal instability.
• Consider advising patient to lie flat until assessment / MRI has been made and log roll.

Paralysis: 

• Where paralysis is observed, patients remain on bed rest.