Malignant Spinal Cord Compression

1. Malignant Spinal Cord Compression Lucy Butler

2. Case 1 • ‘T.T’ • 50 year old female • PMH: Hypertension, Obesity, Depression, Heavy Smoker. • Presented to GP in January with 2/12 hx lower back pain – radicular pain, referred to physiotherapy • 3/52 later unable to mobilise, reduced sensation and power to right leg, urinary incontinence.

3. Admitted to hospital • MRI – compression fracture C6 & T10 with minimal encroachment on spinal canal, compression of epidural space from T4 to mid sacrum. Uniform reduced signal from bone marrow throughout the spine suggestive of diffuse neoplastic infiltration. • Bence Jones protein positive Multiple Myeloma

4. Case 2 • ‘B.C’ • 68 year old gentleman • Keen hill walker • No previous medical history • 3 admissions to hospital with band like pain radiating around upper abdomen and back • Saw GP a few weeks later – struggling to mobilise, constant pain, aware of negative abdo CT at hospital so looked for systemic illness • PSA 176, review of CXR at hospital showed complete flattening of T8

5. Admitted to hospital from urology appointment due to worsening back pain, and onset of bilateral leg weakness - spinal cord compression at T8 Metastatic Prostate Cancer

6. Malignant Spinal Cord Compression

7. “an epidural metastatic lesion causing true displacement of the spinal cord from its normal position in the spinal canal”

8. Emergency • 2-5% of cancer patients have an episode of SCC • More common in myeloma, breast, prostate and lung cancers • The initial presentation in 8% of cancer patients • 10% have a further episode of SCC

9. Presentation • Depends on the level of compression (majority thoracic spine) • 95% have radicular pain • Worse lying flat, sneezing, coughing, and relieved by sitting • Motor weakness/difficulty walking • Sensory disturbance • Sphincter disturbance

11. Yorkshire Cancer Network Goals • Earlier diagnosis and treatment • Faster access to diagnostic MRI • Rapid escalation to definitive therapy • Definitive therapy case-appropriate • Co-ordinated case-appropriate rehab

12. Early recognition and treatment can reduce risk of irreversible disability. • If a cancer patient has symptoms suggestive of spinal metastases then discuss with MSCC coordinator within 24 hours. • If a patient has symptoms of SCC speak to them immediately • If total paraplegia or frail/unsuitable for treatment discuss with their oncologist (if they have one) before transfer/imaging.

13. Diagnosis If symptoms suggestive in cancer patient or suspicious spinal pain in non cancer patient: • Refer to the MSCC co-ordinator • Urgent whole spine MRI (within 24 hrs) • Dexamethasone 16mg (PPI cover) • If total paraplegia >24 hrs or frail/unsuitable for treatment then try to speak with their oncologist first.

14. Then.. Depends on: • Performance status • Prognosis • Disease control elsewhere

15. Surgery • Offer surgery to achieve spinal cord decompression and maximise the probability of preserving spinal cord function • Suitable if unstable spine, disease at one level, radio-resistant disease with disease elsewhere controlled

16. Radiotherapy • Unfit for surgery • Multi-level disease • Disease elsewhere not controlled

17. Best Supportive Care • If neurological function lost • Advanced disease elsewhere • Analgesia, steroids, good nursing care

18. MDT approach • Rehabilitation • Good nursing care- pressure sores, VTE prevention, analgesia • Bladder and bowel continence • OT, physiotherapy, social workers • Financial implications (DS1500)

19. Prevention • If cancer – always think of SCC! (2-5% of cancer patients get SCC) • If no cancer – always think of SCC! (initial presentation in 8%) • Good history and examination • Patient education/information

20. NICE guidelines CG75 • YCN MSCC Pathway