Spinal Cord Compression

1. Spinal Cord Compression Carol S. Viele RN MS OCN Clinical Nurse Specialist Heme-Onc-BMT University of California San Francisco Associate Clinical Professor Dept of Physiological Nursing UCSF School of Nursing

2. Objectives • At the completion of this presentation the participant will be able to: • Describe the most common cancers associated with cord compression • Identify at least 2 symptoms associated with cord compression • Describe the most appropriate nursing interventions for cord compression

3. Definition/Frequency • A mass effect from the tumor with associated edema which results in ischemia and neural damage to the spinal cord • 10% of all patients with cancer will develop this complication

5. Occurrence • The most common source of cord compression is metastasis to the epidural space with or without bony involvement • Tumors can also through the reach the epidural space by direct extension through the intervertebral foramen • Some tumors occur in the cord itself

6. Etiology • Tumor types • Breast, (Number 1 in women) • Lung • Kidney • Myeloma • Prostate • Melanoma • Gastrointestinal tumors • Lynphoma

7. Level of Involvement • Cervical area 10% • Thoracic area 70% • Lumbosacral 20%

8. Symptoms • Back pain is usually the first symptom • 95% of patients with a cord compression experience back pain • Pain will precede other symptoms by weeks to months • Early cord compression may be asymptomatic

9. Manifestations • Pain • Localized • Radicular • Severity • Position changes • Cough • Weightbearing • Valsalva maneuver

10. Manifestations • Weakness 75-85% • May progress rapidly • Bilateral • Corresponds to the level of cord involvemnent • Spasticity • Hyperreflexia • Abnormal stretch reflexes • Extensor plantar response

11. Manifestations • Sensory loss • Bowel dysfunction • Bladder dysfunction • Impotence

12. Diagnosis • Thorough physical examination • Palpation • Gentle percussion over bony areas • Neurologic exam • Laboratory data – Increased alkaline phosphatase may indicate bony involvement

13. Diagnosis • Radiographs- may reveal erosion of the pedicle, • Lytic lesions of the vertebral body • Collapse of the vertebral body • Bone scan- 20% of scans reveal lesions missed on plain films • CT • Used to determine extent of tumor

14. Diagnosis • MRI ( Tool of choice) • Able to determine prevertebral, vertebral, extradural, intradural, extramedullary and intramedullary lesions • Provides better anatomic visualization with sagittal and axial images of the spinal cord • Fine needle aspiration • May provide tissue confirmation

15. Treatment • Criteria: • Primary tumor type • Level of myelopathy • Degree of spinal block • Potential for neurologic reversibility

16. Treatment • Surgery • Radical resection if an a candidate • Complete block • Single lesion where complete removal is possible • Diagnosis is uncertain • Mild deficits • New data supports surgery over treatment with RT if patient is a good surgical candidate

17. Treatment • Radiation therapy • If not a surgical candidate • Incomplete block • Severe deficits • Relapse in area of prior radiation if short survival is expected

18. Treatment Radiation- often initiated as an emergency if not a surgical candidate • Therapy • Treatment field extends 1-2 vertebral bodies above and below level of compression • 3000-4000 cGy over 2-4 weeks • 2/3 of patients remain stable or improve • 65-75% achieve pain relief

19. Treatment • Steroids • Dexamethasone • Bolus IV 10 mg • Oral 4-6 mg q 6 hours for 2 days then a slow taper • 25% of patients with cord compression require maintenance to maintain neurologic function • Steroid related side effects may occur • Hyperglycemia • GI bleeding • Psychosis

20. Treatment • Chemotherapy • May be given in highly sensitive tumors • Always given with other modalities

21. Outcome • Pretreatment ambulatory ability is the main determinant of post treatment ambulatory ability • 90% of patients ambulatory before therapy are after • Only 10% of paraplegics become ambulatory after therapy

22. Prognosis • Median survival is 6 months if patient presents as a paraplegic • 50% of patients who walk in with a cord compression are alive at 1 year • If patient was ambulatory prior to RT survival is 8-10 months

23. Recurrent Disease • Options • If RT given may be a surgical candidate if survival of > 12 months predicted • Repeat RT • Risks of repeat RT • Radiation myelopathy • Collateral damage

24. Nursing Interventions • Thorough assessment and early MD/Provider notification of changes in • Pain • Sensory function • Motor function • Urinary function • Bowel function

25. Nursing Interventions • Maintenance of functional status • Bowel program • Bladder program • Skin care • Rehabilitation services • PT • OT

26. Nursing Interventions • Education • Patient • Family • Significant others • Care givers

27. Nursing Interventions • Emotional support • Decrease anxiety • Referrals • Social worker • Psychologists • Psychiatrist • Chaplain

28. Nursing Interventions • Referrals • Care coordination • Case manager • Home care • Rehabilitation center • Skilled nursing facility • Hospice

29. References • Schulmeister, L., Gatlin, C.,( 2008) Spinal cord compression in Oncology Nursing Secrets, Gates, R. and Fink, R. (eds) Hanley and Belfus, Philadelphia, 546-550 • Quinn, J., De Angelis, L.(2000) “Neurologic emergencies in the cancer patient”, SeminOncol, 27: 311- 321 • Tan, S. Recognition and Treatment of Oncologic Emergencies (2002), Journal of InfusionNursing,25:3, 182-188

30. References • www.uptodate.com, Spinal Cord Compression, Accessed 7/9/09