MSCC CARE PATHWAYS & CASE STUDIES. By Michael Balloch Spine CNS

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1 MSCC CARE PATHWAYS & CASE STUDIES By Michael Balloch Spine CNS

2 Aims To be familiar with the routes of MSCC prentaion

3 How the guidelines work in practice Routes of presentation Generic intervention Managing patients not known to have cancer Factors influencing the decision for surgical intervention or oncology management Case studies

4 Routes of Presentation GP Self referral CNS Community or Hospital Palliative Care Teams Transfer from DGH A&E NGH WPH Direct NGH

5 Generic Interventions Patient history: Symptoms Duration, intensity, progression PMH Co-morbidities, Performance status Neurological assessment Baseline & daily re-assessments MRI whole spine

6 Flat bed rest until spinal stability has been assessed Pain control High dose Dexamethasone (PPI cover) VTE prophylaxis General Nursing care and psychological support

7 Known Cancer Diagnosis Liaison with Oncology team regarding prognosis and PS prior to this episode Surgical intervention If not a surgical candidate for Radiothapy

8 Not a known cancer Eliminate cancers where surgery is not necessarily the primary treatment: Prostate PSA and DRI (Degaralix) Myeloma myeloma screen + Benz jones Lymphoma examination / history, Lymphoma kit (Chemotherapy is optimal treatment for Haematological malignancies)

9 Consider germ cell tumours (particularly in younger men) Total HCG, AFP and Plap CT Chest, Abdomen & Pelvis If likely Renal Cell patient will need embolisation prior to surgery.

10 Factors influencing the choice of primary treatment Is this a cancer which is better treated by chemotherapy / hormone blockade? Is this technically possible? Is the patient able to tolerate the procedure and the recovery period? (prognosis / PS)

11 Patient symptoms suggestive of MSCC High suspicion MSCC / History of cancer with: NEW onset of pain Back pain band-like Radicular pain Neurological changes Weakness to limbs Altered sensation Urinary / faecal incontinence

12 Role of Radiotherapy Given if surgery not technically possible or due to patient limiting factors Post surgery usually 6 weeks post-op (rehab and wound healing)

13 CASE STUDY 1

14 Case one DT 49 year old Male Presenting to Rotherham hospital worsening back pain Left sided hip and leg pain Clinically well obs stable PMH Squamous Cell carcinoma right side of his neck Gout HTN Never smoked Doesn t drink Social Lives with wife & four children

15 Examination NGH 2/12/15 Neurological exam Digital Rectal Examination (DRE) Normal tone / sensation Rectum empty Lower limb Exam Tone: R normal, L slightly flaccid Power: R 5/5, L 4/5 Reflex: R Present, L Absent Sensation: R Peripheral neuropathy, L reduced L4 No bladder / bowel dysfunction

16 High or low suggestion of MSCC?

17 Patient symptoms suggestive of MSCC High suspicion of MSCC History of cancer with: NEW onset of pain Back pain band-like Radicular pain Neurological changes Weakness to limbs Altered sensation Urinary / faecal incontinence

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19 X-ray Implies fracture at L4 No history of trauma? Pathological

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24 MRI Confirming Metastatic lesion L4, causing compression? From pre Ca? Unknown Already done Myeloma screen, PSA 2.3

25 Decompression at L4 & stabilisation from L2-S1 3/12/15 Bone biopsy Head & Neck MDT +/- oncology F/U Chase Biopsy Palliative Care involvement Discharged 9/12/15

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28 20/12/16 Re- admitted 2 weeks post discharge at 22:00 Increased Back pain Reduced mobility Normal tone Reduced neurology from L2/3 Reduced reflexes Worse on mobilisation

29 High or low suggestions for MSCC?

30 MRI Reports wide spread spinal Mets Deterioration at L4 since previous scan Worsening of the central canal stenosis

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33 Plan 22/12/15 Dexamethasone & PPI CT Chest Abdo Pelvis D/W oncology Will see as OPA in 2days 2 nd Biopsy Problem No one able to do CT biopsy

34 Plan Further Decompression of L4 & open biopsy. Home for Xmas Back Boxing day for theatre

35 Able to mobilise better/ pain a lot better. Discharged home 29/12/16 Follow up with Oncology CUP Community Palliative Care DN wound check Follow up Spinal team 8 weeks

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37 Case TW 68 year old male Neck/ Right arm pain PMH Recent DVT Deranged clotting Prostate Ca (under WPH) PS-0

38 Presenting DRI neck pain normal neurology Had X-ray Any suggestions of MSCC? High or low?

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40 Plan at DRI MRI cervical CT neck with contrast Referred / transfer to NGH

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44 NGH On examination appears to have normal upper and lower limb neurology Aspen Collar Lay flat for pain What do we do?

45 Plan Immobilise (Keep Flat) Discuss options with patient For Gardner-Wells traction Reduce the dislocation & realign the spine Theatre at some point Posterior stabilisation of C0-C4 Other considerations Deranged clotting pre DVT Haematologists involvement

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49 Posterior C0-C4 stabilisation & decompression 16/03/16

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52 22/03/16 Doing well post operatively Progressing with mobilising Pain controlled Sitting out No neurological deterioration Complication Chest infection Difficulty swallowing SALT Review Soft diet Planning for biopsy on metastatic deposit on his hip As not safe to obtain one from c spine He has done as an inpatient

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