Malignant Spinal cord Compression Dr. Thiru Thirukkumaran Palliative Care Services - Northwest Tasmania
Background Statistics of SCC -1 Incidence of SCC Vertebral body metastases 85 % Para-vertebral (Lymphoma) mass 10 % Intra-medullary mass 4 % Haematogenous spread 1 %
Background Statistics of SCC -2 Site of Malignant Spinal cord Compression Cervical level 10 % Thoracic level 70 % Lumbo-Sacral Level 20 % More than one level 20 % 3-5 % of the patient s with cancer have spinal metastases 1 10 % of patient s with skeletal metastases develop MSCC.
Background Statistics of SCC -3 60 % of all the cases of MSCC from Breast Lung & Prostate Cancers. Bronchus } Breast, } cancers leads to Bony Mets! Brostate } Bhyroid } Bidney } In 0.23 % of the patient s MSCC will be their presenting feature. 8% 2 ry to Myeloma. Median survival of patient with MSCC is 2-3 months 1 ; 17% alive at 1 year & 10% at 18 months 2.
The main pathophysiological pathway of SCC development in cancer patients is summarized below
Metastatic Spinal cord Compression Magnetic resonance image Diagrammatic illustration Re-produced from K. Lee et al. Int. J for Qty in Health Care. 2007;pp 1-5. Re-produced from Abrahm JL. J Support Oncol. 2004;2:377 401.
Symptoms & Signs of MSCC Back pain 90 % Leg weakness Increase reflexes usually progressive, unremitting & keep the patient awake at night Numbness or a Sensory Level, or both Sphincter disturbances Urinary hesitancy (late feature) Bowel symptoms such as constipation Tenderness over the affected vertebrae Radicular Pain, particularly on coughing / sneezing Note: Clinical signs can be subtle in the early stages => Need to have high index of suspicion
Clinical Examination Findings Localised spinal tenderness Cervical spinal lesion: ~ Lhermitte s sign: Neck flexion causes electric shocks in trunk/limbs ~ Hoffman s reflex: Brief flexion of Thumb & index-finger on flicking the middle finger s pulp (if above C 5 ) Lumbar lesion: Spastic weakness below sensory level (Below L 1 Level) ~ Exaggerated reflexes ~ Up-going planter responses Cauda-equina lesion (Below L 1 Level) ~ Flaccid weakness ~ Saddle hypoaesthesia ~ Sphincter weakness Conus Mudullaris Lesion ~ Acute urinary & faecal retention
Investigation of MSCC Whole Spine MRI Gold Standard for diagnosis & treatment planning MRI (Li et al.) 4 ~ Sensitivity 93 % ~ Specificity 97 % CT myelography if MRI contra-indicated ( Permanent Pacemaker & Metal work in the spine)
Management MSCC is usually associated with inadequate control of primary tumour. Goal of the treatment is PALLIATIVE & directed at 1. maintain ambulation 2. decreasing tumour bulk 3. relieving the pain Options include 1. symptomatic therapy, 2. Radiation, 3. Neuro-surgery & 4. Chemotherapy.
Symptomatic Management Pain control Nurse flat Management of constipation (Reasons:2 ry to autonomic dysfunction, inactivity & opioids) Spinal braces for patients with spinal instability Occupational Therapy Physiotherapy Psychological support
Corticosteroids Dexamethasone 16mg /day to prevent further damage The steroid helps reduce pressure and swelling around the spinal cord, and can relieve symptoms such as pain. Common short term side effects include hyperglycemia, insomnia and gastric distress. Serious acute adverse effects such as gastrointestinal perforation or bleeding, psychosis, risk of infections
Care Pathway for Management of MSCC
Surgical Intervention Bartels, et al. Spinal Extradural Metastasis: Review of current Treatment Options. CA Cancer J Clin 2008;58:245 259