Malignant Spinal cord Compression - Palliative care · PDF fileSite of Malignant Spinal cord...

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 %

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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 metastases1

10 % of patient’s with skeletal metastases develop MSCC.


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% 2ry 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 % usually progressive, unremitting &

keep the patient awake at night

► Leg weakness

► Increase reflexes

► 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 C5)

• Lumbar lesion: Spastic weakness below sensory level (Below L1 Level) ~ Exaggerated reflexes

~ Up-going planter responses

• Cauda-equina lesion (Below L1 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:2ry 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




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