MSCC CARE PATHWAYS & CASE STUDIES case studies...CASE STUDY 1 Case one DT 49 year old Male...
Transcript of MSCC CARE PATHWAYS & CASE STUDIES case studies...CASE STUDY 1 Case one DT 49 year old Male...
MSCC CARE PATHWAYS &
CASE STUDIES
By Michael Balloch Spine CNS
Aims
To be familiar with the routes of MSCC prentaion
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
Routes of Presentation
Self
referral
A&E
NGH
WPH
CNS GP Community or
Hospital Palliative
Care Teams
Direct NGH
Transfer from DGH
Generic Interventions
Patient history:
Symptoms
– Duration, intensity, progression
PMH
Co-morbidities, Performance status
Neurological assessment
– Baseline & daily re-assessments
MRI whole spine
Flat bed rest until spinal stability has been assessed
Pain control
High dose Dexamethasone (PPI cover)
VTE prophylaxis
General Nursing care and psychological support
Known Cancer Diagnosis
Liaison with Oncology team regarding prognosis
and PS prior to this episode
Surgical intervention
If not a surgical candidate – for Radiothapy
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)
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.
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)
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
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)
CASE STUDY 1
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
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
High or low suggestion of MSCC ?
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
X-ray
Implies fracture at L4
No history of trauma
? Pathological
MRI
Confirming Metastatic lesion L4 , causing compression
? From pre Ca ? Unknown
Already done
Myeloma screen, PSA 2.3
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
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
High or low suggestions for MSCC ?
MRI
Reports wide spread spinal Mets
Deterioration at L4 since previous scan
Worsening of the central canal stenosis
Plan 22/12/15
Dexamethasone & PPI
CT Chest Abdo Pelvis
D/W oncology
Will see as OPA in 2days
2nd Biopsy
Problem
No one able to do CT biopsy
Plan
Further Decompression of L4 & open biopsy.
Home for Xmas
Back Boxing day for theatre
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
Case TW
68 year old male
Neck/ Right arm pain
PMH
Recent DVT
Deranged clotting
Prostate Ca (under WPH)
PS-0
Presenting
DRI neck pain
normal neurology
Had X-ray
Any suggestions of MSCC ?
High or low ?
Plan at DRI
MRI cervical
CT neck with contrast
Referred / transfer to NGH
NGH
On examination appears to have normal upper and
lower limb neurology
Aspen Collar
Lay flat for pain
What do we do?
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
Posterior C0-C4 stabilisation & decompression
16/03/16
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