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"Keep your faith in beautiful things; in the sun when it is hidden, in the Spring when it is gone."

ROY R. GIBSON

Malignant Spinal Cord Compression


What is it?

A real emergency. Tumour, usually a bony metastasis in the vertebra grows and presses on the spinal cord. Initially there may be pain and tenderness at the site of the metastasis. 95% give a history of back pain in the preceding 6-7 weeks. As the tumour grows, increasing pressure on the spinal cord reaches a critical point and often suddenly produces:

If undetected or untreated this can rapidly progress to:

Why is it important?

Early detection and treatment can prevent paralysis and double incontinence. It is not a fatal condition and 30% of patients will survive at least a year. Although rare, it is devastating if diagnosed too late as irreversible paraplegia ensues.

How common is it?

Cord compression affects 5% of all cancer patients. CANCER OF THE BREAST, LUNG AND PROSTATE account for 2/3 cases.

Symptoms


  % patients complaining % found on examination
Central back pain ± vertebral tenderness 80%-95% Then sudden onset of Weakness 76% 87%
Sphincter Disturbance 0% 57%
Sensory Deficit 51% 78%

Patients do not always complain - suspect and ask.
(Kramer JA (1992) Palliative Medicine 6 202-211)

What sort of pain?

Both radicular and funicular pain is made worse by:

This is the stage to suspect and diagnose.

Once weakness, sphincter disturbance and sensory deficit have arisen they progress rapidly. The likelihood of a good outcome from treatment reduces rapidly.

What sort of tests?

Plain x-ray of the spine has diagnostic accuracy of 80% (60% for bone scan), x-ray cervical, thoracic, lumbar spine and pelvis.

MRI scan (urgently) - is the imaging modality of choice. A normal plain X-ray and bone scan do NOT exclude malignant cord compression.

Treatment

Always indicated unless the patient is moribund.

Emergency treatment Dexamethasone

Definitive treatment (urgent)
Surgery particularly if histology suggests non-radiotherapy sensitive tumours e.g. melanoma or spinal instability, histology is uncertain or previous radiotherapy. Laminectomy ± radiotherapy. (Vertebrae intact)
Anterior decompression ± radiotherapy. (Vertebrae significantly eroded)
Radiotherapy particularly if histology suggests radiotherapy sensitive tumours.  

Functional Outcome


Mobility at present % Mobile after treatment
Ambulant 50-80%
Paretic 30-40%
Paraplegic 5%
25% relapse within 6 months

Key Points

If in doubt, discuss with the palliative care physicians or clinical oncologist.

Useful Links

Patient information on Spinal Cord Compression

North of England cancer network guidelines on spinal Cord Compression - PDF file

Lothian Palliative Care guideline on Spinal Cord Compression - PDF file

NICE guideline on metastatic spinal cord compression 2008 - PDF file

© Dr. Eileen Palmer, Dr John Howarth Palliative Care for the Primary Health Care Team (2004) Quay Books ISBN 1856422291

Important News

Important Changes in Cumbria Palliative Care Prescribing Practice

Cumbria is changing practice, from 1st April 2011.

The Area Prescribing Committee has recommended the following changes:

  • All strong opioids are to be prescribed by brand name
  • "Just in Case" prescribing is to be encouraged and promoted
  • Morphine is to replace diamorphine as the subcutaneous injectable strong opioid of choice for palliative care patients in Cumbria

21/03/2011

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North Cumbria Pallative Care website

The award winning North Cumbria Palliative Care website continues to receive around 30,000 page views a year. This is 82 page views every single day of the year, 2,500 hits every month, without any publicity or advertising program.

1/3/2011

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