The Management of Malignant Spinal Cord Compression

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The Management of Malignant Spinal Cord
Compression

• Dr H.K.Lord
• Consultant Clinical Oncologist

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Aim ambulatory patients
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Introduction

• 2-5 of cancer patients have an episode of SCC
• Commoner in myeloma, prostate, lung and breast
  cancer (15-20)
• Initial presentation in 8 cancer patients,
  sometimes of unknown primary
• 10 of patients diagnosed with SCC may have a
  second episode

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Presentation

• Depends on level (77 in T spine) (1)
• Radicular back pain in 85-95
• Worsened by lying flat, weight bearing, coughing
  and sneezing, relieved by sitting

1. Levack P, Graham J, Collie D, Grant R, Kidd J,
Kunkler I, Gibson A, Hurman D, McMillan N,
Rampling R, Slider L, Statham P, Summers D (2001)
A prospective audit of the diagnosis, management
and outcome of malignant spinal cord compression.
Clinical Resource and Audit Group (CRAG) 97/08
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Presentation

• Motor weakness
• Sensory disturbance
• Sphincter disturbance
• However localisation of pain poorly correlates
  with site of disease 16

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Aetiology

• 3 routes
• Vertebral mets invading the epidural space, or
  causing bone destruction and fragments of bone
  compressing the cord
• Retroperitoneal tumours grow through the
  intervertebral foramina
• Compression of blood supply to cord causing
  ischemia and oedema and hence loss of function

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Diagnosis

• In the history - especially in a known cancer
  patient.
• MRI spine urgent
• Referral to Oncology - urgent

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Treatment

• Steroids dexamethasone 16mg po with PPI or H2
  antagonist to reduce oedema
• Thereafter
• Depends on histology
• Depends on patient age
• performance status
• and if disease is controlled elsewhere

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Options

• Surgery
• XRT
• Chemo
• BSC

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Surgery

• Anterior laminectomy allows better removal of
  tumour and re-construction of vertebral body
• Suitable for patients who are fit for surgery,
  have unstable spine, or radio-resistant tumour,
  and disease at only one level, with disease
  elsewhere either absent or controlled

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Surgery XRT (1)

• Trial 2005 surgery radiotherapy (XRT) vs XRT
  alone. US, 7 centres, 101 pts.
• Those receiving surgery XRT vs XRT
• Able to walk 84 vs 57
• Median time able to walk 122 vs 13 days
• Continent 156 vs 17 days
• Regained ability to walk (n 32) 62 vs 19
• Survival 126 vs 100 days

Ref 1. Patchell 2005 Direct decompressive
surgical resection in the treatment of spinal
cord compression caused by metastatic cancer a
randomised trial Lancet 366(9986) 643-8
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Radiotherapy alone

• Remains the majority, despite evidence above
• In patients unfit for surgery with multi-level
  disease with disease elsewhere that may or may
  not be controlled with some residual
  neurological function

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Radiotherapy

• Lack of randomised trials literature review
  only (1)
• 20Gy in 5 over 1 week
• Started as soon as is reasonably practical
• Direct field, prescribed to the depth of the cord

Ref 1. Emergency treatment of malignant
extradural spinal cord compression an
evidence-based guideline DA Loblaw and NJ
Laperriere Journal of Clinical Oncology, Vol 16,
1613-1624,
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Radiotherapy

• May use higher dose if post op or if only site of
  metastasis ( 30Gy in 10)
• If plasmacytoma, use radical dose of 40Gy in 25

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Side effects

• Exit dose bowel diarrhoea
  oesophagus odynophagia
• Skin reaction - mild

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Outcomes

• No immediate benefit
• Some neurological improvement over following
  weeks improved pain control or halting of
  further deterioration
• Glasgow study 74 patients died within 3 months
  of diagnosis (1)

• A McLinton and C Hutchison Malignant spinal cord
  compression a retrospective audit of clinical
• practice at a UK regional cancer centre British
  Journal of Cancer (2006)

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Chemotherapy

• Perhaps as follow up to initial treatment but
  rarely as first line management
• e.g. in lymphoma or small cell lung cancer or
  teratoma

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Best Supportive Care

• Once neurological function lost, recovery
  unlikely.
• If disease elsewhere is advanced, may be
  appropriate not to treat actively.
• Steroids, physiotherapy, analgaesia, good nursing
  care

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Multidisciplinary care

• Rehabilitation
• Nursing care pressure sores thromboembolic
  disease analgaesia
• Personal dignity
• Lack of autonomy
• End stage of illness
• If discharge planned, OT, SW and PT input

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Multidisciplinary care

• Keeping patient and family informed
• Financial assistance (DS1500)

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Prevention

• Listen to patient history early detection
• If known to have bony metastases, role of
  bisphosphonates - prostate and breast cancer
  patients (1)
• Early referral to Oncology

1 J R Ross   Systematic review of role of
bisphosphonates on skeletal morbidity in
metastatic cancer BMJ  2003327469
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Want our patients out walking, with the dog
carrying the stick!
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Thank you

• Any questions?