Case One

MALIGNANT SPINAL CORD

COMPRESSION

What is it?

• compression of the spinal cord by cancer tumour

• extra-dural compression is most common (90%), but can also be intradural

Which part of the spinal cord is affected?• cervical cord 10%

• thoracic cord 70%

• lumbo-sacral cord 20%

• Can also occur at more than one site/level

Which cancers?

• approx 5% of cancer patients develop SCC

• associated more commonly with:

- breast cancer 27%

- prostate cancer 27%

- lung cancer 20%

- myeloma

- kidney cancer

Clinical presentation –

• symptoms may be very subtle

• main problem is the failure to diagnose early resulting in delay in Rx

Clinical presentation –

• localised back pain

• nerve root pain

• progressive numbness/tingling

• sensory loss (objective)

• weakness ('gone off their feet')

• loss of bladder/bowel control

What should make you suspect diagnosis of SCC?• primary tumour is breast, prostate, lung, myeloma

or kidney

• evidence/knowledge of multiple bone metastases, especially in vertebrae

• back pain – night pain, progressive

• bilateral sensory symptoms, weakness

What should you do if you suspect it?

• arrange urgent admission to oncologist/radiotherapist (easier said than done!)

• start dexamethasone 16mg od straight away if any delay in admission (PPI cover)

What happens to the patient in hospital?

• they should start dexamethasone 16mg od if not already on it

• urgent MRI scan of spine

• if proven, urgent radiotherapy to cord compression area

Why is it important to diagnose and treat SCC early?

• the outcome in SCC is critically dependent on the speed of diagnosis and treatment

• it is possible to reverse neurological damage if treated within 24-48 hrs of onset

• speed affects the difference between patient being paralysed for the remainder of their illness or remaining ambulant/walking

Success rates of SCC treatment with Radio Rx

• depends on level of neurological function at presentation to radiotherapist

• if patient is ambulatory – 70% retain ability to walk

• if patient is paraparetic – 35% retain ability to walk

• if patient is paraplegic – 5% retain ability to walk

The role of surgery

Indicated if:

• previous Radio Rx/ no response

• to RadioRx

• life expectancy > three months

• single site

• unstable spine

Take home messages

• SCC is a palliative care emergency

• prompt diagnosis and Rx can prevent paralysis

admit ASAP if suspicion of SCC (as long as patient agrees and is not moribund)

• start steroids if any delay in admission