Spinal cord compression

Question 1

symptoms of SCC

Answer 1

pain typically radicular
exacerbated by coughing or straining
not relieved by bed rest
neurological signs and symptoms: weakness of legs, sensory loss, retention, incontinence, dribbling

Question 2

common cancers to spread to the spine/bone

Answer 2

breast
prostate
lung
myeloma
lymphoma 

CAN be first presentation of malignancy

Question 3

Presentation of SCC

Answer 3

known cancer - not always present (25% first presentation)
known bone involvement
know mets
crush fracture and/or soft tissue tumour extension common

Question 4

Cauda equina syndrome symptoms - tumours below L1/2 can produce cauda equina compression

Answer 4

sciatic pain - often bilateral
bladder dysfunction with retention or incontinence
impotence
sacral anaesthesia
bowel retention or incontinence
weakness

Question 5

Examination in SCC

Answer 5

back examination
lower limb neurological
PR?

findings
pain and tenderness on palpation of vertebrae at site of compression
hyperflexia, sensory loss with ‘sensory level’, limb weakness
motor sensory and autonomic signs

band of hypeasthesia at level of lesion
sensory and motor loss below level of lesion
lesion may be partial or complete

Question 6

Investigations in SCC

Answer 6

MRI whole spine <24 hours (50% have more than 1 level of compression)
Bloods: FBC, U&E, LFT, bone profile

Question 7

immediate Management in SCC

Answer 7

speed essential - once paralysis occurs prognosis decreased

pain control 
Flat bed rest/ log roll 
SCC coordinator 
Dexamethasone 8mg BD immediately (gastro protection)
consider DVT risk
contact oncologist 
MRI <24 hours

Question 8

when is surgery indicated in SCC

Answer 8

patients with mechanical back or neck pain or early neurological symptoms indicating spinal instability 
single or limited level of disease
good performance status
estimated prognosis >3 months
tissue required for diagnosis

Question 9

Red flags/early warning signs of MSCC

Answer 9

referred back pain - band like
pain getting worse and not responding to medication
different character or site to previous symptoms
funny feelings, odd sensations or heavy legs
lying flat increases back pain
agonising pain
gait disturbance, unsteadiness, especially on stairs
sleep disturbed as pain worse at night

motor/sensory/bladder/bowel disturbances late signs

Question 10

prognosis

Answer 10

if mobile 85% will walk again

if paraplegic <15% walk again and survival <4 months

Question 11

site of compression

Answer 11

cervical 10%
thoracic 70%
lumbar 20%

Question 12

treatment of MSCC

Answer 12

MSCC coordinator, oncologist
establish diagnosis and maintain as much function as possible
options:
surgery
Radiotherapy - indicated after surgery, or alternative if not eligible for surgery, aim to give within 24 hours of diagnosis
BSC - best supportive care, established paralysis, poor prognosis, unable to tolerate radiotherapy