Spinal Cord Compression

Question 1

Malignant spinal cord compression (MSCC) is most commonly seen in which cancers?

Answer 1

cancers that spread to bone

Question 2

what are the 2 main types of MSCC and where are the most commonly found?

Answer 2

result of vertebral collapse
result of extradural mets

common site is thoracic spine

Question 3

what are the typical features of pain in MSCC?

Answer 3

• thoracic pain (most common)
• radicular distribution ie radiating along affected dermatome
• worsening over preceding weeks/months
• worse with coughing/sneezing, movement, weight bearing

Question 4

what are the typical sensory/motor symptoms of MSCC?

Answer 4

progressive leg weakness and sensory loss

Question 5

what are the typical autonomic symptoms of MSCC?

Answer 5

urinary incontinence or retention

faecal incontinence

Question 6

on examination

Answer 6

spinal tenderness
UMNL findings
loss of sensation below dermatomal level of compression (T10 sensory level suggests compression at T8 vertebral level)
bladder - retention/incontinence
reduced anal tone

Question 7

what are examples of upper motor neurone findings

Answer 7

hypertonis
hyper-reflexia
clonus
upgoing plantars

Question 8

gold standard investigation

Answer 8

MRI of whole spine

Question 9

what can an MRI show

Answer 9

allows diagnosis
defines level of compression
identifies other levels of compression
allows assessment of stability of the spine

Question 10

when would a CT scan be used

Answer 10

MRi contraindicated (eg pacemaker)
patient is not previously know to have a diagnosis of cancer in order to identify primary site

Question 11

what is another key investigation in suspected MSCC

Answer 11

serum Ca (raised)

Question 12

what are the groups of management

Answer 12

supportive
steroids
surgery
radiotherapy
chemotherapy

Question 13

how would you supportively manage a patient with MSCC

Answer 13

keep patient flat until stability of spine determined
urinary catheter if urinary retention
monitor bowel function + commence bowel regimen if required (laxatives/enemas)
physiotherapy
prophylactic dalteparin if bed-bound

Question 14

what steroids would you give and why?

Answer 14

dexamethasone 8mg bd initially
- oral preferred but S/C or IV if required

helps reduced oedema around lesion

Question 15

what should you keep in mind when giving steroids

Answer 15

side effects

• prescribe with fast-protection eg omeprazole
• monitor blood sugar (daily BM)
• minmise duration of high dose steroids- aim to reduce dose once definitive therapy started

Question 16

when is surgery the preferred treatment

Answer 16

patient is fit with low volume met disease
LE >3 month
isolated posterior cord compression (decompression laminectomy may suffice)
good prior sensory/motor function
no prior history of cancer
strong remainder of spine

Question 17

when is surgery generally avoided

Answer 17

frail patient with large volume met disease
prior poor morbidity
anterior compression (surgery would require vertebral body resection with stabilisation = MAJOR OP)

Question 18

when is radiotherapy used

Answer 18

after surgery to reduce risk of recurrence

instead of surgery in patients not fit for theatre

Question 19

how is radiotherapy delivered

Answer 19

targeted at the level of the spinal cord - 4 fractions delivered over 4 consecutive days

Question 20

when is primary chemotherapy used

Answer 20

if the primary tumour is highly chemosensitive - eg germ cell tumours, lymphomas

if there is no surgical or radiotherapy option

Question 21

prognosis

Answer 21

fully ambulant at diagnosis - 90% remain ambulant

not fully weight bearing or mobile waling aid - most unable to walk again independently

paraplegic - 10% become ambulant after treatment

***better prognosis is related to early diagnosis and management