Dr Kamal Hamed

Introduction Diagnosis of MSCC is an emergency Survival , quality of life are directly related to the patients pretreatment ambulatory status. Emergency MRI and immediate initiation of specific therapy may preserve function. The main causes of delay are failure to diagnose spinal cord compression and failure to investigate and refer urgently (within 24 hours)

60% of the metastases are thoracic. 30% are lumbo sacral 10% are cervical. Commonly, breast and lung cancers cause thoracic lesions Cancer presents as MSCC in 20% of patients.

Patients with cauda equina syndrome experience diminished sensation over the buttocks, posterior-superior thighs, and perineal region 20% -80% experience decreased anal sphincter tone. Urinary retention and over flow incontinence are pathognomonic of the syndrome (90% sensitivity; 95% specificity). Absence of a post-void residual virtually excludes it (negative predictive value 99%(

Anatomy of the spine

85%From vertebral body or pedicle 10% Through intervertebral foramina (from paravertebral nodes or mass) 4% Intramedullary spread 1%(Low) Direct spread to epidural space

Different spinal cord levels supply nerves for different regions of the body

 Thoracic spine

60% Lumbosacral spine 30% Cervical spine 10%

Most commonly seen in

Breast Lung Prostate Lymphoma Myeloma

3-5% of patients with cancer overall

Approx 200 cases per annum in North Trent

Pain Weakness Ataxia Sensory loss

95% 5% 1% 1%

RED FLAGS..

BACK PAIN is the most common symptom of (MSCC), noted by 83%-95% of patients before its diagnosis. Pain, which can be local, referred, and/or radicular, is caused by the expanding tumor in the bone, bone collapse, or nerve damage. Pain is often unilateral with cervical or lumbosacral spine involvement and bilateral with thoracic spine disease. It is usually worse at night and with recumbency, because of lengthening of the spine and distention of the spinal epidural venous plexus. Valsalva manouvres and movement also exacerbate the pain.

Usually first symptom

80-90% of the time

Usually precedes other neurologic symptoms by 7 weeks

Increases in intensity

Severe local back pain Aggravated by lying down

Distension of venous plexus

Bach, F, Larsen, BH, Rohde, K, et al. Metastatic spinal cord compression. Occurrence, symptoms, clinical presentations and prognosis in 398 patients with spinal cord compression. Acta Neurochir (Wien) 1990; 107:37.

 may be mild to begin with lasts for more than 1 - 2 weeks

Pain may feel like a 'band' around the chest or abdomen (radicular)
Can radiate over the lower back, into the

buttocks or legs

Weakness: 60-85%
Tends to be symmetrical Severity greatest with thoracic mets

At or above conus medularis

Extensors of the upper extremities

Above the thoracic spine

Weakness from corticospinal dysfunction Affects flexors in the lower extremities

Patients may be hyper reflexic below the lesion and have extensor plantars

Greenberg, HS, Kim, JH, Posner, JB. Epidural spinal cord compression from metastatic tumor: Results with a new treatment protocol. Ann Neurol 1980; 8:361.

Less common than motor findings Still present in majority of cases Ascending numbness and parathesias
fingers or over the buttocks
Sensory level Saddle anaesthesia

Numbness or 'pins and needles' in toes &

Feeling unsteady on feet, having difficulty with walking, or legs giving way

Loss is late finding

Problems passing urine

may include difficulty controlling bladder function passing very little urine or passing none at all

Constipation or problems controlling bowels

Autonomic neuropathy presents usually as urinary retention
Rarely sole finding

2-5 months median

Common signs of MSCC include radiculopathy, weakness, sensory changes (e.g., paresthesias, loss of sensation). sphincter incontinence, and autonomic dysfunction (e.g., urinary hesitancy, retention). Upper motor neuron weakness is usually symmetric. Early lower motor neuron weakness is often asymmetric and begins in the distal extremities, as do sensory findings.

Requires very prompt diagnosis & treatment to try and prevent catastrophic consequences of paralysis & incontinence

Delay in diagnosis of MSCC results in loss of mobility and bladder dysfunction and decreased survival. Because therapy is usually well tolerated in ambulatory patients (even those with very limited overall prognoses), the diagnosis of MSCC should always be considered urgent

MRI is the gold standard in detecting epidural metastatic disease and frank (SCC) (sensitivity, 93%; specificity, 97%; overall accuracy, 95%). Plain spine radiographs have inadequate sensitivity and a false-negative rate of 10% - 17%. No validated predictive models suggest that clinicians can omit an MRI in a patient with known cancer and back pain. Finding unsuspected lesions is not unusual. In 45% of patients, MRI findings altered the radiation therapy (RT) field. An MRI of the entire spine is therefore required, including T1-weighted sagittal images with T1- or T2weighted axial images in areas of interest.

1. 2. 3. 4.

MRI scan of the whole spine

Knowledge of cancer type & stage Knowledge of patient fitness Current neurological function

Can get compression at multiple levels

5.

Do they have pain?

Have they lost power in their legs? Can they walk? Do they need a catheter?

MRI of spinal cord compression in a women with past history of breast cancer

Metastatic cancer Herniated disc Benign bony lesion Abscess Alcoholic neuropathy Primary tumour Osteoporosis Low potassium

Case report 3/11 cases confirmed MSCC

Until spinal stability is confirmed patients should be managed on bed rest BUT Wherever possible keep the patient moving

Pain control Avoidance of complications

Preserve or improve neurological function

1. 2. 3. 4. 5. 6.

Steroids & gastric protection Analgesia Surgery decompression & stabilisation of the spine Radiotherapy Chemotherapy e.g. lymphoma Hormonal manipulation e.g. prostate Ca

Glucocorticoids reduce injury from traumatic spinal cord injury.

Dexamethasone decreases vasogenic edema.

Day 1-3 4-6 7-9 10-12 13

Dexamethasone daily dose 16mg 8mg 4mg 2mg Discontinue

Administration 16mg OM or 8mg BD (8am & 12noon) 8mg OM 4mg OM 2mg OM

While the patient is on steroids commence PPI (e.g. Lansoprazole) for gastric protection. A slower reducing regimen may be required for patients who have received previous courses of steroids.

Debate is ongoing regarding the merits of RT alone versus surgical therapy followed by RT for selected patients with MSCC. Despite finding few papers of high methodological quality, a 2005 evidence-based review recommended radiation for ambulatory patients without spinal instability, bony compression, or paraplegia on presentation; SURGERY recommended for: patients with progressive neurologic deficits, vertebral column instability, radioresistant tumors (lung, colon, renal cell), intractable pain unrelieved by RT

 Unknown primary tumour Relapse post RT Progression while on RT Intractable pain Instability of spine Patients with a single level of cord compression who have not been totally paraplegic for longer than 48 hours Prognosis >4 months

RCT comparing surgery followed by RT vs. RT alone

Improvement in surgery + RT
Days remained ambulatory (126 vs. 35) Percent that regained ambulation after therapy (56% vs.

19%) Days remained continent (142 vs. 12) Less steroid dose, less narcotics Trend to increase survival
Patchell, R, Tibbs, PA, Regine, WF, et al. A randomized trial of direct decompressive surgical resection in the treatment of spinal cord compression caused by metastasis (abstract). proc Am Soc Clin Oncol 2003; 22:1.

Relieves compression Removes tumour Stabilises spine

But many patients not suitable
Unfit Tumour factors

Approximately 85% of patients with MSCC receive RT alone. The first RT fraction should be delivered within 24 hours of a patients first presentation to the radiation oncologist. RT is directed at vertebral metastatic sites that are painful or are associated with significant epidural involvement or thecal sac indentation (i.e., subclinical SCC). Prospective observational studies have shown that 60% 90% of patients achieve pain relief with RT and dexamethasone. Of patients who are ambulatory before RT, 60% to 100% maintain the ability to walk. RT ports extend one or two vertebral bodies above and below the site of compression

Urgent access 24/7 Dose & schedule

Depending on neurological deficit, PS, previous

treatment and cancer features

Single V fractionated treatment

SCORAD trial

Pre operatively no Post operatively routinely Definitive all pts unsuitable for surgery
Unless Total paraplegia (>24hrs) Very poor prognosis

94% of patients who were ambulatory before surgery plus RT remained ambulatory, whereas only 76% of patients who received RT alone did so. Thirty-two patients (16 in each treatment group) entered the study unable to walk; patients in the surgery group regained the ability to walk in a significantly greater proportion than patients in the RT alone group (10 of 16 [62%] vs. 3 of 16 [19%]; p 0.01). The need for corticosteroids and opioid analgesics was significantly lower in the surgical group, and maintenance of muscle strength, continence, functional scores, and survival (126 vs. 100 days; p 0.033) was significantly greater in the group receiving surgery before RT.

Analysis revealed a superior response of the group randomly selected to receive decompressive surgery plus RT. The posttreatment ambulation rate in the group randomly assigned to combination treatment was 84%, whereas that in the group randomly assigned to RT alone was 57% (p 0.001; odds ratio, 6.2 [95% CI, 2.0 to 19.8]), patients who underwent surgery plus RT retained ambulation for a significantly longer period of time than patients who had RT alone (122 vs. 13 days; p 0.003).

Can be successful in chemosensitive tumours

Hodgkins lymphoma Non-Hodgkins lymphoma Neuroblastoma Germ cell Breast cancer (hormonal manipulation) Prostate cancer (hormonal manipulation)

Because the epidural space is on the systemic side of the blood-brain barrier, chemotherapy and hormonal therapies have been used in individual patients with SCC from Hodgkins and non-Hodgkins lymphomas, germ cell tumors, breast or prostate carcinomas, or neuroblastomas. In these individual case reports, the MSCC completely resolved in five of the seven patients reported. No large case series or randomized controlled trials have been conducted.

Cancer is a hypercoaguable state High burden of tumour in metastatic disease Possible value in prophylaxis against venous thromboembolism If patient not mobile
subcutaneous low molecular weight heparin +/-

compression devices

Factors
Autonomic dysfunction
Limited mobility Opiate analgesic

Risk of perforation
Masked by corticosteroids

Bowel regimen needed

1.

Bed rest V mobilisation

Rehabilitation Braces & collars

2. 3. 4. 5. 6.

Psychological issues Urinary catheter Bowel function Nutrition Discharge issues

Median survival with MSCC is 6 months

Ambulatory patients with radiosensitive tumours have the best prognosis

Likely to remain mobile

Sorensen, PS, Borgesen, SE, Rohde, K, et al. Metastatic epidural spinal cord compression. Results of treatment and survival. Cancer 1990; 65:1502.

MSCC is a poor prognostic indicator in cancer patients Need better detection rates

Data from WPH audit Number of days from admission with spinal cord compression to death
Range = 2 days to 319 days Mean = 58.6 days

The six factors significantly associated with survival were tumor type. other bone metastases. visceral metastases. interval from tumor diagnosis to MSCC. pre-RT ambulatory status, and time developing motor deficits before RT. The score for each prognostic factor was determined by dividing the 6-month survival rate (given in percent) by 10. Total scores represented the sum of the six scores obtained for each prognostic factor.

 Selected patients with cancer with a single contiguous area of compression and a radioresistant tumor may be candidates for initial surgery followed by radiation therapy and rehabilitation. Patients with multiple sites of compression and tumors other than leukemia, lymphoma, myeloma, breast cancer, or prostate cancer generally have short survivals and may be candidates for shortcourse radiation therapy and hospice care. Palliative care can provide expert symptom management and can help patients and their families begin to explore and cope with changes in self-image, independence, and roles in the family and community and, when appropriate, begin advance care planning.

Diagnosis of MSCC is an emergency. Survival and quality of life are directly related to the patients pretreatment ambulatory status. Emergency MRI and immediate initiation of specific therapy may preserve function. Symptomatic therapy includes opioids, corticosteroids, and adjuvants; 85% of patients with MSCC receive radiation therapy