Transcript The Management of Spinal Cord Compression

The Management of
Malignant Spinal Cord
Compression
Dr H.K.Lord
Consultant Clinical
Oncologist
Aim – ambulatory patients
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
Presentation
 Depends
on level (77% in T spine)
 Radicular
(1)
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
Presentation
 Motor
weakness
 Sensory disturbance
 Sphincter disturbance
 However localisation of pain poorly
correlates with site of disease – 16%
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
Diagnosis
 In
the history - especially in a
known cancer patient.
 MRI
spine – urgent
 Referral
to Oncology - urgent
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

Options
 Surgery
 XRT
 Chemo
 BSC
Surgery
 Anterior
laminectomy – allows better
removal of tumour and reconstruction 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
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
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
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,
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#
Side effects
 Exit
 Skin
dose: bowel: diarrhoea
oesophagus: odynophagia
reaction - mild
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)
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)
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
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
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
Multidisciplinary care
 Keeping
patient and family informed
 Financial assistance (DS1500)
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 2003;327:469
Want our patients out walking, with
the dog carrying the stick!
Thank you

Any questions?