Spinal Cord Compression: A Case Study

Angie Angeles-Lo, SN, Kathy Berliner, SN Anthony Bodestyne, SN Lisa Warren, SN

Spinal Cord Compression: Patient History

 Pt Demographics: 55 year old female, diagnosed 1 year prior with metastatic colon cancer. This patient had a section of colon removed in 11/02; she now has a permanent transverse colostomy. She was admitted to Kaiser South San Francisco on 11/20/03 for Spinal Cord Compression with paralysis of the lower extremities.

Spinal Cord Compression: Patient History

 History of Present Hospitalization: In 9/03, multiple retroperitoneal nodes were discovered on CT. On the advice of the physician, the pt flew to El Salvador to visit family. On 11/19, pt awoke with severe 10+/10 back pain accompanied by b/l weakness of the lower extremities. She was seen in the ER in El Salvador where she received epidural analgesia in order to sit through the flight back to the U.S. By the end of the flight, the pt had no sensation or movement of the lower extremities.

Spinal Cord Compression: Diagnostic Tests

 CT Scan: A scan of the thoracic spine done on 11/20. The impression showed probable metastatic disease to the thoracic spine. Air was seen within the epidural space at the lower thoracic level. Exact etiology is unknown.

 MRI: A follow up MRI was done of the thoracic and lower spine that same day. The impression showed extensive metastatic tumor involving the cervical, thoracic, lumbar and sacral vertebrae, with evidence or spinal cord compression at T2 and T9.

Spinal Cord Compression: Pathophysiology

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Definition:

Spinal cord compression damage occur when a tumor directly enters the spinal cord or when the vertebral column collapses from tumor entry. Tumors may begin in the spinal cord but more commonly spread from other areas of the body such as the lung, prostate, breast, colon.

Spinal Cord Compression: Pathophysiology

 Direct compression or distortion of the spinal cord may result from neoplastic infiltration of the vertebral bodies or paravertebral spaces.  Rarely, cancerous growths may originate from structures within the epidural space.

 Nerve tracts most vulnerable to mechanical pressure include the corticospinal and spinocerebellar tracts and the posterior spinal columns.

Spinal Cord Compression: Pathophysiology

 Spinal cord compression usually follows hematogenous dissemination of a malignancy to the vertebral bodies, with subsequent expansion of an epidural mass. Generally, metastatic seeding appears in the thoracic spine 70% of with the lumbar spine being the next most involved site.The cervical spine is affected in approximately 10% of cases.Multiple spinal levels are affected in about 30% of patients.  Systemic cancers with a tendency for spinal cord metastasis include the following: breast, prostate, renal, or lung neoplasms; lymphoma; sarcoma; and multiple myeloma.

Spinal Cord Compression: Pathophysiology

 Spread into the epidural space may occur by means of tumor extension through the intervertebral foramina or hematogenous spread by way of the Batson venous plexus. Additionally, gastrointestinal and pelvic malignancies tend to affect the lumbosacral spine; lung and breast cancers are more likely to affect the thoracic spine.

Spinal Cord Compression: Pathophysiology

 Leptomeningeal metastases spread by means of diffuse or multifocal seeding of the meninges from systemic cancer (eg, lung or breast cancer, melanoma, lymphoma). Consequent signs and symptoms are referable to the brain, cranial nerves, or spine. Evidence of spinal compromise includes lower extremity weakness, paresthesias, reflex asymmetry, and spinal pain.

Spinal Cord Compression: Signs and Symptoms

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Signs and Symptoms

: Spinal cord compression causes back pain, usually before neurologic deficits occur. Neurologic deficits are related to the spinal level of compression and include the following:  1. Numbness  2. T ingling  3. Loss of urethral, vaginal and rectal sensation  4. Muscle weakness  5. If paralysis occurs, it is usually permanent.

 6. Valsalva maneuvers, such as coughing, sneezing, or straining, may exacerbate radicular back pain.

Spinal Cord Compression: Treatment

 Nurses caring for clients with spinal cord compression must recognize the condition early. The nurses assesses the client for neurologic changes consistent with spinal cord compression. The nurse also teaches clients and families to recognize the symptoms of early spinal cord compression and to seek medical assistance as soon as possible.

 Treatment is largely palliative. High-doses radiation is usually administered to reduce the size of the tumor in the area and relieve compression. Radiation may be given in conjunction with chemotherapy to treat the total disease. Surgery is occasionally performed to remove the tumor from the area and rearrange the bony tissue so less pressure is placed on the spinal cord. External back or neck braces may be prescribed to reduce the weight borne by the spinal column and to reduce pressure on the spinal cord or spinal nerves.

Spinal Cord Compression: Patient Medications

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Dexamethasone-

Management of cerebral edema and spianal compression .Potent, locally acting anti-inflammatory and immune modifier.

Action

-suppresses inflammation and the normal immune response.

Dosage

-0.75-9mg PO/IV/IM daily

IM, IV (Adults):

Dexamethasone phosphate

—10 mg initially IV, 4 mg q 6 hr, may be decreased to 2 mg q 8–12 hr, then change to PO.

Adverse reaction

nausea, dizziness, HA

Serious reaction

-anapyhaxis.

Implication-

Assess patient for changes in level of consciousness and headache throughout therapy.

Protonix- For hypersecretory condition, GERD

Dosage

40-120mg PO BID Max:240 mg/d.

Info:

do not crush, cut chew

Action:

Inhibits gastric parietal cell hydrogen-potassium ATPase (proton pump inhibitr)

Adverse RXN

: HA, diarrhea

Serious side effect:

Anaphylaxis

Implication:

monitor for and immediately report S&S of angioedma or severe skin reaction

Spinal Cord Compression: Patient Medications

    Fentanyl Patch: For Chronic Pain

Dosage

: 25-100 mcg/hr patch q72h

Action

: Binds to various opiate receptors, producing analgesia and sedation.

Adverse reaction

: dry mouth, euphoria.

Serious side effect:

respiratory depression, severe HTN.

Implication:

evaluate pain relief. Monitor VS, O2 Sat, bladder function.

Heparin-DVT Tx/prophylaxis

Dosage

: 5000 U SC q8-12h

Action

: with antithrobin III and heparin cofactor, inhibits thrombin and Factor Xa and inhibits conversion of fibrinogen to fibrin

Adverse reaction

: Prolonged clotting time, bleeding

Serious reaction

: hemorrhage

Implication

:Monitor patient for hypersensitivity reactions (chills, fever, urticaria). Report signs to physician.Monitor platelet count every 2–3 days throughout therapy.

Spinal Cord Compression: Patient Medications

 Insulin:Due to glucocorticoid administration.

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Dosage:

Sliding Scale before meals and bedtime

Action:

Lower blood glucose by increasing transport into cells and promoting the conversion of glucose to glycogen

Adverse reaction:

rebound hyperglycemia (Somogyi effect), hypoglycemia

Serious reaction

-anaphylaxis

Implications:

Check type, species source, dose, and expiration date with another licensed nurse. Do not interchange insulins without consulting physician or other health care professional.

Spinal Cord Compression: Radiation Therapy

 Radiation treatment to areas of tumor compression should be pursued after appropriate imaging and consultation.  Cord compression from an epidural tumor is considered one of the few emergencies in radiation oncology.  Spinal cord tolerance to radiation depends on the fraction size and cumulative dose.

Spinal Cord Compression: Radiation Therapy

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Radiation treatment

affects normal cells while damaging cancer cells. Sometimes this effect on normal cells and tissues can cause pain and discomfort.  Skin dryness, difficulty in swallowing or skin sores may occur. The radiation therapy specialist can recommend a program to care for the skin to alleviate these side effects.  Fatigue can be a disabling side effect of cancer, cancer treatments and dealing with pain. It restricts a person's ability to manage their usual activities. 

This patient was receiving external beam radiation for 8 days as palliative treatment to shrink the tumor that invaded the spinal column.

Spinal Cord Compression: Nursing Assessments and Interventions

 Monitor and document vital signs.

Rationale: Obtain info on patient’s overall condition

 Assess neurological status including limb strength, sensation, bladder and bowel function

Rationale: Establish patient’s level of consciousness. Ascertain any evidence of increasing spinal cord compression as indicated by motor dysfunction, weakness, ataxia, sensory loss, numbness, tingling, loss of sensation to pain and temperature, constipation and urinary retention.

Spinal Cord Compression Nursing Assessment

 Monitor blood chemistry and patient for signs of hypercalcemia, such as confusion, drowsiness and lethargy.

Rationale: Elevated calcium levels may be associated with bone mets causing spinal cord compression

 Assess alterations in elimination of urine and feces in terns of urgency, frequency, level of control over function, retention, constipation and incontinence.

Rationale: Early autonomic and nervous system involvement results in constipation and urinary retention. Bowel and bladder incontinence develop with advanced autonomic nervous system involvement.

Spinal Cord Compression: Nursing Assessment

 Assess patient’s pain level. Assess for duration, location, type, intensity and quality. Assess pain interventions.

Consider non-pharmacological interventions such as relaxation, therapeutic massage and adjustment of patient’s position.

 Assess patient’s skin as there are at risk for impaired skin integrity.

Rationale: Maintain good body alignment at all times to decrease the risk of further injury to spine.

Spinal Cord Compression: Nursing Assessment

 Assess for signs and symptoms of deep venous thrombosis due to activity.

This can lead to pulmonary embolism, which can be a lethal complication. Many die within one hour of onset of symptoms or before it has been suspected.

 For a DVT assess for calf and groin tenderness, pain, sudden onset of unilateral swelling of leg and positive Homan’s sign. Symptoms of pulmonary embolism include dyspnea, chest pain, restlessness, cough and hemoptysis. Signs include tachypnea, crackles, pleural friction rub, tachycardia, diaphoresis, fever and petechiae over chest and axilla.

Spinal Cord Compression: Nursing Assessment

 Assess and monitor patient and family’s psychological status and adaptation to diagnosis and implication on lifestyle.

Feelings of helplessness, hopelessness and depression are common. Bed bound patients become withdrawn and lose motivation.

Spinal Cord Compression: Nursing Diagnoses and Interventions

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Impaired physical mobility related to neuromuscular

impairment. Interventions include: maintain proper body alignment, ROM exercises, adequate nutrition, teach patient how to move in bed, monitor skin area over pressure areas.

Risk for falls related to decreased or absent lower

extremity sensation and strength. Interventions include: bed in low position, side rails up, keep frequently used items within patient’s reach, provide assistance with ambulation.

Spinal Cord Compression: Nursing Diagnoses and Interventions

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Risk for impaired skin integrity related to physical immobilization and loss of bladder and bowel control.

Interventions include:

Active or passive range of motions, ambulate to the extend possible, change positions every 2 hours, reduce pressure using things like pillows, air mattresses and bed cradles, maintain good body hygiene, encourage adequate fluid and nutritional intake.

Bowel incontinence related to loss of rectal sphincter control.

Interventions include:

Keep area clean and dry. Monitor anal and genital skin integrity. Record each episode including when it occurs, amount, color and consistency. Provide emotional support for patient.

Spinal Cord Compression: Nursing Diagnoses and Interventions

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Ineffective Individual Coping related to inadequate

level of confidence in ability to cope. Interventions

include:

maintain consistency in approach and teaching whenever interacting with patient, monitor for and reinforce behavior suggesting effective coping continuously, assist patient to identify and use available support systems before discharge from hospital and help patient evaluate which methods he or she have used that have not been successful or have been only partially successful.