mscc care pathways & case studies case studies 2017.pdf · general nursing care and...

MSCC CARE PATHWAYS &

CASE STUDIES

By Michael Balloch Spine CNS

Aims

To be familiar with the routes of MSCC prentaion

How the guidelines work in practice

Routes of presentation

Generic intervention

Managing patients not known to have cancer

Factors influencing the decision for surgical

intervention or oncology management

Case studies

Routes of Presentation

Self

referral

A&E

NGH

WPH

CNS GP Community or

Hospital Palliative

Care Teams

Direct NGH

Transfer from DGH

Generic Interventions

Patient history:

Symptoms

– Duration, intensity, progression

PMH

Co-morbidities, Performance status

Neurological assessment

– Baseline & daily re-assessments

MRI whole spine

Flat bed rest until spinal stability has been assessed

Pain control

High dose Dexamethasone (PPI cover)

VTE prophylaxis

General Nursing care and psychological support

Known Cancer Diagnosis

Liaison with Oncology team regarding prognosis

and PS prior to this episode

Surgical intervention

If not a surgical candidate – for Radiothapy

Not a known cancer

Eliminate cancers where surgery is not necessarily

the primary treatment:

Prostate – PSA and DRI (Degaralix)

Myeloma – myeloma screen + Benz jones

Lymphoma – examination / history, Lymphoma kit

(Chemotherapy is optimal treatment for

Haematological malignancies)

Consider germ cell tumours (particularly in younger

men) Total HCG, AFP and Plap

CT Chest, Abdomen & Pelvis

If likely Renal Cell – patient will need embolisation

prior to surgery.

Factors influencing the choice of

primary treatment

Is this a cancer which is better treated by

chemotherapy / hormone blockade?

Is this technically possible?

Is the patient able to tolerate the procedure and

the recovery period? (prognosis / PS)

Patient symptoms suggestive of

MSCC

High suspicion MSCC / History of cancer with:

NEW onset of pain

Back pain – “band-like”

Radicular pain

Neurological changes

Weakness to limbs

Altered sensation

Urinary / faecal incontinence

Role of Radiotherapy

Given if surgery not technically possible or due to

patient limiting factors

Post surgery – usually 6 weeks post-op

(rehab and wound healing)

CASE STUDY 1

Case one DT

49 year old Male

Presenting to Rotherham hospital

worsening back pain Left sided hip and leg pain

Clinically well obs stable

PMH

Squamous Cell carcinoma right side of his neck

Gout

HTN

Never smoked

Doesn’t drink

Social

Lives with wife & four children

Examination NGH 2/12/15

Neurological exam

Digital Rectal Examination (DRE)

Normal tone / sensation

Rectum empty

Lower limb Exam

Tone: R normal, L slightly flaccid

Power: R 5/5, L 4/5

Reflex: R Present, L Absent

Sensation: R Peripheral neuropathy, L reduced L4

No bladder / bowel dysfunction

High or low suggestion of MSCC ?

Patient symptoms suggestive of

MSCC

High suspicion of MSCC

History of cancer with:

NEW onset of pain

Back pain – “band-like”

Radicular pain

Neurological changes

Weakness to limbs

Altered sensation

Urinary / faecal incontinence

X-ray

Implies fracture at L4

No history of trauma

? Pathological

MRI

Confirming Metastatic lesion L4 , causing compression

? From pre Ca ? Unknown

Already done

Myeloma screen, PSA 2.3

Decompression at L4 & stabilisation from L2-S1

3/12/15

Bone biopsy

Head & Neck MDT

+/- oncology F/U

Chase Biopsy

Palliative Care involvement

Discharged 9/12/15

20/12/16

Re- admitted 2 weeks post discharge at 22:00

Increased Back pain

Reduced mobility

Normal tone

Reduced neurology from L2/3

Reduced reflexes

Worse on mobilisation

High or low suggestions for MSCC ?

MRI

Reports wide spread spinal Mets

Deterioration at L4 since previous scan

Worsening of the central canal stenosis

Plan 22/12/15

Dexamethasone & PPI

CT Chest Abdo Pelvis

D/W oncology

Will see as OPA in 2days

2nd Biopsy

Problem

No one able to do CT biopsy

Plan

Further Decompression of L4 & open biopsy.

Home for Xmas

Back Boxing day for theatre

Able to mobilise better/ pain a lot better.

Discharged home 29/12/16

Follow up with Oncology CUP

Community Palliative Care

DN wound check

Follow up Spinal team 8 weeks

Case TW

68 year old male

Neck/ Right arm pain

PMH

Recent DVT

Deranged clotting

Prostate Ca (under WPH)

PS-0

Presenting

DRI neck pain

normal neurology

Had X-ray

Any suggestions of MSCC ?

High or low ?

Plan at DRI

MRI cervical

CT neck with contrast

Referred / transfer to NGH

NGH

On examination appears to have normal upper and

lower limb neurology

Aspen Collar

Lay flat for pain

What do we do?

Plan

Immobilise (Keep Flat)

Discuss options with patient

For Gardner-Wells traction

Reduce the dislocation & realign the spine

Theatre at some point

Posterior stabilisation of C0-C4

Other considerations

Deranged clotting pre DVT

Haematologists involvement

Posterior C0-C4 stabilisation & decompression

16/03/16

22/03/16

Doing well post operatively

Progressing with mobilising

Pain controlled

Sitting out

No neurological deterioration

Complication

Chest infection

Difficulty swallowing

SALT Review

Soft diet

Planning for biopsy on metastatic deposit on his hip

As not safe to obtain one from c spine

He has done as an inpatient