last malignant spinal cord compression (mscc)

8/13/2019 Last Malignant Spinal Cord Compression (Mscc)

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Dr Kamal Hamed


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IntroductionDiagnosis of MSCC is an emergency

Survival , quality of life are directly related tothe patients pretreatment ambulatory status. Emergency MRI and immediate initiation ofspecific therapy may preserve function.The main causes of delay are failure todiagnose spinal cord compression and failureto investigate and refer urgently (within24 hours)


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60% of the metastases are thoracic.30% are lumbo sacral

10% are cervical.

Commonly, breast and lung cancers causethoracic lesions

Cancer presents as MSCC in 20% of patients.


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Patients with cauda equina syndromeexperience diminished sensation overthe buttocks, posterior-superior

thighs, and perineal region 20% -80% experience decreased anal sphinctertone.Urinary retention and over flow incontinence arepathognomonic of the syndrome (90%sensitivity; 95% specificity). Absence of a post-void residual virtuallyexcludes it (negative predictive value 99%(


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Anatomy of the spine


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85%From vertebral bodyor pedicle

10% Throughintervertebral foramina(from paravertebral nodesor mass)

4% Intramedullary spread

1%(Low) Direct spread toepidural space


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Different spinalcord levels supplynerves fordifferent regionsof the

body


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Thoracic spine 60%Lumbosacral spine 30%Cervical spine 10%


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Most commonly seen in Breast Lung Prostate Lymphoma Myeloma

3-5% of patients with cancer overallApprox 200 cases per annum in North Trent


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Pain 95%

Weakness 5%Ataxia 1%Sensory loss 1%

RED FLAGS..


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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, iscaused by the expanding tumor in the bone, bonecollapse, or nerve damage.Pain is often unilateral with cervical or lumbosacralspine involvement and bilateral with thoracic spinedisease.

It is usually worse at night and with recumbency,because of lengthening of the spine and distention ofthe spinal epidural venous plexus.Valsalva manouvres and movement also exacerbatethe pain.


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Usually first symptom 80-90% of the time

Usually precedes other neurologicsymptoms by 7 weeksIncreases in intensity

Severe local back painAggravated 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 withspinal cord compression. Acta Neurochir (Wien) 1990; 107:37.


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

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


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

At or above conus medularisExtensors of the upper extremitiesAbove the thoracic spine

Weakness from corticospinal dysfunctionAffects flexors in the lower extremities

Patients may be hyper reflexic below thelesion and have extensor plantars

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


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Less common than motor findings

Still present in majority of cases

Ascending numbness and parathesiasNumbness or 'pins and needles' in toes &fingers or over the buttocks

Sensory levelSaddle anaesthesia

Feeling unsteady on feet, having difficulty withwalking, or legs giving way


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Loss is late finding

Problems passing urinemay include difficulty controlling bladder functionpassing very little urineor passing none at all

Constipation or problems controlling bowels

Autonomic neuropathy presents usually as urinary retentionRarely sole finding


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2-5 monthsmedian


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


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


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Delay in diagnosis of MSCC results in loss ofmobility and bladder dysfunction and

decreased survival.Because therapy is usually well tolerated inambulatory patients (even those with verylimited overall prognoses), the diagnosis ofMSCC should always be considered urgent


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MRI is the gold standard in detectingepidural metastatic disease and frank(SCC) (sensitivity, 93%; specificity, 97%;overall accuracy, 95%).

Plain spine radiographs have inadequate sensitivityand a false-negative rate of 10% - 17%.No validated predictive models suggest that clinicianscan omit an MRI in a patient with known cancer andback pain.

Finding unsuspected lesions is not unusual. In 45% ofpatients, 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 T2-

weighted axial images in areas of interest.


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1. MRI scan of the whole spineCan get compression at multiplelevels

2. Knowledge of cancer type &stage

3. Knowledge of patient fitness4. Current neurological

function Have they lost power in theirlegs?Can they walk?Do they need a catheter?

5. Do they have pain?


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MRI of spinal cord compression in awomen with past history of breast

cancer


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http://images.google.co.uk/imgres?imgurl=http://www.saspine.org/conditions/disc06.gif&imgrefurl=http://www.saspine.org/conditions/cervical_disc_prolapse.htm&h=324&w=300&sz=37&hl=en&start=11&um=1&tbnid=Pzy5ft80FG5MGM:&tbnh=118&tbnw=109&prev=/images%3Fq%3Dspinal%2Bcord%2Bcompression%26um%3D1%26hl%3Den%26sa%3DN


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Metastatic cancerHerniated discBenign bony lesionAbscessAlcoholic neuropathyPrimary tumour

OsteoporosisLow potassium

Case report3/11 casesconfirmed

MSCC


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Until spinal stability is confirmed patientsshould be managed on bed rest BUT Whereverpossible keep the patient moving


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Pain control

Avoidance of complications

Preserve or improve neurological function


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1. Steroids & gastric protection2. Analgesia

3. Surgery decompression & stabilisation ofthe spine4. Radiotherapy5. Chemotherapy e.g. lymphoma6. Hormonal manipulation e.g. prostate Ca


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Glucocorticoids reduce injury from traumaticspinal cord injury.

Dexamethasone decreases vasogenicedema.


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Day Dexamethasonedaily dose

Administration

1-3 16mg 16mg OM or 8mg BD(8am & 12noon)

4-6 8mg 8mg OM7-9 4mg 4mg OM

10-12 2mg 2mg OM

13 Discontinue

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


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Debate is ongoing regarding the merits of RT aloneversus surgical therapy followed by RT for selectedpatients with MSCC. Despite finding few papers of high methodological

quality, a 2005 evidence-based review recommendedradiation for ambulatory patients without spinalinstability, bony compression, or paraplegia onpresentation;

SURGERY recommended for:

patients with progressive neurologic deficits,vertebral column instability, radioresistant tumors (lung, colon, renal cell),intractable pain unrelieved by RT


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Unknown primary tumour Relapse post RT Progression while on RT

Intractable painInstability of spine Patients with a single level of cord

compression who have not been totallyparaplegic for longer than 48 hoursPrognosis >4 months


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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 ofdirect decompressive surgical resection in the treatment of spinal

cord compression caused by metastasis (abstract). proc Am SocClin Oncol 2003; 22:1.


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Relieves compressionRemoves tumourStabilises spine

But many patients notsuitable

Unfit Tumour factors


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Approximately 85% of patients with MSCC receive RTalone. The first RT fraction should be delivered within 24hours of a patients first presentation to the radiationoncologist.

RT is directed at vertebral metastatic sites that are painfulor are associated with significant epidural involvement orthecal 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 andbelow the site of compression


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Urgent access 24/7Dose & schedule

Depending on neurological deficit, PS, previoustreatment and cancer featuresSingle V fractionated treatment

SCORAD trial


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Pre operatively noPost operatively routinely

Definitive all pts unsuitable for surgery

Unless Total paraplegia (>24hrs) Very poor prognosis


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94% of patients who were ambulatory before surgery plusRT remained ambulatory, whereas only 76% of patientswho received RT alone did so. Thirty-two patients (16 in each treatment group) entered

the study unable to walk; patients in the surgery groupregained the ability to walk in a significantly greaterproportion 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 maintenanceof muscle strength, continence, functional scores, andsurvival (126 vs. 100 days; p 0.033) was significantlygreater in the group receiving surgery before RT.


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Analysis revealed a superior response of thegroup randomly selected to receivedecompressive surgery plus RT. Theposttreatment ambulation rate in the grouprandomly assigned to combination treatmentwas 84%, whereas that in the group randomlyassigned to RT alone was 57% (p 0.001; oddsratio, 6.2 [95% CI, 2.0 to 19.8]),

patients who underwent surgery plus RTretained ambulation for a significantly longerperiod of time than patients who had RT alone(122 vs. 13 days; p 0.003).


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Can be successful in chemosensitive tumoursHodgkins lymphoma Non-Hodgkins lymphoma NeuroblastomaGerm cellBreast cancer (hormonal manipulation)Prostate cancer (hormonal manipulation)


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Because the epidural space is on the systemicside of the blood-brain barrier, chemotherapyand hormonal therapies have been used in

individual patients with SCC from Hodgkins andnon- Hodgkins lymphomas, germ cell tumors,breast or prostate carcinomas, orneuroblastomas.In these individual case reports, the MSCCcompletely resolved in five of the seven patientsreported.No large case series or randomized controlledtrials have been conducted.


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Cancer is a hypercoaguable stateHigh burden of tumour in metastatic disease

Possible value in prophylaxis against venousthromboembolismIf patient not mobile

subcutaneous low molecular weight heparin +/-compression devices


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FactorsAutonomic dysfunctionLimited mobility

Opiate analgesic

Risk of perforation

Masked by corticosteroids

Bowel regimen needed


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1. Bed rest V mobilisation Rehabilitation

Braces & collars2. Psychological issues3. Urinary catheter4. Bowel function5. Nutrition6. Discharge issues


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Median survival with MSCC is 6 months

Ambulatory patients with radiosensitive

tumours have the best prognosisLikely to remain mobile

Sorensen, PS, Borgesen, SE, Rohde, K, et al. Metastatic epiduralspinal cord compression. Results of treatment and survival. Cancer

1990; 65:1502.

MSCC is a poor prognostic indicator in cancer patientsNeed better detection rates


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Data from WPH auditNumber of days from admission with

spinal cord compression to death

Range = 2 days to 319 days Mean = 58.6 days


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The six factors significantly associated with survivalweretumor type.

other bone metastases. visceral metastases. interval from tumor diagnosis to MSCC.pre-RT ambulatory status, andtime developing motor deficits before RT.

The score for each prognostic factor was determinedby dividing the 6-month survival rate (given inpercent) by 10. Total scores represented the sum ofthe six scores obtained for each prognostic factor.


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Selected patients with cancer with a single contiguousarea of compression and a radioresistant tumor maybe candidates for initial surgery followed by radiationtherapy and rehabilitation.

Patients with multiple sites of compression andtumors other than leukemia, lymphoma, myeloma,breast cancer, or prostate cancer generally have shortsurvivals and may be candidates for shortcourseradiation therapy and hospice care.

Palliative care can provide expert symptommanagement and can help patients and their familiesbegin to explore and cope with changes in self-image,independence, and roles in the family and communityand, when appropriate, begin advance care planning.


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Diagnosis of MSCC is an emergency.Survival and quality of life are directly relatedto the patients pretreatment ambulatorystatus.Emergency MRI and immediate initiation ofspecific therapy may preserve function.

Symptomatic therapy includes opioids,corticosteroids, and adjuvants;85% of patients with MSCC receive radiation

therapy


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last malignant spinal cord compression (mscc)

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