malignant spinal cord compression-- dealing the most common --mets

7/27/2019 Malignant Spinal Cord Compression-- Dealing the most common --Mets

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Maliganant Spinal CordCompression

Dr Sasikumar Sambasivam

Dept. Of Palliative Medicine


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Compressive Myelopathy

Intra medullary

Intradural

Extradural

Extramedullary


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Extramedullary Intramedullary

Motor

a)UMN signs Common Late

b)LMN signs 1or2segments at the site ofroot compression wide (Ant horn cell)

Sensory

a)Pain Root pain Funicular pain

b)Dissociated sensory loss Absent present

c)Sacral sensation Lost Preserved

d)Joint sensation Lost Late involvement

e)Lhermitte`s sign present absent

Autonomic involvement

Bowel and Bladder

Late Early

Intradural Extradural

Mode of onset Asymmetrical ,

acute,rapid

Symmetrical,slow,

progressive

Vertebral No Pain and gibbus Pain and Gibbus


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Extradural Intradural Intramedullary

SpondylosisDisc prolapse

Trauma

Tumor-Metastasis,multiple

myeloma

CVJ anomalies

FluorosisTB spine

Epidural abscess

Epidural haematoma

Tumor-NF,meningioma,lipoma,sarcoma

metastasis

Arachonoiditis

Sarcoidosis

Cervical menigitis

AVMLeukemic infiltration

Arachonoid cyst

SyrinxTumor ependymoma

astrocytoma

Haemagioblastoma

Haematomyelia

COMPRESSIVE MYELOPATHY CAUSES


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METASTASIS:

Metastasis is the most common tumor.

Epidural type of compression

Throacic is common; Lumbar&Sacral Prostate and

ovarian

Breast>Lung>Prostate>Kidney>Lymphoma>

Plasmacell dyscrasia

MRI hypodense in T1;doesnot cross the adjacent

disc space


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Site of Spinal Cord Syndrome

60-80 percent of cases occur in the thoracic

spine

15-30 percent in the lumbosacral spine


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Intradural : Benign and slow growing ; progressive compression signs

Meningioma,Neurofibroma,chordoma,lipoma

dermoid,sarcoma

MENINGIOMA: benignthrocic cord level or near foramen magnum

from arachonoid cells

forms Psammoma bodies

Radiation therapy- Gammma Knife, proton beam treatment

external beam

NEUROFIBROMA: from schwwan cells

arises near posterior root

begins with radicular symptoms

asymetric progressive spinal cord syndrome

need surgical treatment

INTRAMEDULLARY: uncommon

cervical commonly

central cord syndrome or hemicord syndrome

Ependymoma,Haemangioblastoma,secondaries

astrocytoma(lowgrade)

Microsurgical debulking can be tried

RT is not useful

Primary tumors of spinal cordcommon in cervical


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Spinal Cord Syndrome


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Spinal Cord Syndrome

Making the diagnosis early

Imaging studies

Conventional Therapy

Radiation approaches

Surgical techniques


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Compression of the spinal cord is due

predominantly to extradural metastases

(95%) and usually results from tumorinvolvement of the vertebral column. A

tumor may occasionally metastasize to

the epidural space without bony

involvement.

Metastatic spinal cord compression

affects 5 to 14% of all cancer patients.

Although spinal cord compression

occurs in a variety of malignancies, the

most common are lung, breast,

unknown primary, prostate, and renalcancers, as well as lymphoma and

myeloma.


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Symptoms of Spinal Cord Syndrome

Pain

Motor

Sensory Autonomic


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Painusually the first symptom being present in 83 to 95 percent of

patients at the time of diagnosis.

On average, pain precedes other neurologic symptoms of ESCC by

seven weeks.

Affected patients usually notice a severe local back pain which

progressively increases in intensity.

Pain is often worse with recumbency, a feature attributed to distension

of the epidural venous plexus.

Over time, the pain may develop a radicular quality.

Radicular pain is more common in lumbosacral lesions than thoracic

lesions.

Thoracic radicular pain is commonly bilateral and wraps around

anteriorly in a band like fashion.


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Odds of finding epidural metastases based onsymptoms in patients with bone metastases in spine

myelopathy 78%

radicular pain 61%

back pain 36%


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Motor findingsWeakness is present in 60 to

85 percent of patients.

o When the lesion is at or above the conus

medullaris, weakness is from corticospinal

dysfunction and has the typical pyramidal

pattern, preferentially affecting the flexors in

the lower extremities and,

o if above the thoracic spine, the extensors ofthe upper extremities.

o Hyperreflexia below the level of the

compression and extensor plantar responses

may be seen.

o The progression of motor findings untildiagnosis typically consists of increasing

weakness followed sequentially by loss of

gait function and paralysis


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Sensory findingsSensory findings

are a little less common than motor

findings but are still present in a

majority of patients at diagnosis.

Patients frequently report ascending

numbness and paresthesias .

When a spinal sensory level is present,

it is typically one to five levels belowthe actual level of cord compression.

Saddle sensory loss is commonly

present in cauda equina lesions, while

lesions above the cauda equinafrequently result in sparing of sacral

dermatomes to pinprick.


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Loss of bladder and bowel functionBladder and bowel dysfunction due to ESCC is

generally a late finding that may be present in as many as one-half of patients. The

autonomic neuropathy most commonly presents as urinary retention and is rarely the

sole symptom of ESCC


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The median delay to treatment in those with

known malignancy was two months from the

onset of back pain and ten days from the onsetof symptoms of spinal cord compression

Most importantly, the majority of patients

deteriorated by at least one grade in motor or

bladder function during the delay from initialsymptoms of ESCC. The net effect of delayed

recognition and therapy is that the majority of

patients with ESCC are not ambulatory at

diagnosis

Even in recent series, between 48 and 77

percent of patients with newly diagnosed

ESCC are non-ambulatory


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RadiographyPlain spinal radiographs in a cancer patient with back pain,

either major vertebral body collapse or pedicle erosion with a matching

radiculopathy predicts a 75 to 83 percent chance of ESCC when a definitive

study is performed .

False negativeplain spinal radiographs --10 to 17percent of patients.

Three factors are primarily responsible for the false negative results: 50 percent

of bone must be destroyed before a radiograph becomes abnormal; metastatic

involvement of multiple vertebrae may obscure the clinically relevant lesion;

and paraspinal tumor invading through the neural foramen may produce noradiographic abnormality.


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MRI

BONE SCAN

PET SCAN


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Estimated Life Expectancy

Median Survival , n= 1,157, radiation for painful bone mets

breast cancer 16 months(14.2 to 18.5 months)

prostate cancer 9.5 months (7.8 to 11 months)

lung

cancer 3.2 months (2.8 to 3.5 months)

One criterion to consider a patient eligible forsurgery isan expected

survival of at least 3 months. Forradiotherapy,a minimum life

expectancy of at least a month is consideredappropriate since most

beneficial effects are expected to occurafter 3 to 4 weeks.


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Survival is based on several considerations:

- responders live longer (9.5 months versus 2 months)

- ambulatory patients live longer than paralyzed (10 monthsversus 1 month)

-favorable histologies (myeloma, breast, lymphoma) live

longer than other types (12 months versus 4 months)


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Early Detection Inform patients at high risk of developing bone

metastases

Ensure that patients with MSCC and their families andcarers know who to contact if their symptoms progresswhile they are waiting for urgent investigation of

suspected compression.

MRI investigation of choice, CT Scan with 3Dreconstruction for spinal stability.

No role of routine MRI in asymptomatic pts.

Bone scan to rule out other sites of mets

f i l d


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Treatment of spinal metastases and MSCC Treatment is primarily to relieve pain and/or preventvertebral collapse and spinal cord compression.

Definitive treatment of bony instability and/orneurological disability.

Surgery is increasingly the treatment of choice forpatients with MSCC, but the two aims of preserving

neurological function and also achieving spinalcolumn reconstruction that will remain stable duringthe patients remaining life, are not alwaysattainable.

It is important to remember that:


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It is important to remember that:

MSCC is only one manifestation of the underlying malignant diseasewhich itself may need speficic treatment by the primary tumour site

specialist-- ongologist or haemotologist.

The majority of patients with MSCC have metastases in other bonysites or viscera.

Even when a solitary metastasis has progressed to the point thatMSCC has developed, it is unlikely that extralesional excision willeradicate the cancer.

Only about 20% of patients with MSCC will survive more than a year.

Treatment of MSCC is primarily to improve the quality of remaininglife in most cases.

Some epidural tumours (including haemotological malignancies)respond to treatments other than surgery or require only limitedsurgery.

Treatment planning must therefore take account of:


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Treatment planning must therefore take account of: the degree of neurological disability

the general health of the patient

the primary site of tumour

the presence of other spinal and extraspinal metastases the likely response of the tumour to radiotherapy or other adjuvant

therapy.

All of these factors as well as the likely time taken to be treated

and rehabilitated must be balanced against the likelihood of agood functional outcome and long-term survival.

There are some patients who are too unwell for anyintervention and will be given supportive care only.

Surgical procedures need proper patient selection and the bestsuited surgical procedure

Treatment for painful spinal metastases


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Treatment for painful spinal metastases

and prevention of MSCC

Ideally all patients with MSCC should be fully staged beforesurgery but if spinal cord function is deteriorating rapidlythis may not be possible.

Non-mechanical pain -non-invasive methods--analgesics,radiotherapy, drugs including bisphosphonates, andoccasionally chemotherapy as part of the generaltreatment of chemosensitive disease.(Some pts only)

Mechanical painspine support---corsets or braces for thetrunk, and collars or halo jackets.

Internal supportvertebroplasty, kyphoplasty

Treatments


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Bisphosphonates: (Level 1 Evidence)

Offer patients with vertebral involvement from

myeloma or breast cancer bisphosphonates to

reduce pain and the risk of vertebral

fracture/collapse

Offer patients with vertebral metastases fromprostate cancer bisphosphonates to reduce pain

only if conventional analgesia fails to control pain.

Should not be used to treat spinal pain in patientswith other than myeloma, breast cancer or

prostate cancer (if conventional analgesia fails) or

with the intention of preventing MSCC, except as

part of a randomised controlled trial.

Treatments

for painful

spinal

metastases

and

preventionof MSCC

R di th (L l 1)Treatments


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Radiotherapy (Level 1)

30Gy/10 fr; 20Gy/5 fr; 8 Gy /1fr based

on the performace scale.

No role of Prophylactic RT.

for painful

spinal

metastases

and

preventionof MSCC

Vertebroplasty and kyphoplastyTreatments


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Vertebroplasty and kyphoplasty

Consider for patients who have vertebral metastases and no

evidence of compression or spinal instability if they have:

mechanical pain resistant to conventional analgesia, or

vertebral body collapse.

Vertebroplasty or kyphoplasty for spinal metastases should onlybe performed after agreement between appropriate specialists.

There is no health economic evidence regarding vertebroplasty

and kyphoplasty for their use in pain control.

However, there is evidence of cost effectiveness for

vertebroplasty as a definitive treatment for MSCC.

for painful

spinal

metastases

and

preventionof MSCC

Surgery Treatments


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Surgery

Urgent consideration in -- spinal metastases and imaging

evidence of structural spinal failure

If mechanical pain is resistant to conventional analgesia ---

stabilisation surgery even if completely paralysed.

Pts with severe mechanical pain and/or imaging evidence

of spinal instability, but who are unsuitable for surgery are

considered for external spinal support (for example, a halo

vest or cervico-thoraco-lumbar orthosis).

Pts without pain or instability should not be offered

surgery

for painful

spinal

metastases

and

preventionof MSCC

f


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Care of the threatened spinal cord in

patients with MSCC

Immobilisation:

Nursed with flat with neutral spinealignment

close monitoring and intervalassessment during gradual sittingfrom supine to 60 degrees over aperiod of 34 hours.

continue to unsupported sitting ifBP is stable

C ti t idCare of the


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Corticosteroids

Believed to reduce tumour bulk or spinal cord

swelling, relieve spinal cord pressure and improvetreatment outcomes.

Rapid improvement of neurological function butlong term benefit is limited, and there is no

evidence that survival is improved.

Significant side effects on longterm use hencedefinitive therapy.

Loading dose of at least 16 mg of dexamethasoneas soon as possible after assessment, followed bya short course of 16 mg dexamethasone dailywhile treatment is being planned.

threatened

spinal cord

in patients

with MSCC

C ti d th 16 d il iCare of the


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Continue dexamethasone 16 mg daily inpatients awaiting surgery or radiotherapy

After surgery or the start of radiotherapythe dose should be reduced graduallyover 57 days and stopped.

If neurological function deteriorates atany time the dose should be increasedtemporarily.

If no treatment is planned , taper thedose gradually.

Monitor Blood glucose

threatened

spinal cord in

patients with

MSCC

-Corticosteroids

C l i f d fi i i


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Case selection for definitive treatment

Start before any further neurological deterioration

and ideally within 24 hours

establish the primary histology of spinal metastases(by tumour biopsy, if necessary)

Stage the tumours to determine the number,anatomical sites and extent of spinal and visceral

metastases.

Age but PS is an independent predictor of outcome


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Summary of prognostic indicators

Good prognosis Breast cancer as the

primary site

Solitary or few spinalmetastases

Absence of visceralmetastases

Ability to walk aided orunaided

Minimal neurologicalimpairment

No previous radiotherapy.

Poor prognosis Lung or melanoma

primary

Multiple spinal

metastases Visceral metastases

Unable to walk

Severe weakness

Recurrence afterradiotherapy.


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Surgery for the definitive treatment

If surgery is appropriate, attempt to

achieve both spinal corddecompression and durable spinalcolumn stability.

Options: decompression and the spinal column is

stabilised by rods connected to pediclescrews in the healthy vertebra above andbelow the diseased level with or withoutpostero- lateral inter-transverse grafts.

Alternatively, or additionally, the diseasedvertebral body can be resected andreplaced with bone graft and/or metalcages or cement

Surgery for the


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Neurological ability and timing:

Surgery done-- before they lose the ability to walk.

Residual distal sensory or motor function and a

good prognosis --offered surgery in an attempt to

recover useful function, regardless of their ability towalk.

completely paraplegic or tetraplegic for more than

24 hours --should only be offered surgery if spinalstabilisation is required for pain relief

definitive

treatment

Posterior decompression alone should not bef d i i i h MSCC i h

Surgery for the


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performed in patients with MSCC except in therare circumstances of isolated epidural tumouror neural arch metastases without bonyinstability.

Vertebral inv. Or threatened spinal stability,consider posterior decompression withinternal fixation with or without bone grafting.

Consider vertebral body reinforcement withcement for patients with MSCC and vertebralbody involvement who are suitable forinstrumented decompression and lifeexpectancy < 1 yr

Consider vertebral body reconstruction withanterior bone graft for patients with MSCC andvertebral body involvement who are suitablefor instrumented decompression, if life expect>1 yr

definitive

treatment-

Recommendations

Radiotherapy for the definitive treatment


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Radiotherapy for the definitive treatment

Ensure urgent (within 24 hours) access to and availability of

radiotherapy.

Offer fractionated radiotherapy as the definitive treatment ofchoice to patients with epidural tumour without neurologicalimpairment, mechanical pain or spinal instability.

Fractionatedgood prognosis who are having radiotherapy astheir first-line treatment

No role of preop RT if surgery is planned

Postop RT recommended for better outcome


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Offer urgent radiotherapy (within 24 hours) to

all patients with MSCC who are not suitable

for spinal surgery unless:

they have had complete tetraplegia or

paraplegia for more than 24 hours and their

pain is well controlled; or

their overall prognosis is judged to be too poor

Recent Advances in


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Recent Advances in

relation to RT Improving radiation

technology from radiumand cobalt to imageguided IMRT /Tomotherapy andstereotactic radiosurgery(Cyberknife)

Health economic evaluation


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Health economic evaluation

Consider further radiotherapy or surgery for patients who have

responded well to previous radiotherapy and develop recurrentsymptoms after at least 3 months.

If patients have further radiotherapy, the total dose should be

below a biologically equivalent dose of 100 Gy where possible.

Discuss the possible benefits and risks with the patient before

agreeing a treatment plan.

Further research is required into the tolerance of the spinal cord

to radiation damage and its ability to recover and tolerate

repeated courses.

S ti d h bilit ti


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Supportive care and rehabilitation

Bed rest--thigh-length graduated

compression/anti-embolism stockings unless

contra-indicated

high risk of venous thromboembolismlow

molecular weight heparin + mechanical

thromboprophylaxis

Supportive care

d


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Management of

pressure ulcers

Bladder and bowel

continence

management

Maintainingcirculatory and

respiratory functioning

Access to specialistrehabilitation and

transition to care at

home

and

rehabilitation

Tokuhashi scoring system: A revised scoring system for


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Tokuhashi scoring system: A revised scoring system for

preoperative evaluation of metastatic spine tumor prognosis

Spine 2005, 30 (19), 21862191

General condition (performance status) Poor (PS 1040%) 0

Moderate (PS 5070%)1

Good (PS 80100%)2

Number of extraspinal bone metastases foci

3 0

1-2 1

0 2

Number of metastases in the vertebral body

3 0

2 1

1 2

Metastases to the major internal organs

Unremovable 0

Removable 1

No metastases 2

Primary site of the cancer Lung, osteosarcoma, stomach, bladder,

esophagus, pancreas 0

Liver, gall bladder, unidentified 1

Others 2

Kidney, uterus 3

Rectum

4 Thyroid, breast, prostate, carcinoid tumor

5

Palsy

Complete (Frankel A, B)0

Incomplete (Frankel C, D)1

None (Frankel E) 2

Criteria of predicted prognosis:

Total Score (TS) 08 < 6 months,

TS 911 6 months,

TS 1215 1 year


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Thank you.

malignant spinal cord compression-- dealing the most common --mets

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