Malignant Spinal Cord Compression

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See Malignant Spinal Cord Compression Palliative Care Emergency guidance from the Scottish Palliative Care Guidelines.

Malignant Spinal Cord Compression (MSCC) occurs when the dural sac and its contents are compressed at the level of the cord or cauda equine. This may be a result of direct pressure, vertebral collapse or instability caused by metastatic spread or by direct extension of malignancy. It affects 5 to 10% of patients with cancer. Myeloma and lung, Breast and prostate are the commonest malignancies involved, but MSCC should be considered in any malignancy especially with bone involvement.

Cord compression can be the initial presentation of cancer. 1in 5 presenting with MSCC are not previously known to have cancer.1 in 10 MSCC patients will have spinal instability at presentation.

Late diagnosis is common causing permanent loss of function and significant morbidity.

Contacting your local MSCC co-ordinator will ensure rapid assessment, investigation and treatment of the patient. Early treatment may prevent or limit irreversible neurological damage. Please follow the pathway below.

Could this be malignant spinal cord compression (MSCC)

Is this MSCC?

The pathway usually looks for 3 indicators:-

  1. Cancer history, especially if metastatic
  2. New onset back pain
  3. New difficulty walking

Do not discount the MSCC pathway if only 2 indicators. If unsure use the pathway described in the sections below.

Cancer diagnosis:

  • Is there a cancer diagnosis?
  • Is the patient under investigation for cancer?

Symptoms

Early signs:

  • New onset difficulty walking
    • Use of walking aids, unexplained falls, lack of proprioception, weakness unilateral/ bilateral
  • Severe back pain - radicular in nature
    • New progressive intractable pain. Descriptors include band like pain around chest or down legs

Late signs:

  • Weakness
  • Sensory disturbance
  • Bladder/ bowel disturbance
  • Paralysis

Contact

Monday-Friday 9am-5pm:

  • MSCC Co-ordinator via bleep 2134 or via Raigmore switchboard (01463 704000)

Out of hours:

  • On-call oncologist via Raigmore switchboard (01463 704000)

Treatment

Dexamethasone
Administer 16mg dexamehtasone daily (consider gastro-protective cover if patient is high risk)

If MRI scan negative stop any additionally prescribed dexamethasone.

If MRI scan is positive then continue on dexamethasone 16mg once daily until treatment is completed. Then followr a stepwise reduction of dexamethasone reducing to a minimum as soon as possible as guided by clinical condition of the patient. 

Analgesia as required

Moving/ handling

If mobile at presentation:

  • Local agreement in NHS Highland is to keep a mobile patient mobile.
  • Advise not to carry anything
  • Seek assistance on transfer and climbing stairs
  • Refrain from driving.

If severe pain on movement:

  • May indicate spinal instability.
  • Consider advising patient to lie flat until assessment/ MRI has been made and log roll.

Paralysis:

  • Where paralysis is observed, patients remain on bed rest.

Last reviewed: 28 June 2019

Next review: 28 June 2021

Author(s): Superindendent Radiographer (Pre-Treatment)

Version: 6

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Lead MSCC Co-ordinator

Document Id: TAM115