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Metastatic Spinal Cord Compression ( MSCC )

Malignant or Metastatic Spinal Cord Compression –occurs when the dural sac and its
 contents are compressed at the levels of the cord or cauda equina. This may be as a result of direct pressure , vertebral collapse or instability caused by metastatic 
spread or by direct extension of malignancy ( Scottish Palliative Care Guidelines )

How common ? True spinal emergency A delay in diagnosis can lead to irreversible loss of neurologic function Relatively common complication of cancer , occurring in 5-10 % of patients with malignancy , often complicating the end stage of patients life In 20-23 % of patients it can be the presenting feature of malignancy Most common tumours that metastasize to the spine are advanced breast , lung , prostate and kidney tumours Any systemic cancer including haematological malignancies can metastasise to the spine Spine is the most common osseous site for metastatic disease due to the inherent rich vascular supply and extensive lymphatic drainage Exact incidence is not known NICE guidance states approximately 4000 cases / year in England and Wales Average at diagnosis is 65 ( NICE )

How does it happen ? Haematogenous spread with bony metastasis to the vertebral spine causes collapse and compression , accounting for over 85 % of MSCC -bony destruction and expansion of the tumour then cause collapse and compression of the dural sac , root sleeves and their contents leading to vascular compromise , vasogenic oedema and demyelination Local tumour extension into spinal cord Deposition of tumour cells within the spinal cord from a distant tumour

Why important –MSCC is a complication of cancer Poor overall prognosis from this condition of 2-3 months ↑↑ ed pain Motor and sensory loss Paraplegia and urinary / faecal incontinence ↑ ed risk of skin breakdown , venous thromboembolism , sepsis and pneumonia Decreased QOL The incidence of MSCC is likely to increase as improved cancer treatments resulting in better survival and outcomes

Which segment –Lumbar spine seems to be most frequently involved followed by thoracic and cervical segments But clinically symptomatic spinal metastasis are most often localised to the thoracic spine , followed by the lumbar and cervical segments

Spinal cord compression-Back pain is the earliest and most compelling manifestation of MSCC in over 95 % of patients Suspect spinal cord compression in any patient with cancer Presentation can be varied with with a wide variety of neurological symptoms affecting any or all of the motor , sensory and autonomic NS Pain can be
◘ localized ( in & around spinal column ) due to periosteal stretching and inflammation caused by
 tumour growth OR
◘ radicular ( nerve root pain affecting on or both sides of the body )
◘ have both components
◘ thoracic and upper lumbar radicular pain can be reported as abdominal pain Spinal nerve root pain may be burning , shooting , numbing in character or may radiate down anterior or posterior thigh ( like sciatica ) like a band around chest or abdomen pain may get worse with coughing , straining or lying flat ( epidural plexus extension ) new difficulty with walking or climbing stairs reduced power ( motor weakness )
motor weakness can be either upper or lower motor neuron or even a combination sensory impairment or altered sensation in limbs bowel or bladder disturbance ( typically urinary retention )
: loss of sphincter control is a late sign with a poor prognosis






A study was conducted in Edinburgh , Aberdeen and Glasgow in 1988-90 which 
showed that

 at the time of diagnosis 82 % of patients were unable to walk independently pain was described in 94 % of patients and had been present for a median 3 months priro to the diagnosis of MSCC pain had the typical distribution and nature of nerve root pain in 79 % of patients 
( with descriptors such as ” band -like” ,” thoracic pain ” , ” worse on sneezing and coughing or bending “, ” sharp ” , ” burning “, ” worse on lying flat ” weakness or difficulty walking was reported in 85 % of patients and was present for a median duration of 20 days preceding diagnosis

Cauda Equina Syndrome –Cauda Equina Syndrome ( CES ) is a serious neurological condition in which the neurological 
dysfunction affects the lumbar and sacral nerve roots within the vertebral canal. Prompt recognition and is of paramount
 importance as patients can be left with permanent and disabling neurological deficits involving the lower limb 
sensorimotor function , bladder , bowel and sexual functions One of the major causes of litigation Can result from 
○ disc herniation
○ low back surgery , h/o trauma
○ malignancy ( primary and secondary )
○ epidural haematoma , epidural abscess
○ vertebral fracture or subluxation






Important to understand that CES is the same process but happens at or below the level of the cauda equina 
( typically at L1 level ) and may present with
 new , severe root pain affecting low back , buttocks , perineum , thighs , legs loss of sensation often with tingling or numbness in the saddle area motor weakness , sensory loss or radicular pain ( usually bilateral ) loss of lower limb reflexes bladder , bowel and sexual dysfunction – happen earlier than in cord compression and urinary retention with
overflow incontinence is an important predictor with a sensitivity of 90 % and specificity of 95 % loss of anal – reflex

Provide written information for people at risk and document – e, g MSCC Card
for PILs see Links and Resources section Get familiar with local protocols – keep the number of MSCC coordinator in your diary. The MSCC coordinator can be the single point of contact Ensure analgesia using WHO pain ladder Consider high-dose dexamethasone in MSCC ( unless contraindicated and in discussion with specialists )
◘ usually 16 mg daily as 8 mg bd
◘ gastro-protection MRI is the gold standard and should be done within 24 hrs in cases with high index of 
suspicion ( bone scans and XRs are inadequate )
CT is used to aid surgical or radiotherapy Rc planning Treatment can be
○ surgery if spinal instability and neurological signs present- decompression and spinal stabilisation procedures
○ Radiotherapy
○ combination radio , chemo and surgery 
○ bisphosphonates

EMERGENCY REFERRAL IS ESSENTIAL – explain , provide analgesia and discuss with 
MSCC coordinator / Local Oncology Service / Trauma and Orthopaedics / Neurosurgical team ( CES )

LINKS AND RESOURCES

Patient Information

Information on Spinal Cord Compression from Cancer Research UK https://www.cancerresearchuk.org/about-cancer/coping/physically/spinal-cord-compression/about

MSCC Alert Card from Macmillan Cancer Support http://be.macmillan.org.uk/Downloads/CancerInformation/MAC17346MSCCAlertZcard.pdf

Full guidance for the patient from Macmillan cancer support https://www.macmillan.org.uk/information-and-support/coping/side-effects-and-symptoms/other-side-effects/malignant-spinal-cord-compression.html#268842

Prostate Cancer UK info on MSCC  https://prostatecanceruk.org/prostate-information/advanced-prostate-cancer/metastatic-spinal-cord-compression-mscc

Information from The Christie foundation for the patient https://www.christie.nhs.uk/media/1119/legacymedia-4947-439-spinal-cord-compression-what-to-look-out-for.pdf

Cauda Equina Syndrome -Information for patients from University Hospital of Southampton ( advice to ignore the contact details unless from Southampton ) https://www.uhs.nhs.uk/Media/Controlleddocuments/Patientinformation/Brain-and-spine/Caudaequinasyndrome-patientinformation.pdf

Motivated patient – advice to watch the video from Learnzone/org.uk – also available in Welsh https://learnzone.org.uk/blog/articles/article.php?post=119

Information for Clinicians

NICEGuideline Metastatic Spinal Cord Compression Diagnosis and management of patients at risk of or with metastatic spinal cord compression 2008 https://www.nice.org.uk/guidance/cg75/evidence/full-guideline-242052589

Scottish Palliative Care Guidelines – Metastatic spinal cord compression https://www.palliativecareguidelines.scot.nhs.uk/guidelines/palliative-emergencies/Malignant-Spinal-Cord-Compression.aspx 

The Christie NHS Foundation- MSCC guide to early recognition and rapid response in Primary Care https://www.christie.nhs.uk/patients-and-visitors/services/metastatic-spinal-cord-compression-mscc/information-for-professionals/guidelines

Oxford Medical Education- Metastatic Spinal Cord Compression ( MSCC ) and Cauda Equina Syndrome http://www.oxfordmedicaleducation.com/oncology/mscc-cauda-equina-syndrome/

Article –Metastatic Spinal Cord Compression: Unraveling the Diagnostic and Therapeutic Challenges http://ar.iiarjournals.org/content/38/9/4987.full# 

NHS England – Referral of patients with spinal metastatic disease and suspected metastatic spinal cord compression guideline https://www.england.nhs.uk/mids-east/wp-content/uploads/sites/7/2018/08/guidelines-for-the-referral-of-patients-spinal-metastatic-disease-v2.pdf

 

References How not to miss metastatic spinal cord compression Chitra Nair , Shirjit Pannikar, Arpratan Ray British Journal of General Practice 2014 ; 64 (626 ) : e596-e598 Malignant spinal cord compression A Graham Macdonald , Daniel Lynch , Ian Garbett , Nauzen Nazeer J R Coll Physicians Edin 2019 ; 49 : 151-6 Metastatic spinal cord compression in adults NICE Quality standard Feb 2014 Metastatic Spina Cord Compression ; Unraveling the Diagnostic and Therapeutic Challenge stergios Boussios et al Anticancer Research International Journal of Cancer Research and Treatment ( see under links ) Scottish Palliative Care Guidelines – Malignant spinal cord compression Cauda equina syndrome : implications for primary care by Jeremy Fairbank Professor of Spine Surgery , Nuffield Orthopaedic Center , Oxford Various leaflets from The Christie NHS Foundation Trust Cauda Equina Syndrome Jonathan Pararajasingham University College London Hospital NHS Foundation Trust Article in InnovAiT October 2011

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