Spinal cord compression bhf aos study day mar 2014 final


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    This presentation has been written to help you raise awareness of the NICE clinical guideline on Metastatic spinal cord compression: Diagnosis & management of adults at risk of and with MSCC. This guideline has been written for healthcare professionals and other staff who care for people with metastatic spinal cord compression.
    The guideline is available in a number of formats, including a quick reference guide. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. See the end of the presentation for ordering details.
    You can add your own organisation’s logo alongside the NICE logo.
    We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in you presentation, and ‘additional information’ that you may want to draw on, such as rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full.
    This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
    Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
    The NICE guideline contains lots of recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. They are divided into 5 areas and we will consider each in turn.
    The guideline includes detailed recommendations for the management of complications which do not form part of the key priorities for implementation but are an essential component of the care pathway for patients. These include:
    Venous thromboembolism
    Pressure ulcers
    Bladder and bowel continence management
    Circulatory and respiratory functioning
    Dosage and monitoring recommendations are also made for corticosteroids. In addition there are detailed treatment options for pain relief and to prevent MSCC.
    Additional information:
    Ensure that patients with MSCC and their families and carers know who to contact if their symptoms progress while they are waiting for urgent investigation of suspected MSCC
    Discuss with the MSCC coordinator urgently (within 24 hours) patients with or without a cancer diagnosis who have symptoms suggestive of spinal metastases
    Discuss with the MSCC coordinator immediately patients with or without a cancer diagnosis who develop neurological symptoms or signs suggestive of MSCC
    Perform frequent clinical reviews of patients with or without a cancer diagnosis who develop neurological symptoms or signs suggestive of MSCC
    Recommendations in full:
    Inform patients at high risk of developing bone metastases, patients with diagnosed bone metastases, or patients with cancer who present with spinal pain about the symptoms of MSCC. Offer information (for example, in the form of a leaflet; see appendix D of the NICE guideline) to patients and their families and carers which explains the symptoms of MSCC, and advises them (and their healthcare professionals) what to do if they develop these symptoms. []
    Contact the MSCC coordinator urgently (within 24 hours) to discuss the care of patients with cancer and any of the following symptoms suggestive of spinal metastases:
    - pain in the middle (thoracic) or upper (cervical) spine
    - progressive lower (lumbar) spinal pain
    - severe unremitting lower spinal pain
    - spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing)
    - localised spinal tenderness
    - nocturnal spinal pain preventing sleep. []
    Contact the MSCC coordinator immediately to discuss the care of patients with cancer and symptoms suggestive of spinal metastases who have any of the following neurological symptoms or signs suggestive of MSCC, and view them as an oncological emergency:
    - neurological symptoms including radicular pain, any limb weakness, difficulty in walking, sensory loss or bladder or bowel dysfunction
    - neurological signs of spinal cord or cauda equina compression. []
  • Spinal cord compression bhf aos study day mar 2014 final

    1. 1. Malignant Spinal Cord Compression An Introduction to Acute Oncology Study Day 26th March 2014 Dr Bernie Foran Consultant Clinical Oncologist & Honorary Senior Lecturer Weston Park Hospital
    2. 2. Outline of Talk • Clinical case • The anatomy of the spinal cord • Definition of malignant spinal cord compression (MSCC) • Incidence • Symptoms & signs • Investigations • Treatments • Outcomes • NICE guidance
    3. 3. Clinical Case 56 year old man with history of HTN & OA Presents to GP with 1 month history of back pain unresponsive to paracetamol Pain beginning to wake him at night More pain with lying down Shooting pains down right leg
    4. 4. Examination • Observations - normal range • CVS, Resp, GI, GU exams - normal • Back exam – Inspection: normal – Palpation: some pain in L1 region – ROM: normal – Some pain in right leg with straight leg raising
    5. 5. Lumbar Spine x-ray Age related degeneration Working diagnosis Sciatica V Back strain Treatment recommended NSAIDS Few days of bed rest
    6. 6. 4 weeks later • Pain does not resolve • Various forms of pain control tried & fail • Wakes up, difficulty supporting his weight – subjective leg muscle weakness • Wife calls 999 • Taken to local A&E
    7. 7. In A&E • Objective leg weakness on physical exam • A very keen medical student does a rectal exam and discovers a large nodular prostate • PSA: 45.0 • MRI Spine…..
    8. 8. Anatomy of the spine
    9. 9. Different spinal cord levels supply nerves for different regions of the body
    10. 10. What is malignant spinal cord compression? • Occurs when cancer cells grow in/near to spine and press on the spinal cord & nerves • Results in swelling & reduction in the blood supply to the spinal cord & nerve roots • The symptoms are caused by the increasing pressure (compression) on the spinal cord & nerves
    11. 11. Method of spread 85%From vertebral body or pedicle 10% Through intervertebral foramina (from paravertebral nodes or mass) 4% Intramedullary spread 1%(Low) Direct spread to epidural space
    12. 12. Location Thoracic spine 60% Lumbosacral spine 30% Cervical spine 10%
    13. 13. Most commonly seen in • Breast • Lung • Prostate • Lymphoma • Myeloma – 3-5% of patients with cancer overall – Approx 200 cases per annum in North Trent What types of cancer cause it?
    14. 14. What are the signs & symptoms of MSCC?
    15. 15. First Symptoms Pain 95% Weakness 5% Ataxia 1% Sensory loss 1% RED FLAGS…..
    16. 16. First Red Flag: Pain • Usually first symptom – 80-90% of the time • Usually precedes other neurologic symptoms by 7 weeks – Increases in intensity • Severe local back pain • Aggravated by lying down – Distension of venous plexus Bach, F, Larsen, BH, Rohde, K, et al. Metastatic spinal cord compression.Bach, F, Larsen, BH, Rohde, K, et al. Metastatic spinal cord compression. Occurrence, symptoms, clinical presentations and prognosis in 398 patients withOccurrence, symptoms, clinical presentations and prognosis in 398 patients with spinal cord compression. Acta Neurochir (Wien) 1990; 107:37.spinal cord compression. Acta Neurochir (Wien) 1990; 107:37.
    17. 17. – may be mild to begin with – lasts for more than 1 - 2 weeks • Pain may feel like a 'band' around the chest or abdomen (radicular) – Can radiate over the lower back, into the buttocks or legs Back pain
    18. 18. Second Red Flag: Motor • Weakness: 60-85% – Tends to be symmetrical – Severity greatest with thoracic mets • At or above conus medularis – Extensors of the upper extremities • Above the thoracic spine – Weakness from corticospinal dysfunction – Affects flexors in the lower extremities • Patients may be hyper reflexic below the lesion and have extensor plantars Greenberg, HS, Kim, JH, Posner, JB. Epidural spinal cord compressionGreenberg, HS, Kim, JH, Posner, JB. Epidural spinal cord compression from metastatic tumor: Results with a new treatment protocol. Annfrom metastatic tumor: Results with a new treatment protocol. Ann Neurol 1980; 8:361.Neurol 1980; 8:361.
    19. 19. Third Red Flag: Sensory • Less common than motor findings • Still present in majority of cases • Ascending numbness and parathesias • Numbness or 'pins and needles' in toes & fingers or over the buttocks – Sensory level – Saddle anaesthesia • Feeling unsteady on feet, having difficulty with walking, or legs giving way
    20. 20. Fourth Red Flag: Bladder & Bowel Function • Loss is late finding • Problems passing urine – may include difficulty controlling bladder function – passing very little urine – or passing none at all • Constipation or problems controlling bowels • Autonomic neuropathy presents usually as urinary retention – Rarely sole finding
    21. 21. Duration of symptoms before diagnosis 2-5 months median
    22. 22. It is an oncological emergency Requires very prompt diagnosis & treatment to try and prevent catastrophic consequences of paralysis & incontinence
    23. 23. Investigations & information needed prior to Rx 1. MRI scan of the whole spine  Can get compression at multiple levels 2. Knowledge of cancer type & stage 3. Knowledge of patient fitness 4. Current neurological function  Have they lost power in their legs?  Can they walk?  Do they need a catheter? 5. Do they have pain?
    24. 24. MRI of spinal cord compression in aMRI of spinal cord compression in a women with past history of breastwomen with past history of breast cancercancer
    25. 25. Differential diagnosis • Metastatic cancer • Herniated disc • Benign bony lesion • Abscess • Alcoholic neuropathy • Primary tumour • Osteoporosis • Low potassium Case report 3/11 cases confirmed MSCC
    26. 26. Treatment Until spinal stability is confirmed patients should be managed on bed rest BUT Wherever possible keep the patient moving
    27. 27. Treatment Objectives • Pain control • Avoidance of complications • Preserve or improve neurological function
    28. 28. Treatment options include: 1. Steroids & gastric protection 2. Analgesia 3. Surgery – decompression & stabilisation of the spine 4. Radiotherapy 5. Chemotherapy e.g. lymphoma 6. Hormonal manipulation e.g. prostate Ca
    29. 29. WPH Reducing regimen for Spinal Cord Compression Day Dexamethasone daily dose Administration 1-3 16mg 16mg OM or 8mg BD (8am & 12noon) 4-6 8mg 8mg OM 7-9 4mg 4mg OM 10-12 2mg 2mg OM 13 Discontinue • While the patient is on steroids commence PPI (e.g. Lansoprazole) for gastric protection. • A slower reducing regimen may be required for patients who have received previous courses of steroids.
    30. 30. Anticoagulation • Cancer is a hypercoaguable state • High burden of tumour in metastatic disease • Possible value in prophylaxis against venous thromboembolism • If patient not mobile – subcutaneous low molecular weight heparin +/- compression devices
    31. 31. Constipation • Factors – Autonomic dysfunction – Limited mobility – Opiate analgesic • Risk of perforation – Masked by corticosteroids • Bowel regimen needed
    32. 32. • 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 ofPatchell, R, Tibbs, PA, Regine, WF, et al. A randomized trial of direct decompressive surgical resection in the treatment of spinaldirect decompressive surgical resection in the treatment of spinal cord compression caused by metastasis (abstract). proc Am Soccord compression caused by metastasis (abstract). proc Am Soc Clin Oncol 2003; 22:1.Clin Oncol 2003; 22:1. Surgery
    33. 33. Direct decompressive surgery • Relieves compression • Removes tumour • Stabilises spine But many patients not suitable • Unfit • Tumour factors
    34. 34. Indications for Surgery • Unknown primary tumour • Relapse post RT • Progression while on RT • Intractable pain • Instability of spine • Patients with a single level of cord compression who have not been totally paraplegic for longer than 48 hours • Prognosis >4 months
    35. 35. Radiotherapy • Urgent access 24/7 • Dose & schedule – Depending on neurological deficit, PS, previous treatment and cancer features • Single V fractionated treatment – SCORAD trial
    36. 36. Radiotherapy
    37. 37. Radiotherapy • Pre operatively – no • Post operatively – routinely • Definitive – all pts unsuitable for surgery – Unless • Total paraplegia (>24hrs) • Very poor prognosis
    38. 38. Chemotherapy • Can be successful in chemosensitive tumours – Hodgkin’s lymphoma – Non-Hodgkin’s lymphoma – Neuroblastoma – Germ cell – Breast cancer (hormonal manipulation) – Prostate cancer (hormonal manipulation)
    39. 39. Other considerations 1. Bed rest V mobilisation • Rehabilitation • Braces & collars 1. Psychological issues 2. Urinary catheter 3. Bowel function 4. Nutrition 5. Discharge issues
    40. 40. Prognosis • Median survival with MSCC is 6 months • Ambulatory patients with radiosensitive tumours have the best prognosis – Likely to remain mobile Sorensen, PS, Borgesen, SE, Rohde, K, et al. Metastatic epiduralSorensen, PS, Borgesen, SE, Rohde, K, et al. Metastatic epidural spinal cord compression. Results of treatment and survival. Cancerspinal cord compression. Results of treatment and survival. Cancer 1990; 65:1502.1990; 65:1502. MSCC is a poor prognostic indicator in cancer patients Need better detection rates
    41. 41. Number of days survival following admission with spinal cord compression Data from WPH audit Number of days from admission with spinal cord compression to death Range = 2 days to 319 days Mean = 58.6 days
    42. 42. Metastatic spinal cord compression Implementing NICE guidance 2008 NICE clinical guideline 75
    43. 43. Key priorities for implementation The areas identified as key priorities for implementation are: – Service configuration & urgency of treatment – Early detection – Imaging – Treatment of spinal metastases & MSCC – Supportive care & rehabilitation
    44. 44. – Inform patients with cancer who are at risk of MSCC • information about the symptoms of MSCC • what to do & who to contact if symptoms develop – Discuss with the MSCC coordinator immediately patients with cancer who have symptoms of spinal metastases & neurological symptoms or signs suggestive of MSCC • view as an emergency. – Discuss with the MSCC coordinator within 24 hours patients with cancer who have symptoms suggestive of spinal metastases Early detection