Malignant spinal cord compression

Malignant spinal cord compression

Nov 14, 2018 0
medical oncology,onthepods

Sarah Dalton chats to Angelina Tjokrowidjaja about malignant spinal cord compression, a common complication of cancer that occurs in up to 10% of patients. As a junior doctor, you might encounter a spinal cord compression in the Emergency Department, during an after-hours shift on haematology or oncology wards, or when on rotation in these areas. Malignant spinal cord compression can cause pain and potentially irreversible neurological deficits, early recognition is key for a good outcome.

Summary Writer:  Jane McDonnell

Script Writer:  Angelina Tjokrowidjaja

Editor:  Angelina Tjokrowidjaja

Interviewer:  Sarah Dalton

Interviewee:  Angelina Tjokrowidjaja

About Dr Angelina Tjokrowidjaja

Dr Angelina Tjokrowidjaja is currently a Medical Oncology Clinical Trials Fellow at St George Hospital and a PhD candidate at the NHMRC Clinical Trials Centre, New South Wales, Australia. Angelina completed her Master of Medicine (Clinical Epidemiology) while working as a junior doctor at Royal Prince Alfred Hospital, New South Wales. She is currently researching how to better individualise targeted and biological therapies in patients with advanced cancers using biomarkers. Angelina is also invested in teaching and is a tutor of medical students and junior doctors in the university and clinical setting.

Malignant spinal cord compression

With Dr Angelina Tjokrowidjaja, Medical Oncology Clinical Trials Fellow at St George Hospital, Sydney, New South Wales, Australia

Introduction

Spinal cord compression is a common complication of cancer and occurs in up to 10% of patients. It can cause pain and potentially irreversible neurological deficits. Early recognition is vital for better outcomes. A junior doctor may encounter a spinal cord compression in the Emergency Department, during an after-hours shift on haematology or oncology wards or when on rotation in these areas.

  • Consider patients who have cancers which have a predilection for bone metastasis
    • Solid malignancies: breast, prostate, lung and renal cancer
    • Haematological malignancies: multiple myeloma, non-Hodgkin lymphomas, some leukaemias
  • Note a patient presenting with undifferentiated back pain and no history of cancer may have cord compression as a first presentation of cancer
  • For any cancer patient who presents with new back pain, consider cord compression
  • Most common first symptom reported is pain. Pain may be:
    • In the neck or back depending on where the vertebral metastasis is in the spine
    • localised, referred or radicular
  • Red flag symptoms: pain worse on lying down or pain that wakes patient up in the night
  • Neurological deficits – usually motor more than sensory
    • Progressive bilateral weakness, numbness, paraesthesia
  • Autonomic dysfunction (e.g. bowel and bladder dysfunction) is a late feature of cord compression
    • An exception is cord compression that affects the conus medullaris – this may present initially with back pain and only bladder or bowel symptoms
  • Is the patient in pain?
    • If so, give analgesia – this will make examination easier for both the patient and yourself
  • Signs of impaired mobility
    • Mobility aids, bottle for urination
    • Assess gait
  • Thorough neurological examination
    • Including tone, power, reflexes and sensation
    • Look for bilateral weakness in legs, hyporeflexia below the level of the cord compression
  • PR examination including peri-anal sensation and anal tone in the case of cauda equina (depressed reflexes in lower limbs)
  • Palpate vertebral column for location of tenderness
  • Urgent MRI whole spine within 24 hours
    • MRI does not need to have gadolinium contrast (if it does, tumour will enhance better)
  • Talk to radiology registrar to convey urgency

Case

You are the junior doctor on an after-hours shift on a medical oncology ward. You are asked to review a 70-year-old patient who has decreased mobility. You have a lot of other jobs.

 

 

  • When was the patient admitted? For what reason was the patient admitted?
  • What type of cancer?
  • Does the patient have known metastasis and if so, does it involve bone?
  • What is the patient’s baseline mobility and function?
  • Has the nurse looked after the patient previously and noticed a deterioration?
  • The main differential to exclude is cord compression
  • Others also include: stroke, new brain metastases, drug effects (e.g. statin-related myopathy)
  • Contact the treating team
  • Consider empiric dexamethasone (8mg mane, 8mg midi) with PPI cover
  • MRI whole spine
  • Notify radiology and neurosurgery registrars
    • Include salient information
    • Use ISBAR (Identify, Situation, Background, Assessment and Recommendation)
    • Include your examination findings and instituted therapy
    • Find out if they are known to a radiation oncologist
  • Treatment aimed at preserving function and preventing neurological deficits
  • Treatment depends on certain factors
    • Patient factors – prognosis, performance status
    • Tumour factors – radioresistant or radiosensitive tumour, levels involved, systemic burden of disease
    • Treatment factors – is it feasible to do decompression for the patient?
  • Landmark trial comparing surgery with decompression followed by radiotherapy vs radiotherapy alone
    • Surgery plus decompression group had improved outcomes in regaining mobility
    • Caveat: this patient group had one level of involvement, prognosis of more than 3 months and surgically feasible to have procedure performed
  • For patients who are not surgical candidates or have multiple involved levels, radiotherapy is an option
    • Usual dose is 25Gy over 5 fractions
    • More can be done if they have a good prognosis
    • A single palliative dose can be given if they have a poor prognosis
  • Develop a good relationship with patients
  • Encourage patients to contact doctors and tell doctors about symptoms including pain
  • Be upfront about diagnoses such as cord compression and prognostic outlook
  • Be available for patients and families after the initial discussion to answer any further concerns
  • Get allied health involved to optimise function – Occupational Therapist, Physiotherapist and social work
  • Early recognition of cord compression is crucial
    • It should be considered in differentials (and excluded) in any cancer patient complaining of new onset back pain
  • As a junior doctor on the wards, do a thorough neurological examination
  • Once there is a clinical suspicion of cord compression, get a prompt MRI and liaise with medical oncology, radiology and neurosurgery

 

Tags: #back pain,#bone metastasis,#cancer,#cord compression,#ISBAR,#malignant spinal cord compression,#medical oncology,#MRI,#neurological deficits,#neurology,#neurosurgery,#pain,#radiology,#spinal cord,#spinal cord compression,#spinal injury,#spine,#undifferentiated back pain

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