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Neoplastic Spinal Cord Compression

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Spinal cord compression occurs when there is compression of the spinal cord or cauda equina at any level secondary to effects of a malignancy. This can include metastatic infiltration to vertebral column causing instability or pathological fractures as well as direct pressure from malignancy to the spinal cord. This condition affects around 5-10% of all patients with a malignancy and is more common in lung, prostate and breast cancer.

Symptoms and Signs
  • Pain is the earliest sign (predating neurological symptoms by 7 weeks) & is present in around 90%
    • Usually it is in the thoracic region, but it can affect any part of the spine & can be more radicular affecting the limbs due to referred pain
    • Pain does not always correspond to the exact level therefore it is best to always request an MRI of the full spine
    • Usually it is progressively worsening, continuous in nature & is worse at night
    • Pain is classically worse when lying flat and worse when coughing or straining or on movement
  • Numbness and sensory disturbance
  • Motor weakness (this is a late sign!)
  • Bladder and bowel dysfunction (always ask about back pain & red flags, if a patient comes in complaining of these symptoms!)
As expected symptoms will vary depending on the level but given the difficulty in differentiating it clinically it is best to be thorough & systematic. Spinal cord compression is more likely to be thoracic with neurology in the upper limbs with bladder & bowel changes being a very late sign. Whereas in cauda equina, the lower limbs are classically affected with earlier bladder & bowel dysfunction and saddle anaesthesia.

Examination
  • Give analgesia as necessary to do a full neurological examination of the upper & lower limbs 
  • PR examination to check for sensation and anal tone
  • Bladder scan (pre and post void) to look for evidence of urinary retention
Investigations
  • MRI whole spine is the gold standard - it is sensitive and specific & must be done within 24 hours. You must discuss this with seniors & radiology to obtain this urgently. 
  • CT scans can be considered if an MRI is contraindicated, but can be falsely reassuring
Management
  • If spinal cord compression is suspected
    • High dose dexamethasone is given straight away usually for patients with neurological deficits unless there are good contrainidications
      • Dosing should be confirmed with seniors/oncology/neurosurgery but a classic regime might be 10mg stat followed by 16mg daily (8mg at morning & lunch) with PPI cover
    • Analgesia
    • VTE proxphylaxis (up to 10% might have a DVT given advanced cancer & immobility being major risk factors)
  • If spinal cord compression is confirmed
    • Inform (or refer) to their local oncology centre
    • Usually patients have a contact number card on them
    • You want to know what their prognosis & treatment has been
    • Whether they would be for radiotherapy
    • To confirm immediate management including dexamethasone
    • To confirm whether transfer to their care would be beneficial 
  • Refer to neurosurgery 
    • Often referrals are via: https://www.referapatient.org/
    • You will want to transfer the images (ask the radiographers how to do this)
    • You want to know is the lesion amenable to spinal surgery?
    • Would they accept an urgent transfer (if it is)?
  • Palliative care input should be considered especially if patient is unable to have radiotherapy

References & Further reading
https://www.palliativecareguidelines.scot.nhs.uk/guidelines/palliative-emergencies/Malignant-Spinal-Cord-Compression.aspx
http://www.oxfordmedicaleducation.com/oncology/mscc-cauda-equina-syndrome/
https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-neoplastic-epidural-spinal-cord-compression
https://www.uptodate.com/contents/treatment-and-prognosis-of-neoplastic-epidural-spinal-cord-compression

Written by Dr Shamilah Rahman
Edits by Dr Akash Doshi CT2

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