Management decision factors
- Oncological factors
- Radio- and chemo- sensitivity of the malignancy
- patient’s stage and prognosis.
- Neurological factors
- include the symptoms and deficits of neurological compression, and the presence of a radiologically compressive lesion which explains them.
- A complete cord lesion lasting longer than 24 hours is extremely unlikely to improve following decompression.
- Biomechanical factors
- Mechanical pain and deformity may be indications for surgical stabilization, but the integrity of adjacent levels is required to capture spinal elements with instrumentation.
- Additional CT scanning may be helpful in providing this information but a patient with compromise of long segments of the spine is unlikely to become a surgical candidate.
- Patient factors
- Performance status, comorbidity,
- Age
- Regardless of treatment modality surg or radio (65 cut off) Chi et al. 2009 (Patchell Group)
- randomized clinical trial comparing surgery versus radiation for MESCC
- as age increases, the chances of RT alone being equal to surgery increases.
- no difference in outcome between treatments for patients >or=65 years of age.
- Ambulation preservation was significantly prolonged in patients <65 years of age undergoing surgery compared to radiation alone (P = 0.002).
- Patient wishes
- Early decisions should be made about aggressiveness of MSCC treatment in those with
- A poor performance status and widespread metastatic disease or
- Completely paraplegic or tetraplegic for more than 24 h, and
- Too frail or unfit for specialist treatment.
- Definitive treatment within 24 hours
- Advocate using Tokuhashi, ASA grading
- Staging tumour asap
NICE Guidelines
Metastatic spinal cord compression
General
- Pressure care
- Enoxaparin
- Catheter
Mobilization
- NICE
- Patients with severe mechanical pain suggestive of spinal instability, or any neurological symptoms or signs suggestive of MSCC, should be
- nursed flat with neutral spine alignment (including 'log rolling' or turning beds, with use of a slipper pan for toilet) until bony and neurological stability are ensured and cautious remobilisation may begin.
- Once any spinal shock has settled and neurology is stable, carry out close monitoring and interval assessment during gradual sitting from supine to 60 degrees over a period of 3 to 4 hours.
- When can patients with MSCC begin gradual sitting,
- if their blood pressure remains stable and no significant increase in pain or neurological symptoms occurs, continue to unsupported sitting, transfers and mobilisation as symptoms allow.
- If a significant increase in pain or neurological symptoms occurs return them to a position where these changes reverse and reassess the stability of their spine.
- After a full discussion of the risks, patients who are not suitable for definitive treatment should be helped to position themselves and mobilise as symptoms permit with the aid of orthoses and/or specialist seating to stabilise the spine, if appropriate.
Analgesia
- Conventional analgesia
- Eg: NSAIDs, non-opiate and opiate medication
- PRN
- Use WHO three-step pain relief ladder.
- Brace
- Specialist pain care
- Spidural or intrathecal analgesia
- intrathecal morphine pump
- Bisphosphonates (see below)
- ONLY to be used for vertebral metastases from (reduce sclerosis)
- breast,
- myeloma
- prostate cancer
- Radiotherapy
- Indicated
- for non-mechanical spinal pain
- Not with the intention of preventing MSCC.
- 8 Gy single fraction palliative radiotherapy
- Even if pt are completely paralysed
- Percutaneous injection of acrylic surgical cement
- Indicated (NICE)
- In the absence of MSCC or spinal instability,
- vertebral metastases causing
- mechanical pain resistant to conventional analgesia,
- vertebral body collapse.
- for vertebral diseases that is not unstable
- Kyphoplasty
- Indicated
- For painful VCFs (Vertebral compression fractures) in patients with cancer
- Berenson 2011 RCT n134
- For painful VCFs in patients with cancer, kyphoplasty is an effective and safe treatment that rapidly reduces pain and improves function
- Vertebroplasty
- Weill 1996 Prospective study n37
- More support for kyphoplasty than vertebroplasty due to poor design of this paper and RCT of Berenson's paper
- Gives persistent pain relief 73% in the long term (>1 year)
Hypercalcemia
- Renal
- Hydration to improve urinary calcium output.
- Isotonic sodium chloride solution is used, because increasing sodium excretion increases calcium excretion.
- loop diuretic inhibits tubular reabsorption of calcium,
- furosemide having been used up to every 2 hours.
- Attention should be paid to other electrolytes (i.e., magnesium and potassium) during saline diuresis.
- These treatments work within hours and can lower serum calcium levels by 1 to 3 mg/dL within a day.
- Bisphosphonates
- (such as etidronate, pamidronate, alendronate, tiludronate, and risedronate) serve to block bone resorption over the next 24 to 48 hours by absorbance into the hydroxyapatite and by shortening the life span of osteoclasts.
- Collar if necessary
- No NGT required unless high cervical
Bisphosphonates
- NICE
- vertebral involvement from
- Always
- myeloma
- breast cancer
- Only if conventional analgesia fails to control pain
- For prostate cancer
- Not to be use for other types of mets
- Aim
- Reduce pain
- if conventional analgesia fails
- ONLY to be used for vertebral metastases from
- breast,
- myeloma
- prostate cancer
- should not be used as prophylaxis for malignant spinal cord compression.
- Reduce the risk of vertebral fracture or collapse.
Steroids
- Dexamethasone
- 16mg stat then 16mg daily <3 week
- Contraindicated in lymphoma
- Wean if no further surgery or RTx
- Give with PPI
- NICE
- Cont. dexamethasone 16 mg daily in patients
- awaiting surgery or radiotherapy for MSCC.
- After surgery or the start of radiotherapy the dose should be reduced gradually over 5 to 7 days and stopped.
- If neurological function deteriorates at any time the dose should be increased temporarily.
- who do not proceed to surgery or radiotherapy. Slowly wean
- If neurological function deteriorates at any time the dose should be reconsidered.
- Monitor blood glucose levels in all patients receiving corticosteroids
- Evidence
- Dose
- Vecht et al:
- no difference between High (100mg → 16mg PO OD) vs Low dose (10mg → 16mg PO OD) dex in pain, ambulation or bladder function after 24 hrs.
- Sorensen et al:
- 59% in High dose Dex (96 mg IV bolus followed by 96 mg (24 mg QID)3 d then weaned over 14 days) group were ambulatory vs. 33% in control group (No steroids) at 6 mo post treatment
- Duration (Not more than 40 days)
- Martenson et al
- a jump in steroid toxicity after 40 days of treatment in a population comprised solely of MSCC patients.
- Weissman et al
- A sharp increase in the proportion of patients suffering side effects from 5% to 76% after 3 weeks of treatment in a retrospective analysis of a mixed group of neurooncology patients
- Brain mets
- MSCC
- CT Guided biopsy for the 10-20% unknown primary
Evidence surgery vs radiotherapy
- Young et al., 1980
- A previous randomised controlled trial of laminectomy and radiotherapy compared with radiotherapy alone as a treatment for MSCC had found no difference in neurological outcome between the groups
- Patchell et al 2005
- Promotes surgery but flawed
- Selection bias, and therefore that the treatment may be applicable to a small subgroup of patients with MSCC
- Chi et al., 2009
- Patchell study demonstrated that the beneficial effect of surgery over radiotherapy alone is lost for patients above the age of 65
- Rades et al 2010
- Retrospective propensity matched cohort
- RT VS RT + Surgery
- Similar motor fx outcome (27 vs 26%) and mobility outcome (68 vs 69%)
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