Metastatic Spinal Cord Compression (MSCC)
MSCC is the compression of the spinal cord, or cauda equina, by direct pressure and/or vertebral collapse as a result of metastatic spread that may cause neurological deficit and paralysis.
MSCC is an oncological emergency. Delays in diagnosis and treatment may result in reduced quality of life and prognosis for patients.
The majority of cases occur in patients with a pre-existing cancer diagnosis. It is the first cancer presentation in approxiamtely 20% of cancer patients.
MSCC is most common in patients with lung cancer (20-31%), prostate (18-21%), breast (13-17%), haematological malignancies (8-10%), gastrointestinal (5-13%), kidney (3-12%)
Questions
- Does the patient have new/severe progressive pain?
- How long has the patient experienced symptoms?
- Does the patient have localised spinal tenderness?
- Does the patient have radicular pain?
- Does the patient have any new/worsening limb weakness, sensory loss, bladder or bowel dysfunction?
- Does the patient have any signs of cord/cauda equina compression?
Grade 1 (Green)
Mild paraesthesia, subjective weakness – no objective findings
Advice
- Activate MSCC pathway
- Advise on pain management
- Inform the Acute Oncology Team to assess patient within 24 hours
Grade 2 (Amber)
Mild/moderate sensory loss, moderate paraesthesia, mild weakness with no loss of function
Advice
- Investigate/examine to rule out MSCC and activate MSCC pathway
- Spine MRI within 24 hours of arrival
- High dose steroids and PPI
- Treat as unstable spine until results of MRI available
- Admission for monitoring and assessment
- Refer to MSCC coordinator and alert neurosurgery to review images
- Pain control
- Consider Cancer of Unknown Primary in patients without pre-existing cancer diagnosis
- Alert Acute Oncology Team or oncologist on-call
Treatment should start within 24 hours of diagnosis
Grade 3 (Red)
Severe sensory loss, paraesthesia or weakness that interferes with function
Advice
- Investigate/examine to rule out MSCC and activate MSCC pathway
- Spine MRI within 24 hours of arrival
- High dose steroids and PPI
- Treat as unstable spine until results of MRI available
- Admission for monitoring and assessment
- Refer to MSCC coordinator and alert neurosurgery to review images
- Pain control
- Consider Cancer of Unknown Primary in patients without pre-existing cancer diagnosis
- Alert Acute Oncology Team or oncologist on-call
Treatment should start within 24 hours of diagnosis
Grade 4 (Red)
Paralysis
Advice
- Investigate/examine to rule out MSCC and activate MSCC pathway
- Spine MRI within 24 hours of arrival
- High dose steroids and PPI
- Treat as unstable spine until results of MRI available
- Admission for monitoring and assessment
- Refer to MSCC coordinator and alert neurosurgery to review images
- Pain control
- Consider Cancer of Unknown Primary in patients without pre-existing cancer diagnosis
- Alert Acute Oncology Team or oncologist on-call
Treatment should start within 24 hours of diagnosis
See Metastatic spinal cord compression overview (NICE website)
Handover management with patient’s team, discuss all interruptions of treatment with team +/- AOS prior to proceeding.
Arrange follow up review as necessary.
Initial assessment – patient referred to ED if any suspect of MSCC
- History of complaint
Questions
- Does the patients have new/severe progressive pain?
- How long has patient experienced symptoms?
- Does the patient have localised spinal tenderness?
- Does the patient have radicular pain?
- Does the patient have any new/worsening limb weakness, sensory loss, bladder or bowel dysfunction?
- Does the patient have any signs of cord/cauda equina compression?
Observations: neurological examination, temperature, pulse, blood pressure, respiratory rate, Saturation of oxygen. EWS. AVUP (Alert Voice Unresponsive Pain)
Investigations: Urgent FBC, U&E, LFT, G&S, Ca, MRI spine within 24 hours of arrival
Treatments
- High dose dexamethasone and PPI cover
- Analgesia
- Urgent discussion with a consultant neuro- or spinal- surgeon and with a consultant clinical oncologist and with either treating medical oncologist or on-call medical oncologist
- Neurological management should be carried out by Regional MSCC Treatment Centre (SGH)
- Please ensure prompt availability of imaging
- If MSCC is the first cancer presentation, consider lesion biopsy prior to any intervention (radiotherapy)
- Radiotherapy can be given post-operatively (usually within 2 weeks)
- Some tumours are extremely chemotherapy sensitive. Primary chemotherapy might be considered prior to radiotherapy or surgery for tumours such as gestational trophoblastic disease, germ cells tumours, small cell lung cancer, lymphoma, leukaemia, myeloma.
- Refer to http://pathways.nice.org.uk/pathways/metastatic-spinal-cord-compression for further advice.
