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Outline

Author: Michael Canty

Malignant Spinal Cord Compression!!navigator!!

  • The spine is the most common site of bony metastases in patients with cancer. Malignant spinal cord or cauda equina compression will occur in 5–10% of patients with a malignancy. The thoracic region (70%) is the most common site of compression, followed by the lumbar (20%) and cervical (10%) spine.
  • The most common primaries leading to spinal metastases are cancers of the lung, breast, and prostate, accounting for 70% of cases; however, cord or cauda equina compression may also occur secondary to myeloma, lymphoma, melanoma, renal, and gastrointestinal cancer.
  • Metastases spread to the spine either directly, or haematogenously, via arterial supply or venous drainage (e.g. prostate malignancy spreads from the pelvis via the valveless veins of Batson's plexus).
  • Treatment rarely prolongs survival but can reduce pain and improve quality of life, especially in crucial areas such as mobility and continence.

Other Types of Cord and Cauda Equina Compression!!navigator!!

  • Degenerative disease, such as spondylosis and intervertebral disc disease, can cause an insidious onset of myelopathy in a variety of demographics and age groups. With the exception of cauda equina syndrome secondary to acute lumbar disc prolapse, definitive management of this subgroup is rarely as urgent as in malignant disease, but investigation and referral should still occur promptly.
  • Spinal extradural abscess is a rare entity, usually presenting with severe spinal pain and systemic upset. In the presence of neurological signs and symptoms, investigation and management must be rapid.
  • Spinal extradural haematoma is a very rare condition, usually a complication of anticoagulation. It tends to present suddenly with dramatic progressive deterioration.

Priorities ⬆ ⬇

  1. Clinical assessment

    Examine the spine and perform a full neurological examination, including assessment of perineal and perianal sensation, and anal tone (Box 70.1).

  2. If the clinical features indicate spinal cord compression or cauda equina syndrome, arrange emergency MRI imaging of the entire spine
    • If MRI imaging is unavailable, discuss with neurosurgery or oncology whether referral for imaging elsewhere is indicated. Consider CT scanning of the spine.
    • Plain X-rays may confirm the diagnosis while waiting for MRI. Look for bone loss, pedicle destruction (the ‘winking owl’ sign), collapse or deformity.
    • Arrange baseline blood tests and a chest X-ray.

  3. If malignancy is thought likely, give high dose dexamethasone

    Typically 8–16 mg IV as a loading dose. Always co-prescribe a proton pump inhibitor or ranitidine.

Further Management ⬆ ⬇

Outline

Confirmed Malignant Spinal Cord or Cauda Equina Compression!!navigator!!

  • Refer urgently to neurosurgery and oncology for consideration of surgery and/or radiotherapy, and to get advice on further management.
  • Patients able to walk, but with a recent motor or sphincter deterioration, non-radiosensitive tumours, single-site compression, and with a prognosis of >6 months, are good candidates for surgery. Surgery may also be required for tissue diagnosis in an unknown primary where CT-guided biopsy is not possible or unavailable.
  • Patients with minimal deficit, or complete, established weakness, may be better managed by radiotherapy. Radiotherapy confers excellent pain relief.
  • Surgery may also be indicated in patients with actual or impending instability, and good performance status. These patients should be maintained on strict bed rest. Seek advice from neurosurgery, or a spinal surgeon
  • Surgery is also considered in radio-resistant tumours, such as melanoma, renal, or gastrointestinal carcinoma, or in patients that have progressed despite radiotherapy. However, infection and impaired tissue healing is a major concern in the latter group.
  • Arrange further investigations to seek a primary tumour, if none is known; or to re-stage known disease, depending on specialist advice. This is usually in the form of a CT scan of the chest, abdomen and pelvis; a myeloma screen; tumour markers; and a bone scan.

Confirmed Non-Malignant Spinal Cord or Cauda Equina Compression!!navigator!!

Stop steroids. Seek advice on further investigation and management from neurosurgery.

Further Reading ⬆

Al-Qurainy R, Collis E (2016) Metastatic spinal cord compression: diagnosis and management. BMJ 353, i2539. DOI: 10.1136/bmj.i2539

Fehlings M, Nater A, Tetreault L, et al. Survival and clinical outcomes in patients with metastatic epidural spinal cord compression: results from the AOSpine prospective multi-centre study of 142 patients. Global Spine J 2016; 06-GO223. DOI: 10.1055/s-0036-1582880.