Case One

MALIGNANT SPINAL CORD COMPRESSION

What is it? compression of the spinal cord by cancer tumour extra-dural compression is most common (90%), but can also be intradural

Which part of the spinal cord is affected? cervical cord 10% thoracic cord 70% lumbo-sacral cord 20% Can also occur at more than one site/level

Which cancers? approx 5% of cancer patients develop SCC associated more commonly with: -breast cancer27% -prostate cancer27% -lung cancer20% -myeloma -kidney cancer

Clinical presentation – symptoms may be very subtle main problem is the failure to diagnose early resulting in delay in Rx

Clinical presentation – localised back pain nerve root pain progressive numbness/tingling sensory loss (objective) weakness ('gone off their feet') loss of bladder/bowel control

What should make you suspect diagnosis of SCC? primary tumour is breast, prostate, lung, myeloma or kidney evidence/knowledge of multiple bone metastases, especially in vertebrae back pain – night pain, progressive bilateral sensory symptoms, weakness

What should you do if you suspect it? arrange urgent admission to oncologist/radiotherapist (easier said than done!) start dexamethasone 16mg od straight away if any delay in admission (PPI cover)

What happens to the patient in hospital? they should start dexamethasone 16mg od if not already on it urgent MRI scan of spine if proven, urgent radiotherapy to cord compression area

Why is it important to diagnose and treat SCC early? the outcome in SCC is critically dependent on the speed of diagnosis and treatment it is possible to reverse neurological damage if treated within hrs of onset speed affects the difference between patient being paralysed for the remainder of their illness or remaining ambulant/walking

Success rates of SCC treatment with Radio Rx depends on level of neurological function at presentation to radiotherapist if patient is ambulatory – 70% retain ability to walk if patient is paraparetic – 35% retain ability to walk if patient is paraplegic – 5% retain ability to walk

The role of surgery Indicated if: previous Radio Rx/ no response to RadioRx life expectancy > three months single site unstable spine

Take home messages SCC is a palliative care emergency prompt diagnosis and Rx can prevent paralysis

admit ASAP if suspicion of SCC (as long as patient agrees and is not moribund) start steroids if any delay in admission