1. Metastatic Spinal Cord Compression (MSCC)

2. Definition
“MSCC is compression of the dural sac and its contents by an extradural tumour mass in the epidural space, either at the level of the spinal cord or cauda equina.”
Drudge-Coates and Rajbabu, 2008

3. Caused by… OR
Irreversible neurological damage ensues with resulting paraplegia. (Levack et al, 2002).

4. Primary tumours of the SC
Background
Metastases to the SC occur in 3-5% of all patients with Cancer with…
Known lung Metastases
Primary tumours of the SC
50% of cases
Prostate
Breast
Lung
RISK
NICE, 2008 & Schiff, 2003

5. Bowel & bladder dysfunction
Clinical Features
Clinical Features
Pain
Motor Deficits
Sensory Deficits
Bowel & bladder dysfunction
Schiff, 2003

6. Early Δ & Rx are KEY Early recognition & reporting of symptoms
Swift referral pathways
Appropriate investigations
Prompt Rx
NICE, 2008

7. Levack et al (2001) found that 77% of patients diagnosed with SCC had an established Δ of cancer, whereas 23% presented with SCC as the first presentation of malignancy.

8. Outpatient Physiotherapists must have their ears open to the following…
Progressive &/or severe unremitting LBP
Pain in upper or middle spine
Back pain aggravated by straining, coughing or sneezing
Localised tenderness over spine
Back pain at night
Brooks, 1998

9. Neuro S&S: Radicular pain, limb weakness, ↓mobility, sensory loss, bladder/bowel dysfunction
NICE, 2008

10. Physiotherapy and Cancer Care
Within Cancer Care, Dietz (1981) identified 4 levels of rehabilitation:
↓ the potential disabilities through educational, physical and psychological interventions
Preventive
↓ or eliminate disease through Rx & return to previous levels of functioning
Restorative
Adapt to disabilities & disease
Supportive
Palliative
Maintain a good QoL through the minimization of complications

11. The Association of Physiotherapists in Oncology and Palliative Care
The aim of the physiotherapist is to assist these individuals to minimize some of the effects which the disease or its treatment has on them
(ACPOPC, 1993 as cited in Bancroft, 2003)

12. NICE Guidelines findings regarding PT availability for MSCC Patients
CCs 48%
SSUs: 48%
PCDs: 56%
PT and OT availability
Access to specialist PT
Daily PT OT
Referral to specialist rehab services
CCs 63%
SSUs: 81%
PCDs: 59%
CCs 63%
SSUs: 76%
CCs 93%
SSUs: 90%

13. SUHT Management Guidelines
Immediate
Inform Doctor regarding anyone with suspected/at risk of MSCC
Complete bed rest –nurse flat until spinal stability confirmed
Dexamethasone: 16mg/day
Emergency MRI or CT if MRI unavailable
Urgent referral to clinical oncologist & D/W neuro/spinal surgical team
Paraplegia present < 24 hours, regardless of onset
Surgical decompression if possible
If not, Radiotherapy
Established paraplegia
Pressure area care
Catheter
Regulation of bowel activity; use regular enemas or suppositories
PT and OT input
Psychological readjustment
PCT Ax is recommended for Mx and/or rehab
SUHT, 2007

14. Key NICE Recommendations
Service configuration and urgency of treatment
Early detection
Imaging
Treatment of spinal metastases and MSCC
Supportive care and rehabilitation
NICE, 2008

15. Recommendations with significant costs : estimated annual incremental costs resulting from ↑ in surgical activity for treatment & prevention of MSCC
£14,023
Recommendations with significant savings: supportive care and rehabilitation post discharge of patients
£ -17,513
Net resource impact of MSCC guideline
£ -3,490

16. References
Bancroft, M.I., Physiotherapy in Cancer Care: a theoretical approach (2003). Physiotherapy. 89, 12:
Brooks, C. Radiation Therapy: Guidelines for Physiotherapist (1998). Physiotherapy. Vol. 84 (8):
Dietz, J.H. (1981) Rehabilitation Oncology, John Wiley, New York
Drudge-Coates, L. and Rajbabu, K. Diagnosis and management of malignant spinal cord compression: part 1 (2008). Int. J. of Palliative Nursing. Vol. 14 (3):
Loblaw DA, Perry J, Chambers A, Laperriere NJ (2005) Systematic review of the diagnosis and management of malignant extradural spinal cord compression: the Cancer Care Ontario Practice Guidelines Initiative's Neuro-Oncology Disease Site Group. Journal of Clinical Oncology 23: 2028–2037
NICE Clinical Guideline 75. Metastatic Spinal Cord Compression: Diagnosis and management of adults at risk of and with metastatic spinal cord compression (2008).
Schiff, D. Spinal Cord Compression (2003). Neurol. Clin. N. Am. 21: 67-86
The Palliative Care Handbook: Advice on Clinical Management (6th Ed.) CMH, SUHT (2007).