1. Back and Neck Pain in Patients with Metastatic Disease: Assessing and Managing Potential Spinal Cord Compression Mara Lugassy MD Hospice Medical Director MJHS Hospice and Palliative Care

2. Objectives Describe the epidemiology of malignant cord compression Recognize characteristic signs and symptoms of cord compression Describe immediate interventions for suspected cord compression Identify prognostic indicators for recovery of neurologic function

3. Potential Cord Compression: A Palliative Care Emergency Impacts quality of life Intervention available Time sensitive Easily missed

4. Cord Compression: Epidemiology Approximately 2-5% of cancer patients 20% of cases: the initial manifestation of malignancy –Especially common in lung and hematologic malignancies Schiff D et al, Neurology 1997;49:452.

5. Who Gets it? Metastatic disease from ANY primary site Most common diagnosis: –Solid Tumors: Lung, Breast, Prostate Cancer –Hematologic: non-Hodgkin Lymphoma, Multiple Myeloma Highest Incidence Rates: –Based on population based series of >15,000 cases –Multiple Myeloma (15%), Lymphoma (13.9%), Prostate Cancer (5%) Mak et al, Int J Radiat Oncol Biol Phys 2011;80:824

6. Cord Compression versus Normal Structure Univeristy of Alabama, Dept of Pathology

7. Cord Compression: How it Occurs Approximately 90% of cases due to metastasis in vertebral bodies (anterior to cord) Tumor expands into epidural space around thecal sac Obstruction of epidural venous plexus -> vasogenic edema in white matter and grey matter -> spinal cord infarction

8. Characteristics Thoracic Spine 60% Lumbosacral Spine 30% Cervical Spine 10% Multilevel involvement: 30% Cole and Patchell, Lancet Neurol 2008; 7:459

9. Pain Usually the earliest symptom Present in around 95% of cases at diagnosis Precedes other symptoms on average by 1-2 months

10. Pain Severe Localized Progressing over time Sudden worsening: possible compression fracture Pain with movement: potential spinal instability Tender to palpation

11. Pain ***Worse with LYING DOWN***

12. Pain Can progress to radicular pain –Commonly bilateral –Thoracic: band like, wrapping around chest –Lumbosacral: radiating down legs –Cervical: radiating down arms –Worsened by coughing, sneezing, or Valsalva

13. Pain Referred Pain: C7: refers to interscapular region L1: refers to iliac crests, hips, sacroiliac region Furnicular Pain: compression of dorsal columns and spinothalamic tract – pain distant to compression site eg. cervical or high thoracic compression resulting in “sciatic” pain or pseudoclaudication pain in legs

14. Motor Symptoms Weakness: 60-85% of cases at diagnosis Ranges from mild to paraplegia Ataxia Importance of baseline exam

15. Motor Signs Hyperreflexia below the lesion Extensor plantar responses Clonus

16. Sensory Rarely the initial symptom Occurs in approximately 60% at time of diagnosis numbness and paresthesias Sensory level usually 1-5 levels below level of lesion Saddle anesthesia: cauda equina syndrome Lhermitte phenomenon: cervical and upper thoracic cord compression

17. Autonomic Dysfunction A LATE finding Constipation Urinary retention – Patient may be unaware due to sensory loss Sexual dysfunction Incontinence

18. What Next? Immediate management/symptom control Formulate goals of care Imaging Definitive Therapies

19. Treatment Goals Maintain quality of life –Maintain neurologic function –Control pain –Prevent complications Treatment usually has no impact on survival

20. Immediate Management: Steroids Reduce tumor and spinal cord edema Can improve or stabilize neurologic deficits Analgesia against bone pain Preferred agent: dexamethasone –Reduced mineralocorticoid effect

21. Dexamethasone 57 patients with cord compression randomized to dexamethasone/+radiation therapy or radiation alone –96 mg dexamethasone IV, then 24 mg qid, then 10 day taper –Higher percentage in dexamethasone group remained ambulatory at conclusion of therapy and at six months (59 vs 33%) Sorensen et al, Eur J Cancer 1994;30A:22.

22. Dexamethasone Dosing 20 patient undergoing RT randomized to either 96 or 16 mg dexamethasone daily x 2 days with 10 day taper –No advantage for pain control or one month ambulation –Higher adverse events in high dose group 37 patients randomized to 10 or 100 mg bolus followed by 16 mg PO daily –No difference in pain control or neurologic outcome Vecht et al,Neurology 1989 39:1255; Graham et al, Clin Oncol 2006 18:70

23. Supportive Care Analgesia –Most require standing and prn opioid dosing –Necessary to tolerate imaging GI prophylaxis –In setting of high dose steroids

24. Supportive Care Urinary Retention –Patient may be unaware –Check post void residual, institute intermittent catheterization if residual >100 ml Constipation –Requires aggressive management –Exacerbated by opioid use Pressure Ulcers –Increased risk with weakness and sensory loss

25. Imaging Should be done emergently -Need to image the entire spine MRI: study of choice CT Myelography: alternative study

26. Definitive Therapies - Radiation Benefits in pain control and preservation of neurologic function Response depends on: –Radiosensitivity of tumor –Performance status at diagnosis –Speed of development of neurologic deficits

27. Definitive Therapies - Prognosis 67-72% of patient who are ambulatory at time of treatment remain ambulatory 1/3 of nonambulatory patients (paraparesis) regain ability to walk 2-6% with paraplegia regain ability to walk Higher likelihood of walking again if motor deficits develop more slowly (weeks) or if treatment begins <12 hours after loss of ambulation Among patients requiring catheter, 20-40% become catheter free Maranzano et al, J Radiat Oncol Biol Phys 1995; 32:959; Zaidat and Ruff, Neurology 2002, 58:1360.

28. Definitive Therapies - Surgery Tumor debulking and stabilization followed by radiation therapy Randomized trial: patients with single level cord compression, excluded for paraplegia>48 hours Surgical decompression within 24 hours of diagnosis and RT 2 weeks later versus RT within 24 hours of diagnosis Patchell et al, Lancet 2005;366(9486)643-648

29. Definitive Therapies - Surgery Primary end point: ambulatory rate after treatment Surgical group –significantly better ambulatory rate (84 vs 57%) –Ambulated for longer period (122 days vs 13 days) –Non-ambulatory patients more likely to regain ability to walk (62 vs 19%)

30. Surgery - Indications Unknown primary tumor Recurrent cord compression in previously radiated area Spinal instability or bony impingement of cord Primary modality with: –Radio-insensitive tumors –No paraplegia >48 hours –One level cord compression –No other contraindications –Limited systemic tumor

31. Conclusions Careful history is key to identification Recovery depends on early diagnosis and action Multiple interventions available to improve and maintain quality of life