1. Spinal Cord Compression Carol S. Viele RN MS OCN Clinical Nurse Specialist Heme-Onc-BMT University of California San Francisco Associate Clinical Professor Dept of Physiological Nursing UCSF School of Nursing

2. Objectives At the completion of this presentation the participant will be able to: –Describe the most common cancers associated with cord compression –Identify at least 2 symptoms associated with cord compression –Describe the most appropriate nursing interventions for cord compression

3. Definition/Frequency A mass effect from the tumor with associated edema which results in ischemia and neural damage to the spinal cord 10% of all patients with cancer will develop this complication

5. Occurrence The most common source of cord compression is metastasis to the epidural space with or without bony involvement Tumors can also through the reach the epidural space by direct extension through the intervertebral foramen Some tumors occur in the cord itself

6. Etiology Tumor types –Breast, (Number 1 in women) –Lung –Kidney –Myeloma –Prostate –Melanoma –Gastrointestinal tumors –Lynphoma

7. Level of Involvement Cervical area 10% Thoracic area 70% Lumbosacral 20%

8. Symptoms Back pain is usually the first symptom 95% of patients with a cord compression experience back pain Pain will precede other symptoms by weeks to months Early cord compression may be asymptomatic

9. Manifestations Pain –Localized –Radicular –Severity –Position changes –Cough –Weightbearing –Valsalva maneuver

10. Manifestations Weakness 75-85% –May progress rapidly –Bilateral –Corresponds to the level of cord involvemnent SpasticityHyperreflexia Abnormal stretch reflexes Extensor plantar response

11. Manifestations Sensory loss –Bowel dysfunction –Bladder dysfunction –Impotence

12. Diagnosis Thorough physical examination –Palpation –Gentle percussion over bony areas –Neurologic exam Laboratory data – Increased alkaline phosphatase may indicate bony involvement

13. Diagnosis Radiographs- may reveal erosion of the pedicle, –Lytic lesions of the vertebral body –Collapse of the vertebral body Bone scan- 20% of scans reveal lesions missed on plain films CT –Used to determine extent of tumor

14. Diagnosis MRI ( Tool of choice) –Able to determine prevertebral, vertebral, extradural, intradural, extramedullary and intramedullary lesions –Provides better anatomic visualization with sagittal and axial images of the spinal cord Fine needle aspiration –May provide tissue confirmation

15. Treatment Criteria: –Primary tumor type –Level of myelopathy –Degree of spinal block –Potential for neurologic reversibility

16. Treatment Surgery –Radical resection if an a candidate –Complete block –Single lesion where complete removal is possible –Diagnosis is uncertain –Mild deficits –New data supports surgery over treatment with RT if patient is a good surgical candidate

17. Treatment Radiation therapy –If not a surgical candidate –Incomplete block –Severe deficits –Relapse in area of prior radiation if short survival is expected

18. Treatment Radiation- often initiated as an emergency if not a surgical candidate –Therapy Treatment field extends 1-2 vertebral bodies above and below level of compression 3000-4000 cGy over 2-4 weeks 2/3 of patients remain stable or improve 65-75% achieve pain relief

19. Treatment Steroids –Dexamethasone Bolus IV 10 mg Oral 4-6 mg q 6 hours for 2 days then a slow taper 25% of patients with cord compression require maintenance to maintain neurologic function Steroid related side effects may occur –Hyperglycemia –GI bleeding –Psychosis

20. Treatment Chemotherapy –May be given in highly sensitive tumors –Always given with other modalities

21. Outcome Pretreatment ambulatory ability is the main determinant of post treatment ambulatory ability 90% of patients ambulatory before therapy are after Only 10% of paraplegics become ambulatory after therapy

22. Prognosis Median survival is 6 months if patient presents as a paraplegic 50% of patients who walk in with a cord compression are alive at 1 year If patient was ambulatory prior to RT survival is 8-10 months

23. Recurrent Disease Options –If RT given may be a surgical candidate if survival of > 12 months predicted –Repeat RT Risks of repeat RT –Radiation myelopathy –Collateral damage

24. Nursing Interventions Thorough assessment and early MD/Provider notification of changes in –Pain –Sensory function –Motor function –Urinary function –Bowel function

25. Nursing Interventions Maintenance of functional status –Bowel program –Bladder program –Skin care –Rehabilitation services PTOT

26. Nursing Interventions Education –Patient –Family –Significant others –Care givers

27. Nursing Interventions Emotional support –Decrease anxiety –Referrals Social worker PsychologistsPsychiatristChaplain

28. Nursing Interventions Referrals –Care coordination –Case manager –Home care –Rehabilitation center –Skilled nursing facility –Hospice

29. References Schulmeister, L., Gatlin, C.,( 2008) Spinal cord compression in Oncology Nursing Secrets, Gates, R. and Fink, R. (eds) Hanley and Belfus, Philadelphia, 546-550 Quinn, J., De Angelis, L.(2000) “Neurologic emergencies in the cancer patient”, Semin Oncol, 27: 311- 321 Tan, S. Recognition and Treatment of Oncologic Emergencies (2002), Journal of Infusion Nursing,25:3, 182-188

30. References www.uptodate.comwww.uptodate.com, Spinal Cord Compression, Accessed 7/9/09 www.uptodate.com

31. Case Study 67 year old male presents with pain numbness and inability to walk, found on floor by Family and brought to ER Dx: Metastatic prostate cancer being treated over the last year with multiple therapies Family reports multiple falls over the last week Physical exam: –Weakness bilaterally in both extremities –Decrease anal tone –Bladder found to be full by Doppler, patient reports inability to empty bladder well over the last few days

32. Case Study What do we do now?