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Home | Articles | Oncology | Malignant Spinal Cord Compression

Malignant Spinal Cord Compression

Last updated 14th January 2021

Aetiology

  1. May occur with any malignancy though 60% due to breast, prostate or lung cancer. Others include myeloma, renal cell carcinoma and non Hodgkin’s lymphoma
  2. May be presenting feature of cancer in up to 20% patients
  3. 60% of MSCCs are thoracic, 30% lumbar and 10% cervical

Suspect With Known Malignancy and Any of:

  1. Significant localised back pain esp thoracic
  2. Radicular pain eg round chest, down front or back of thighs
  3. Severe, progressive pain or poor response to medication
  4. Sensory/motor changes including mobility and sphincter problems – thoracic MSCC classically causes bilateral UMN signs in legs with sensory level and urinary retention while lumbosacral MSCC more likely to cause bilateral LMN weakness with saddle anaesthesia (cauda equina syndrome).
  5. NB Normal neuro exam does not preclude evolving cord compression.

What To Do Next

  1. Give loading dose Dexamethasone 16mg orally as soon as possible after assessment if likelihood of MSCC seems high. Continue at 16mg od until result of MRI available
  2. Request whole spine MRI – see below how to do this
  3. If MRI contraindicated then arrange urgent CT whole spine – modern CT imaging means that addition of myelography hardly ever necessary

How to Request Whole Spine MRI

  1. All patients – discuss with SPC team first on 33347 then if agreed email referral to [email protected]
  2. There is one cord compression slot per day between 12 and 1pm Monday to Friday and
  3. If more than one referral then SPC team will prioritise
  4. Request should be for MRI whole spine to exclude compression at more than one level
  5. Patient should know that MRI whole spine takes 1 hour.

Contraindications to MRI

  1. Cardiac pacemaker/ICD
  2. Cerebral aneurysm clip
  3. Electronic non-removable implant eg cochlear implant
  4. Metallic foreign body in proximity of vital organ eg eye, carotid
  5. Metallic implants and stents inserted < 6weeks ago unless clearly declared as MRI safe

Patients Who Present on a Friday Afternoon

  1. Dilemma as MRI service not available in Dumfries at weekends
  2. Discuss with SPC team whether better to give Dexamethasone and keep in Dumfries over weekend or transfer to Edinburgh for further immediate assessment

Further Management

  1. Direct decompressive surgical resection followed by radiotherapy has been shown to be superior to radiotherapy alone

Outcome

  1. Outlook is generally poor – median survival 3-6 months and 1YS of around 30%
  2. Pretreatment ambulatory status is single most important predictor of a good functional outcome

Summary

  1. Suspect if known malignancy and significant local back pain or radicular pain
  2. Give Dexamethasone 16mg stat orally unless contraindicated
  3. Refer SPC team for urgent review and decision re MRI

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