Metastatic Spinal Cord Compression

 

Condition  

Cancerous tumour have the ability to spread throughout the body. In principle, any malignant tumor can spread to any organ although specific tumours typically spread to certain tissues. A tumour, which has spread to another tissue is called a metastasis. If the metastasis is in the spine, it can effect the stability of the vertebral body and cause pressure on the spinal cord, nerve roots or cauda equina (see ‘The normal structure of the spine’).

Symptoms    

  • Pain: Any unusual neck or back pain in a patient with a known cancer should be treated with suspicion and should be investigated urgently. The pain is usually progressing and does not depend on activities. Many patients have pain at rest and at night. It might be localised to a certain area but can be widespread, too.
  • Radicular pain is caused by pressure on a nerve root. Although this type of pain is most common in patients with degenerative spine problems it can also be cause by entrapment of a nerve by a metastasis.
  • Paralysis and numbness develop if the metastasis compresses the spinal cord (myelopathy). If patient with a known or suspected tumour experience any of these signs, they should have an urgent MRI scan within 24 hours of onset of symptoms. Bladder and bowel problems can be the result of metastatic compression of the spinal cord or cauda equina. Incontinence of faeces or urine should be urgently investigated (see also ‘cauda equina syndrome’)

Complications     

The biggest risk of metastatic spinal cord compression is permanent paralysis and incontinence,  either directly by pressure on the spinal cord by the metastasis or indirectly due to instability and collapse of the vertebral body.

Investigations

All patients with signs of metastatic spinal cord compression should be investigated urgently. This usually requires urgent hospital admission. In my practice, a team of Oncologists (tumour specialists), spine surgeons, radiologists and pathologists will oversee the management of any patient with metastatic spinal cord compression. MRI scan is usually the investigation of choice. Plain x-rays in flexion and extension might also be useful in addition if instability is suspected. It is also important to have a clear understanding how widespread the cancer is. Therefore, patients will usually require further CT scans of the chest and abdomen and other tests. This should be under the supervision of a specialist.

Treatment and Outlook    

It is important to remember that metastatic spinal cord compression is a complication of the underlying malignant tumour. The overall prognosis is therefore dependant on the treatment available for the cancer. Treatment for metastatic spinal cord compression has three goals:

  1. Pain relief  can be achieved by drugs, radiotherapy and surgery.
  2. Decompression of the spinal cord can effectively be treated by radiotherapy and/or surgery.
  3. Stabilisation of the spine is done surgically. Only in rare cases a brace might be indicated.

The National Institute for Clinical Excellence (NICE) has issued guidelines regarding the treatment of patients with metastatic spinal cord compression (www.nice.org.uk/nicemedia/pdf/CG75FullGuideline.pdf). Which option is most appropriate in a specific case depends on a number of factors. It is important that all options are discussed with the patient and that relevant specialists are involved. As time is an important factor, specialist teams should be involved urgently.

According to the NICE guidelines (above), the key factors in the management of patients with symptoms of metastatic spinal cord compression are:

  • Urgent assessment by a doctor and referral to a specialist team
  • Urgent MRI scan, within 24hours of onset of symptoms
  • Multidisciplinary team decision which treatment should be offered

The key factors for  surgery are:

  • Decompression should always be done in combination with stabilisation (spinal fusion) apart form exceptional cases.
  • Surgery should not be offered if complete paralysis has been present for more that 24hours unless for pain relief or instability.
  • Surgery should be performed before radiotherapy as the post-operative risks (infection, wound break down) are significantly  higher if radiotherapy is done before surgery.
  • Major surgery should only be performed if patients are expected to survive longer than 3 months.