malignant spinal cord compression - palliative care · pdf filesite of malignant spinal cord...
TRANSCRIPT
Malignant Spinal cord Compression
Dr. Thiru Thirukkumaran
Palliative Care Services - Northwest Tasmania
Background Statistics of SCC -1
Incidence of SCC ► Vertebral body metastases – 85 %
► Para-vertebral (Lymphoma) mass – 10 %
► Intra-medullary mass – 4 %
► Haematogenous spread – 1 %
Template copyright: Dr Thiru's Palliative Care Blog
http://www.palliativedoctor.net/
Background Statistics of SCC -2
Site of Malignant Spinal cord Compression
► Cervical level – 10 %
► Thoracic level – 70 %
► Lumbo-Sacral Level – 20 %
More than one level – 20 %
3-5 % of the patient’s with cancer have spinal metastases1
10 % of patient’s with skeletal metastases develop MSCC.
Background Statistics of SCC -3
60 % of all the cases of MSCC from Breast Lung & Prostate Cancers.
Bronchus }
Breast, } cancers leads to Bony Mets!
Brostate }
Bhyroid }
Bidney }
In 0.23 % of the patient’s MSCC will be their presenting feature.
8% 2ry to Myeloma.
Median survival of patient with MSCC is 2-3 months 1 ; 17% alive at 1 year & 10% at 18 months 2.
Template copyright: Dr Thiru's Palliative Care Blog
http://www.palliativedoctor.net/
The main pathophysiological pathway of SCC development in
cancer patients is summarized below
Template copyright: Dr Thiru's Palliative Care Blog
http://www.palliativedoctor.net/
Metastatic Spinal cord Compression
Magnetic resonance image Diagrammatic illustration
Re-produced from K. Lee et al. Int. J for Qty in Health Care. 2007;pp 1-5. Re-produced from Abrahm JL. J Support Oncol. 2004;2:377–401.
Template copyright: Dr Thiru's Palliative Care Blog
http://www.palliativedoctor.net/
Symptoms & Signs of MSCC
► Back pain – 90 % usually progressive, unremitting &
keep the patient awake at night
► Leg weakness
► Increase reflexes
► Numbness or a Sensory Level, or both
► Sphincter disturbances
► Urinary hesitancy (late feature)
► Bowel symptoms such as constipation
► Tenderness over the affected vertebrae
► Radicular Pain, particularly on coughing / sneezing
Note: Clinical signs can be subtle in the early stages
=> Need to have high index of suspicion
Template copyright: Dr Thiru's Palliative Care Blog
http://www.palliativedoctor.net/
Clinical Examination Findings
• Localised spinal tenderness
• Cervical spinal lesion:
~ Lhermitte’s sign: Neck flexion causes ‘electric shocks’ in trunk/limbs
~ Hoffman’s reflex: Brief flexion of Thumb & index-finger on flicking the
middle finger’s pulp (if above C5)
• Lumbar lesion: Spastic weakness below sensory level (Below L1 Level) ~ Exaggerated reflexes
~ Up-going planter responses
• Cauda-equina lesion (Below L1 Level)
~ Flaccid weakness
~ Saddle hypoaesthesia
~ Sphincter weakness
• Conus Mudullaris Lesion
~ Acute urinary & faecal retention
Template copyright: Dr Thiru's Palliative Care Blog
http://www.palliativedoctor.net/
Investigation of MSCC
• Whole Spine MRI Gold Standard for diagnosis &
treatment planning
• MRI (Li et al.) 4 ~ Sensitivity 93 %
~ Specificity 97 %
• CT myelography if MRI contra-indicated
( Permanent Pacemaker & Metal work in the spine)
Template copyright: Dr Thiru's Palliative Care Blog
http://www.palliativedoctor.net/
Management
• MSCC is usually associated with inadequate control of
primary tumour.
• Goal of the treatment is PALLIATIVE & directed at
1. maintain ambulation
2. decreasing tumour bulk
3. relieving the pain
• Options include 1. symptomatic therapy,
2. Radiation,
3. Neuro-surgery &
4. Chemotherapy.
Template copyright: Dr Thiru's Palliative Care Blog
http://www.palliativedoctor.net/
Symptomatic Management
• Pain control
• Nurse flat
• Management of constipation (Reasons:2ry to autonomic dysfunction, inactivity & opioids)
• Spinal braces for patients with spinal instability
• Occupational Therapy
• Physiotherapy
• Psychological support
Template copyright: Dr Thiru's Palliative Care Blog
http://www.palliativedoctor.net/
Corticosteroids
• Dexamethasone 16mg /day to prevent further
damage
• The steroid helps reduce pressure and
swelling around the spinal cord, and can
relieve symptoms such as pain.
• Common short term side effects include
hyperglycemia, insomnia and gastric distress.
• Serious acute adverse effects such as
gastrointestinal perforation or bleeding,
psychosis, risk of infections
Template copyright: Dr Thiru's Palliative Care Blog
http://www.palliativedoctor.net/
Care Pathway for
Management of MSCC
Template copyright: Dr Thiru's Palliative Care Blog
http://www.palliativedoctor.net/
Surgical Intervention
Bartels, et al. Spinal Extradural Metastasis: Review of current Treatment Options.
CA Cancer J Clin 2008;58:245–259
Template copyright: Dr Thiru's Palliative Care Blog
http://www.palliativedoctor.net/