If you suspect MSCC, examine for a motor, reflex and sensory level with normal neurological findings above the level of compression. The signs are often lower motor neurone at the level of compression and upper motor neurone below it.3 Many clinicians use the Medical Research Council muscle weakness grading (see Box 3).3 To check for L’Hermitte’s sign, ask the patient to flex their neck; if this elicits pain shooting down the spine, it suggests a lesion of the dorsal columns of the cervical or upper thoracic cord.1 In MSCC, the signs are often symmetrical.
Cauda equina compression
In cauda equina lesions, signs and symptoms, which are often asymmetrical, are caused by nerve root compression. Patients often complain of pain in the distribution of the affected nerve and/or dermatomal sensory disturbance (numbness, burning, paraesthesia). The combination of pain and sensory disturbance is often referred to as a radiculopathy. Examination of the patient may elicit weakness and lower motor neurone signs. Disturbed sphincter function may result in incontinence or urine retention. A palpable bladder and lax anal tone may be found.
Treatment and investigations
Once suspected, MSCC/cauda equina compression patients should be nursed supine (or as supine as comorbidities allow) until urgent radiological investigations are undertaken and spinal stability is assessed.
If involvement of the cervical spine is suspected, appropriate immobilising cervical collars should be fitted (initial fitting of the collar should be under the supervision of an experienced physiotherapist or doctor).
Steroids are the first treatment. Dexamethasone 16mg daily in divided doses should be prescribed. Consideration should be given to co-prescribing a proton pump inhibitor if other risk factors for GI toxicity exist, for example, the patient is aged over 65 years or is also taking NSAIDs.
The investigation of choice is a whole spine MRI (Figure 1). If an MRI is not available or contraindications exist, for example, the patient has a pacemaker, a CT scan should be undertaken. It is imperative that the whole spine is imaged because there may be several levels of compression.
Once diagnosed, definitive treatment options include radiotherapy, chemotherapy, spinal surgery, neurosurgery, and more recently, percutaneous vertebral cementoplasty.5 The appropriate treatment modality will depend on the patient’s performance status and preference, local resources, previous diagnosis of malignancy (for patients in whom MSCC is the first presentation of malignancy, spinal surgery to achieve histological diagnosis should be considered), tumour type (some tumours, such as lymphoma, are often better treated with chemotherapy rather than radiotherapy), treatments given for previous episodes of MSCC and general prognosis.
Whichever treatment options are provided, most patients will benefit from a multidisciplinary approach, including physiotherapy, occupational therapy and psychological support.
Prognosis following diagnosis of MSCC or cauda equina compression is often determined by the underlying malignancy but because cord compression signifies disseminated disease, the prognosis is often poor (three to six months). The level and degree of spinal compression will determine prognosis because patients with significant muscle and sensory loss, and high thoracic or cervical cord compression, often have an ineffective cough and poor respiratory reserve, which leaves them susceptible to overwhelming chest infections. In such cases, prognosis may be in the order of weeks.
Clinicians should note that MSCC can recur. One study on cancer of the prostate found up to 45 per cent of patients had a further episode of MSCC at the same site or a new spinal level.6
Autonomic dysreflexia, although rare, is a medical emergency associated with spinal cord injury. It is thought to be due to a surge of sympathetic neurotransmitter release in patients with spinal cord injury (usually above mid-thoracic level). Patients present with headaches, flushing, sweating and very high BP. It can be precipitated by bladder distension, faecal impaction, and skin ulceration. Left untreated, the acute severe hypertension can lead to vascular complications, for example, acute coronary syndrome, pulmonary oedema, cerebral haemorrhage or seizures.
NICE is in the process of producing national guidance for the management of patients with MSCC;7 the document is due to be published in November 2008.
|D. Nikki Pease is consultant in palliative medicine and honorary senior lecturer, Velindre Hospital, Cardiff. Competing interests: None declared|
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2. Smith E, Hampel N, Ruff R. Spinal cord compression secondary to prostate carcinoma: treatment and prognosis. J Urol 1993;149:330-3.
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5. NICE. Percutaneous cementoplasty for palliative treatment of bony malignancies. Interventional procedure guidance 179. NICE, London, June 2006.
6. Huddart A, Rajan B, Law M et al. Spinal cord compression in prostate cancer: treatment outcome and prognostic factors. Radiother Oncol 1997;44:229-36.
7. NICE. Metastatic spinal cord compression. (accessed June 2008).
1. Caraceni A, Martini C, Simonetti F. Neurological problems in advanced cancer. In: Doyle D, Hanks G, Cherny N, Calman K (editors). (third edition). Oxford University Press, Oxford, 2004.2. Smith E, Hampel N, Ruff R. Spinal cord compression secondary to prostate carcinoma: treatment and prognosis. 1993;149:330-3.3. Longmore M, Wilkinson I, Turmezei T, Cheung C (editors). (seventh edition). Oxford University Press, Oxford, 2007.4. Fuller B, Heiss J, Oldfield E. Oncological emergencies. In: DeVita V, Hellman S, Rosenberg S (editors). (fifth edition). Lippincott-Raven, Wickford, 1997.5. NICE. 179. NICE, London, June 2006.6. Huddart A, Rajan B, Law M . Spinal cord compression in prostate cancer: treatment outcome and prognostic factors. 1997;44:229-36.7. NICE. . (accessed June 2008).
Originally published in the June 2008 edition of MIMS Oncology & Palliative Care.