It must be emphasised that the key prognostic factor is the neurological status at the time of diagnosis,9-12 making early detection crucial. At the initial clinical suspicion of an impending (or early) spinal cord/cauda equina compression, a series of therapeutic steps should be undertaken. High-dose dexamethasone (preferably 16mg daily) should be given, together with a gastroduodenal protector such as ranitidine, omeprazole, or lansoprazole. Dexamethasone has the potential to avert the progression from an impending to an overt cord compression. It also reduces the associated radiculopathy pain within about 48 hours of starting treatment. In addition, this regimen will reduce the inevitable initial neural oedema that is likely to occur with any subsequent radiotherapy to the spine.
Urgent MRI of the entire spine (usually organised with the help of the designated co-ordinator for the trust/unit)13 and referral to the oncologist should be arranged. Radiotherapy to the affected spine is given at the discretion of the oncologist. Chemotherapy can be useful in certain malignancies, such as small-cell lung cancer, breast cancer, myeloma, and lymphoma.
However, if there is neurological compromise, spinal instability or severe unremitting mechanical pain, careful consideration should be given to spinal decompression and stabilisation surgery, taking into account the patient’s preference, general fitness, and overall prognosis.13 In these circumstances, preoperative radiotherapy should not be given, but postoperative radiotherapy may be given, provided there is a satisfactory surgical outcome and the wound is healed.
Pain control is achieved with opioids, the use of adjuvant analgesics such as gabapentin or pregabalin for radiculopathy pain, and dexamethasone to reduce perineural oedema. Benzodiazepines can be useful in reducing associated erector spinae muscle spasm and thereby improving pain. Once pain control is achieved, gentle mobilisation should be encouraged.An adequate bowel regimen is needed if sphincters are affected (for example, semisolid stool to be manually evacuated twice a week if anal sphincter tone is absent). Urethral catheterisation is also often required. A multidisciplinary approach is essential, because patients require help to achieve physical and psychological adjustment to the clinical effects of SCC that will enable them to enjoy the best possible quality of life.
Malignant spinal cord compression is a clinical emergency. Clinical detection in the impending stage of compression is possible and clinically rewarding because it will improve morbidity and mortality. Firm neurological signs appear late. Escalating spinal pain aggravated by any form of straining, often with associated radiculopathy pain, is a sufficient clue to early clinical detection of an impending SCC or cauda equina compression. However, for patients with an established SCC or cauda equina compression, a holistic, multidisciplinary approach is required to provide the best possible quality of life.
|Dr Marie Joseph is medical director and consultant in palliative medicine at St Raphael’s Hospice, Sutton, Surrey, and Macmillan consultant at the Epsom & St Helier University Hospitals NHS Trust, Surrey. Competing interests: None declared.|
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Originally published in the September 2009 edition of MIMS Oncology & Palliative Care.