Metastatic spinal cord compression

What is a Metastatic Spinal Cord Compression (MSCC)? 

The spinal cord is a bundle of nerves that runs from the brain and to the lower part of the back, and has important roles in functions such as movement, bladder and bowel functioning, sensations of touch, pain, and temperature.  

Spinal cord compression occurs when there is pressure on the spinal cord, which can stop the nerves functioning normally. This can occur when cancer grows in the bones of the spine or in surrounding tissues of the spinal cord.  

MSCC is rare, between 5-10% of cancer patients develop a spinal cord compression. The most common types of cancers that can spread to the bone is prostate, lung, and breast cancer.  

If MSCC are not diagnosed/treated urgently, damage to the spinal cord can lead to permanent paralysis.  

Metastatic Spinal Cord Compression- Red Flag Symptoms 

Please see below the list of some of the common signs and symptoms which patients diagnosed with MSCC have reported.  

Diagnosing and early treatment is crucial to improve a patient’s quality of life with MSCC.  

It is important to note that having some of these symptoms does not necessarily mean a diagnosis of MSCC, however reporting of symptoms and investigations are essential to come to a diagnosis.

Metastatic spinal cord compression (MSCC) key red flags

• Past medical history of cancer (note 25% of patients do not have a diagnosed primary)
• Early diagnosis is essential – as the prognosis is severely impaired once paralysis occurs
• A combination of red flags increases suspicion – the more red flags the higher the risk and the greater the urgency

Credit: The above information has been produced by The Christie NHS Foundation Trust. The Greater Manchester and Cheshire MSCC guidelines can be accessed on The Christie NHS Foundation Trust website.

Most common symptoms include:  

• New or persistent worsening back or neck pain  

• Cervical or thoracic pain  

• Lumbar or sacral pain  

• Spinal pain aggravated by straining (on movement, lifting, coughing or sneezing)  

• Localized spinal tenderness 

• Pain that keeps the patient awake at night  

• ‘Band-like’ pain around the chest or abdomen  

• Pain spread into the lower back/buttocks/legs  

Early warning signs of MSCC

The following has been produced by Greenhalgh S, Turnpenny J, Richards L, Selfe J (2010)

• R- Referred back pain is multi-segmental or band-like
• E- Escalating pain which is poorly responsive to treatment (including medication)
• D – Different character or site to previous symptoms
• F – Funny feelings, odd sensations or heavy legs (mult-segmental)
• L – Lying flat increases back pain
• A – Agonising pain causing anguish and despair
• G – Gait disturbance, unsteadiness, especially on stairs (not just a limp)
• S – Sleep grossly disturbed due to pain being worse at night

NB – established motor, sensory, bladder, bowel disturbances = late signs

Other symptoms include:  

• Limb weakness (feeling unsteady on feet, difficulty walking and experiencing legs giving way, loss of power or heaviness and difficulty using arms)  

• Loss of coordination  

• Sensory disturbance (numbness, burning sensation, pins and needles) 

• Problems with bladder (incontinence or passing little or no urine)  

• Problems controlling bowels (incontinence or increasing constipation)  

Metastatic spinal cord compression – signs and symptoms

• Worsening back or neck pain
• Pain in the spine that gets worse on movement on lifting something heavy or on coughing or sneezing
• Pain that keeps the patient awake at night
• Numbness, a burning feeling or pins and needles in the toes, fingers or over the buttocks
• Pain that fees like a band around the chest or abdomen or spreads into the lower back, buttocks or legs
• Problems controlling the bladder (incontinence) or passing little or no urine
• Patie is feeling unsteady on their feet, having difficulty walking, experiencing legs giving way
• Problems controlling the bowel (incontinence) or increasing constipation

Important information 

If you suspect or have any concerns your patients may have MSCC, it is important to act quickly in order to ensure the best outcome can be achieved.  

• If known to oncology: Refer to oncology at JCUH for suspected/confirmed MSCC. Referrals available on Webice or external internet web resource (please follow the instructions provided). For advice, contact the Acute Oncology Service (AOS) team.   

• If not previously known to oncology/ Admit: to local A&E if patient is in the community.  

• Steroids: Start 16mg of dexamethasone OD or 8mg BD (with PPI cover (gastric cover) (unless contraindicated).  

• Bed rest: Patient to be nursed flat until MRI scan has been reported to prevent any neurological deterioration and preserve spinal stability.  

• Imaging: MRI of the whole spine to be done within 24 hours if there is a suspension of MSCC. T1 and T2 sequences with T2 axials of any region of interest). If there is any contraindication against having an MRI, a CT of the whole spine (sagittal slice) should be completed.  

• Referral: Consider referral for spinal surgery. If specialist spinal opinion is rejected or not appropriate, refer for urgent same day referral to the MSCC service.  

If you are a patient and have concerned about having symptoms of MSCC, please contact your GP, oncologist or specialist nurse or health care professional urgently.  

If you are a practitioner and are concerned regarding a patient, please contact the Palliative Radiotherapy Inpatient Service Management (PRISM)/MSCC co-ordinating service urgently.  

Please note: that referrals will no longer be accepted over the telephone. A referral form MUST be completed and then notify the relevant team. This is done via WEBICE referrals or (for external users) an external emergency radiotherapy referral form is available on this intranet page. 

Steroid management recommendations:

On suspicion or confirmed diagnosis of MSCC or IMSCC (with or without neurology, and in severe pain)- as soon as possible start dexamethasone 16mg daily (8mg BD) with PPI cover unless contraindicated (for medical reasons and/or significant suspicion of lymphoma).  

After the initial dose, continue on 16mg of dexamethasone daily whilst awaiting surgery or radiotherapy. After surgery or at the start of radiotherapy, reduce the dose gradually until stopped (see recommendations below). 

If MSCC/IMSCC is not confirmed following investigations, stop dexamethasone. No need to reduce slowly, unless indicated otherwise. 

Dexamethasone regime following radiotherapy treatment- the aim is to discontinue steroids within 10-14 days post treatment unless the patient is previously taking long term steroids.  We recommend following taper (and discontinue) regime on the table below: (*) 

Prescribe with PPI cover of lansoprazole 30mg or Omeprazole 40mg (daily during duration of dexamethasone).  

Observe for any worsening neurology- if any neurological deterioration occurs during the dose reduction, the dose should be increased again to the previous satisfactory dose and maintained for a further 2 weeks before attempting to taper the dose again. 

*Please note: This is a general recommendation for prescribing of dexamethasone in the management of MSCC, different regimes can be used depending on the clinical situation and practitioner preference. For any enquiries, please contact the PRISM team or on-call CCO for further advice if needed.  

(Information gathered from NICE guideline [NG234] recommendations and agreement amongst the Oncology Consultant team at South Tees NHS Foundation Trust).  

Other considerations when prescribing steroids: 

• Check for any contraindications to using steroids/steroid use. 

• Stop any NSAIDS or Aspirin.  

• Monitor for hyperglycaemia and candida.