Metastatic spinal cord compression Implementing NICE guidance 2008

Metastatic spinal cord compression Implementing NICE guidance 2008 NICE clinical guideline 75

Related NICE guidance This guideline is related to the following guidance: • Improving outcomes for people with brain and other CNS tumours. NICE cancer service guidance (2006) • Improving outcomes for people with sarcoma. NICE cancer service guidance (2006) • Improving supportive and palliative care for adults with cancer. NICE cancer service guidance (2004)

What this presentation covers Background Key priorities for implementation Costs and savings Discussion Find out more

Background • MSCC is a rare complication of cancer and is usually an oncological emergency. • Some patients experience significant delays from the time when they first develop symptoms to referral. • Nearly half of all patients with MSCC are unable to walk at the time of diagnosis. • Early detection, treatment and care can reduce the risk of developing avoidable disability and premature death. • Early surgery may be more effective than radiotherapy at maintaining mobility.

Key priorities for implementation The areas identified as key priorities for implementation are: • • • Service configuration and urgency of treatment Early detection Imaging Treatment of spinal metastases and MSCC Supportive care and rehabilitation

Service configuration and urgency of treatment • Every cancer network should ensure that appropriate services are commissioned and in place for the efficient and effective diagnosis, treatment, rehabilitation and ongoing care of patients with MSCC. These services should be monitored regularly through prospective audit of the care pathway.

Early detection • Inform patients with cancer who are at risk of MSCC information about the symptoms of MSCC and what to do and who to contact if those symptoms develop. • Discuss with the MSCC coordinator immediately patients with cancer who have symptoms of spinal metastases and neurological symptoms or signs suggestive of MSCC and view as an emergency. • Discuss with the MSCC coordinator within 24 hours patients with cancer who have symptoms suggestive of spinal metastases.

Imaging • It is important that MRI should be done quickly, dependent upon signs and symptoms.

Treatment of spinal metastases and MSCC: 1 • Nurse flat with spine in neutral alignment patients with severe mechanical pain suggestive of spinal instability or neurological symptoms or signs suggestive of MSCC until spinal and neurological stability are ensured.

Treatment of spinal metastases and MSCC: 2 • Start definitive treatment, if appropriate, before any further neurological deterioration and ideally within 24 hours of the confirmed diagnosis of MSCC.

Treatment of spinal metastases and MSCC: 3 • Carefully plan surgery to maximise the probability of preserving spinal cord function without undue risk to the patient, taking into account their overall fitness, prognosis and preferences.

Treatment of spinal metastases and MSCC: 4 • Ensure urgent (within 24 hours) access to and availability of radiotherapy and simulator facilities in daytime sessions, 7 days a week, for patients with MSCC requiring definitive treatment or who are unsuitable for surgery.

Supportive care and rehabilitation • Start discharge planning and ongoing care including rehabilitation on admission.

Costs and savings Estimated cases per year in England: 3, 100 Recommendations with significant costs Estimated annual incremental costs resulting from increase in surgical activity (£ 000 s per year) 14, 023 Surgery for treatment and prevention of MSCC Recommendations with significant savings Supportive care and rehabilitation post discharge of patients Net resource impact of MSCC guideline Savings (£ 000 s per year) -17, 513 -3, 490

Costs and savings Recommendations that may result in additional costs depending on local circumstances: - Early diagnosis: improving access to MRI scanning services -Treatment: increasing number of surgical procedures Recommendations that may result in additional savings include preventing late crisis intervention or need for supportive care.

Discussion • How cancer networks coordinate and audit the pathway? • How do we ensure 24 -hour availability of senior clinical advisers in centres treating patients with MSCC? • How do we ensure 24 -hour provision of the role of MSCC coordinator? • How do we raise primary care awareness of significant symptoms? • How can we improve timeliness of referral and imaging? • What is the current provision of community-based rehabilitation and supportive care services and do we need to improve this?

Find out more Visit www. nice. org. uk/CG 75 for: • • the NICE guideline the quick reference guide ‘Understanding NICE guidance’ local patient information template implementation advice costing report and template audit support