Metastatic Spinal Cord Compression MSCC Definition MSCC is

Metastatic Spinal Cord Compression (MSCC)

Definition “MSCC is compression of the dural sac and its contents by an extradural tumour mass in the epidural space, either at the level of the spinal cord or cauda equina. ” Drudge-Coates and Rajbabu, 2008

Caused by… OR Irreversible neurological damage ensues with resulting paraplegia. (Levack et al, 2002).

Background Metastases to the SC occur in 3 -5% of all patients with Cancer with… Lung Breast Prostate 50% of cases Known lung Metastases R I S K Primary tumours of the SC NICE, 2008 & Schiff, 2003

Clinical Features Pain Bowel & bladder dysfunction Clinical Features Motor Deficits Sensory Deficits Schiff, 2003

Early recognition & reporting of symptoms Prompt Rx Early Δ & Rx are KEY Swift referral pathways Appropriate investigations NICE, 2008

Levack et al (2001) found that 77% of patients diagnosed with SCC had an established Δ of cancer, whereas 23% presented with SCC as the first presentation of malignancy.

Outpatient Physiotherapists must have their ears open to the following… Progressive &/or severe unremitting LBP Pain in upper or middle spine Localised tenderness over spine Back pain at night Back pain aggravated by straining, coughing or sneezing Brooks, 1998

Neuro S&S: Radicular pain, limb weakness, ↓mobility, sensory loss, bladder/bowel dysfunction NICE, 2008

Physiotherapy and Cancer Care • Within Cancer Care, Dietz (1981) identified 4 levels of rehabilitation: Preventive • ↓ the potential disabilities through educational, physical and psychological interventions Restorative • ↓ or eliminate disease through Rx & return to previous levels of functioning Supportive • Adapt to disabilities & disease Palliative • Maintain a good Qo. L through the minimization of complications

The Association of Physiotherapists in Oncology and Palliative Care The aim of the physiotherapist is to assist these individuals to minimize some of the effects which the disease or its treatment has on them (ACPOPC, 1993 as cited in Bancroft, 2003)

NICE Guidelines findings regarding PT availability for MSCC Patients Access to specialist PT Referral to specialist rehab services • CCs 63% • SSUs: 76% • CCs 93% • SSUs: 90% PT and OT availability OT • CCs 48% • SSUs: 48% • PCDs: 56% Daily PT • CCs 63% • SSUs: 81% • PCDs: 59%

Immediate SUHT Management Guidelines Inform Doctor regarding anyone with suspected/at risk of MSCC Complete bed rest –nurse flat until spinal stability confirmed Dexamethasone: 16 mg/day Emergency MRI or CT if MRI unavailable Urgent referral to clinical oncologist & D/W neuro/spinal surgical team Paraplegia present < 24 hours, regardless of onset Surgical decompression if possible If not, Radiotherapy Established paraplegia Pressure area care Catheter Regulation of bowel activity; use regular enemas or suppositories PT and OT input Psychological readjustment PCT Ax is recommended for Mx and/or rehab SUHT, 2007

Key NICE Recommendations – Service configuration and urgency of treatment – Early detection – Imaging – Treatment of spinal metastases and MSCC – Supportive care and rehabilitation NICE, 2008

• Recommendations with significant costs : estimated annual incremental costs resulting from ↑ in surgical activity for treatment & prevention of MSCC £ 14, 023 • Recommendations with significant savings: supportive care and rehabilitation post discharge of patients £ -17, 513 • Net resource impact of MSCC guideline £ -3, 490

References • Bancroft, M. I. , Physiotherapy in Cancer Care: a theoretical approach (2003). Physiotherapy. 89, 12: 729733. • Brooks, C. Radiation Therapy: Guidelines for Physiotherapist (1998). Physiotherapy. Vol. 84 (8): 387 -395. • Dietz, J. H. (1981) Rehabilitation Oncology, John Wiley, New York • Drudge-Coates, L. and Rajbabu, K. Diagnosis and management of malignant spinal cord compression: part 1 (2008). Int. J. of Palliative Nursing. Vol. 14 (3): 110 -116. • Loblaw DA, Perry J, Chambers A, Laperriere NJ (2005) Systematic review of the diagnosis and management of malignant extradural spinal cord compression: the Cancer Care Ontario Practice Guidelines Initiative's Neuro-Oncology Disease Site Group. Journal of Clinical Oncology 23: 2028– 2037 • NICE Clinical Guideline 75. Metastatic Spinal Cord Compression: Diagnosis and management of adults at risk of and with metastatic spinal cord compression (2008). • Schiff, D. Spinal Cord Compression (2003). Neurol. Clin. N. Am. 21: 67 -86 • The Palliative Care Handbook: Advice on Clinical Management (6 th Ed. ) CMH, SUHT (2007).