Sometimes cancer grows in the bones of the spine, or in the tissues around the spine and causes pressure on the spinal cord. This is called malignant or metastatic spinal cord compression (MSCC) and should be treated as an emergency.
Metastatic spinal cord compression (MSCC) is defined as spinal cord (or cauda equina) compression caused by collapse of vertebra(e) or instability due to metastatic spread or direct extension of a malignant tumour that threatens or causes neurological disability.
It is important for all health and care professionals to be aware of the signs of MSCC and carry out a risk assessment particularly for high risk tumour groups (people with cancers of breast, prostate and lung which have a higher likelihood of spreading to the bone, or people with myeloma).
Signs (‘red flags’) of MSCC include:
- A new, unexplained back or neck pain
- Numbness or pins and needles that is new or quickly getting worse
- Reduced mobility, falls or feeling unsteady on the feet (including leg weakness or legs giving way)
- Problems passing urine (incontinence or passing only small amounts of urine or none at all)
- Bowel problems (incontinence, being newly constipated, or constipation getting worse)
These symptoms can also be caused by a number of other conditions but should always be checked by a relevant healthcare professional. In England, every setting providing cancer treatment should have access to a metastatic spinal cord compression (MSCC) coordinator to advise what to do if the person with cancer you are with has signs of MSCC. MSCC coordinators are frequently part of an Acute Oncology specialist advisory service and there is usually a triage line or hotline number linked to the local cancer centre you can call for advice. This is increasingly the case across other regions of the UK, too. Contact the MSCC coordinator immediately to discuss the care of patients with cancer and symptoms suggestive of metastatic spinal cord compression or new spinal metastases.
Management of people with suspected or confirmed MSCC is covered by NICE Clinical Guidelines Metastatic Spinal Cord Compression (2008) and includes the following:
- Assume the spine is unstable until investigations prove otherwise: keep the person flat on bed or stretcher with neutral spine alignment (which might mean transferring to hospital via a stretcher, not walking or in a wheelchair). People with confirmed or suspected neck MSCC in the neck, immobilisation with hard collar may be needed
- Usually, an MRI scan of the whole spine will be requested within 24 hours
- Treatment for MSCC should start as soon as possible after the diagnosis (usually within 24 hours) and may be spinal surgery or radiotherapy
- Refer to physiotherapist within 24 hours of admission, occupational therapist within 24/48 hours of admission7 and to other members of MDT as appropriate, e.g. social worker, specialist nurse, specialist palliative care team, clinical psychologist who would be at a registered, enhanced or advanced level of practice
The physiotherapist and occupational therapist at a registered, enhanced or advance level of practice will:
- Carry out holistic assessment and assessment for co-morbidities
- Undertake respiratory assessment and treat as appropriate
- Carry out neurological assessment
- Teach active, active/assisted exercises; perform passive movements within pain limits as appropriate
- Ensure good positioning and provide advice on pressure relief management
- Commence gentle re-mobilisation as soon as possible and when pain well controlled and spinal stability has been established. This usually involves gradual sitting from lying flat to 45 degrees initially. If tolerated, progress to 60 and 90 degrees as able, usually the same day. Monitor neurology and pain during this process.
- Carry out mobility assessment and gradually mobilise as patient’s condition allows and as per agreed local protocol (NB. Return to bedrest on increased symptoms such as increased pain and/or neurological symptoms)
- Teach transfers as appropriate (e.g. how to get out of bed into a chair or onto a commode or toilet)
- Assess for and provide mobility aids and gait re-education, stairs assessment and continue rehabilitation
- Carry out wheelchair & cushion and/or hoist assessments as indicated and provide advice on regular pressure relief
- Assist with psychological adjustment and goal setting related to loss of functional independence, self-esteem and quality of life
- Assess home environment and support equipment and adaptations as indicated