Metastatic spinal cord compression MSCC

MSCC is caused by compression of the dural sac and its contents (spinal cord or cauda equina) by an extradural or intradural mass,
and it leads to irreversible neurological damage such as paraplegia or tetraplegia depending on the level of the lesion.
Extradural masses are the more common.


Haematogenous spread with bony metastasis to the vertebral spine causes collapse and compression, accounting for over 85% of MSCC.


How does it present?

• Back pain isthe most common firstsymptom, occurring in 95% of patients for up to two months before signs related to MSCC appear.
• Motor deficit. Limb weakness is the second most common symptom, affecting 60-85% of patients at the time of diagnosis of MSCC. Patients may complain of an unsteady gait or a rapid onset of difficulty in walking, standing, or transferring from bed to chair that has progressed over days or a few weeks.
• Sensory deficit: Patients may complain of paraesthesia, decreased sensation and numbness of toes and fingers which may extend 1-5 dermatomes below the true level of cord compression. Radicular sensory loss and loss of tendon reflex  can be seen on clinical. A combination of rapid onset sensory and motor symptoms should raise a high degree of suspicion of MSCC.
• Autonomic dysfunction: bladder and bowel dysfunction such as urinary retention, urinaryor faecal incontinence, or constipation.
• Cauda equine sd: extreme pressure and swelling of the nerves at the end of the spinal cord. Symtomps: decreased awareness at presentation on passing urine or opening bowels, without a motor deficit and sometimes in the absence of pain. Clinical signs are decreased sensation over the buttocks, posterior-superior thighs, and perineal regionin a saddle distribution, with most patients exhibiting decreased anal sphincter tone on examination. Urinary retention.

How to confirm the diagnosis? MRI of the whole spine.

What to do about MScc:
Offer corticosteroids and analgesia and consider spinal stability while the patient is assessed.loading dose of
16 mg of dexamethasone (given intravenously or orally)
followed by a short course of 16 mg dexamethasone daily (given
in divided doses, such as 8 mg twice daily orally). Steroids are contraindicated if lymphoma isthe suspected cause of the MSCC
as the oncolytic effect of the steroids may impair tissue diagnosis. Steroids have no effect on survival.

Timely referral for neurosurgery or radiotherapy, or both, provides better outcomes longer term, but palliative care is the treatment of choice for some patients.


Box 1: NICE recommendations for diagnosis and management of patients at risk of or with metastatic spinal cord
compression (MSCC)6
• Contact the relevant team urgently (within 24 hours) to discuss the care of patients with
cancer and pain with any of the following characteristics suggestive of spinal metastases:
– Pain in the middle (thoracic) or upper (cervical) spine
– Progressive lower (lumbar) spinal pain
– Severe unremitting lower spinal pain
– Spinal pain aggravated by straining (for example, at stool) or when coughing or sneezing
– Localised spinal tenderness
– Nocturnal spinal pain preventing sleep.








Resources:

Bmj learning
BMJ 2016;353:i2539 doi: 10.1136/bmj.i2539 (Published 19 May 2016)

Loblaw DA, Mitera G, Ford M, Laperriere NJA. A 2011 updated systematic review and
clinical practice guideline for the management of malignant extradural spinal cord
compression. Int J Radiat Oncol Biol Phys 2012;84:312-7. doi:10.1016/j.ijrobp.2012.01.
014 pmid:22420969.

Bucholtz JD. Metastatic epidural spinal cord compression. Semin Oncol Nurs
1999;15:150-9. doi:10.1016/S0749-2081(99)80002-3 pmid:10461699.

 Levack P, Graham J, Collie D, et al. A prospective audit of the diagnosis, management and outcome of malignant spinal cord compression. Clinical Resource and Audit Group,
2001.