* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project
North Haven Hospice 1 specialist NHH, Dargaville, midnorth, far north hospices and Whangarei hospital • Support and Education for all 3-4 MOSS IPU nurses, community nurses counselling, social worker support, chaplaincy, bereavement support equipment North Haven Hospice 90% of patients want to be at home Symptom management, Respite, End-of-Life care, Alive Discharge rate from IPU? 70% Cancer, 30% non-malignant i.e. COPD,RF,HF, MND, Paeds Aiming to help with the more complex symptom management patients with a life limiting illness with a prognosis of less than a year Malignant Spinal Cord Compression By Richard Corkill Palliative Care Specialist . Learning Objectives 1 1. 2. 3. Understand the importance of educating patients with cancer about bone metastases and metastatic spinal cord compression (MSCC) Know where to seek advice when you suspect a patient may have spinal metastases or metastatic spinal cord compression Recognise those signs and symptoms which should prompt urgent or immediate action Learning Objectives 2 4. 5. Know which imaging methods to use to investigate patients Have a general overview of the different types of treatment for MSCC Malignant Spinal Cord Compression (Definition) Spinal cord compression due to malignancy is defined as a compression of the thecal sac by tumour in the epidural space 85% Malignant Spinal Cord Compression Importance Incidence 10% of Cancer Patients failure to recognises it results in increased patient suffering Prompt treatment is essential to maintain function Treatment should start within 24-48 hours of neurological damage when potentially reversible Delays due to failure to recognise symptoms, lack of clear referral pathway and no investigation pathway Friday referral why? MSCC Demographics 40-60 years of age Cervical, Thoracic & Lumbar spinal areas Multiple levels (20%) 10% further episode 10% MSCC – first presentation of cancer Cancer sites • Breast (15-20%), Prostate (15-20%), Lung (15-20%) • Myeloma(5-10%), Lymphoma(5-10%), thyroid, renal, melanoma Malignant Spinal Cord Compression Diagnosis Symptoms • Back pain (90%), band-like, radicular, worse at night and on coughing, not responsive to normal analgesia (3/12) • Weakness(70%), gone off legs (50% immobile at diagnosis (70% remain) • Tingling and Numbness ascends legs, sensory loss(50%) • Bladder and bowel problems(40%) incontinence, frequency, overflow, palpable bladder. • Pain may improve with increasing SCC Signs Malignant Spinal Cord Compression Diagnosis • Pyramidal Weakness • Motor level • Sensory level • Loss of reflexes • Reduced anal tone • Palpable bladder • Spinal bony tenderness Spinal Metastases Severe unremitting or progressive spinal pain Spinal pain aggravated by straining (e.g. cough, sneezing, passing stool) Nocturnal spinal pain preventing sleep Localised spinal tenderness Metastatic spinal cord compression Spinal met symptoms + • Radicular pain • Limb weakness • Difficulty walking • Sensory loss or bladder or bowel dysfunction • Neurological signs of spinal cord or cauda equina compression Malignant Spinal Cord Compression Investigation Urgent whole spine MRI (95% accuracy) • (ask for urgent report or films) Bloods FBC, U+E’s, Cal, LFT Immunoglobulin electrophoresis, BJ urine, PSA, LDH, BHCG and AFP Abdo U/S, Mammogram CT spine if MRI Contraindicated Plain X-Rays Malignant Spinal Cord Compression Treatment Depends upon patient wishes, performance status, length of neurological problem, and response to steroids Management multidisciplinary Strict bed rest, log-rolling, bed pans, eating! Dexamethasone 16 mg iv stat or po plus cover with a PPI Steroids+ • • • • • RT Sx + RT Sx (decompression+ spinal stabilization) Chemo (lymphoma and SCLCa) Symptom Control LCP, Dex, NSAIDs Morphine, Catheter Treatment - Surgery Solitary lesion Rapid onset symptoms Prognosis of greater 3 months Short premorbid period Good bone either side of lesion Fit enough for surgery No known histology Unstable spine or vertebral bone fragment Previous radiotherapy Neurological deterioration on radiotherapy Radio-resistant tumour MSCC Surgery + RT vs RT 101 pts 7 centres 2005 ant approach Criteria Retained ability to walk Median time able to walk Median time continent Immobile – walked Overall survival Opioids Steroids Sx+RT 84% vs RT vs 57% 122 vs 13 days 156 62 126 Less Less vs vs vs vs vs 17 days 19% 100 days more more Malignant Spinal Cord Compression Prognosis 70-80% of patients who were ambulatory at start of treatment retain ability Only 5% of paraplegic patients regain walking ability with radiotherapy Hence need for earlier diagnosis 3-6/12 Lung – Breast and Prostate respectively If long history (1-2/52) then irreversible Malignant Spinal Cord Compression Prognosis Pre-treatment neurological status Time to treatment Vascular event – sudden onset Vertebral collapse Performance status and disease status Malignant Spinal Cord Compression Discussion Need to keep eyes open Early referral if appropriate Don’t wait for dexamethasone response or for Friday Be aware of those that would benefit from surgical intervention Increasing evidence for surgery in improving function Malignant Spinal Cord Compression Future Known malignancy (esp breast, prostate and lung) with spine bone mets and increasing back refer on to get urgent MRI NICE Guidance 2008 Need clear pathway for diagnosis and treatment, local access to urgent MRI within 24 hours and informing high risk patients of symptoms and access to help. Organisations may wish to consider their pathways and training for staff in rapid assessment and handling of such patients Cochrane Collaboration 2010 Interventions for the treatment of metastatic extradural SCC in adults Stable spines & mobile pts – RT Mobile pts with poor prognostic factors for RT - Surgery Non-ambulant pts with single compression, <48 hr paraplegia, radioresistant tumours and a predicted survival of >3/12 - Surgery High dose Dex – signif side effects Going Forward What clinical practice changes could you make? Clinical Audit of mscc patients in Northland over last 5 years. Pathway development Patient information card or letter.