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Malignant Epidural
Spinal Cord Compresson
Greg Patey, MD, CCFP, FCFP
May 23, 2014
GREG PATEY – MAY 23 , 2014
Spinal Cord Compression
- Objectives
• Preamble
• Etiology/Incidence
• Symptoms
• Investigations
• Treatment
• Conclusion/discussion
Spinal Cord
– basics
•
Cord Compression
– preamble
• skeleton is most common organ for metastases
from solid tumors
• “cord compression considered to be any
radiologic evidence of thecal sac indentation”
• spinal boney mets can result in pain,
hypercalcemia, pathologic fracture, spinal cord
compression and/or cauda equina involvement,
unstable spinal column
Cord Compression
– etiology/occurrence
• can be from any primary – most likely from
lung, breast, myeloma
• likelihood of any cancer patient suffering cord
compression in 5 years before death = 2.5%
• 7% of all deaths from prostate ca will have
experienced SCC.
Cord Compression
– etiology/occurrence
• autopsy study showed 5% of patients dying with
cancer had MSCC
• annual incidence in the US = 3.4%
• 20% of the time it is the initial manifestation
of cancer
Cord Compression
– etiology/occurrence
• thoracic spine (60%), lumbar spine (30%),
cervical (10%)
• multiple epidural deposits present in 30%
• effects can include minor sensory changes,
motor and autonomic changes, severe pain,
complete paralysis
Cord Compression
– impact
• morbidity and survival are compromised with
spinal cord compression, whether ambulatory or
not.
• ambulatory patients with no visceral mets and
no more than 15d between developing motor
symptoms and receiving therapy have the best
survival
Cord Compression
– impact
• prediction of ambulation depends on patient’s
ambulatory status prior to therapy and time
between developing motor deficits and starting
therapy
• non-ambulatory patients develop bowel
problems, require bladder catheterization,
require analgesics.
• delay to treatment
Cord Compression
– the symptoms
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•
•
•
•
•
Back pain
Weakness
Sensory loss
Bowel and bladder incontinence, Constipation
Urinary retention
Ataxia
Cord Compression
– the symptoms
•
•
•
•
•
•
Back pain
Weakness
Sensory loss
Bowel and bladder incontinence, Constipation
Urinary retention
Ataxia
Cord Compression
– the symptoms
•
•
•
•
•
•
Back pain
Weakness
Sensory loss
Bowel and bladder incontinence, Constipation
Urinary retention
Ataxia
Cord Compression
– the symptoms
•
•
•
•
•
•
Back pain
Weakness
Sensory loss
Bowel and bladder incontinence, Constipation
Urinary retention
Ataxia
Cord Compression
– the symptoms
•
•
•
•
•
•
Back pain
Weakness
Sensory loss
Bowel and bladder incontinence, constipation
Urinary retention
Ataxia
Cord Compression
– the symptoms
•
•
•
•
•
•
Back pain
Weakness
Sensory loss
Bowel and bladder incontinence, Constipation
Urinary retention
Ataxia
Cord Compression
– the symptoms
•
•
•
•
•
•
Back pain
Weakness
Sensory loss
Bowel and bladder incontinence, Constipation
Urinary retention
Ataxia
Cord Compression
– the symptoms
• Best predictor of outcome is the neurologic
status at time of presentation
• Those who have already lost ambulatory
function rarely walk again
Cord Compression
– examination/investigation
• Investigation aimed at proving neoplastic mass
causing extrinsic compression of thecal sac
• MRI
• Multiple metastatic epidural deposits
Cord Compression
– differential
• Benign MSK conditions
• Epidural abscess
• Bony mets without epidural extension
• Intramedullary mets, less common
Cord Compression
– differential
• Leptomingeal mets
• Malignant plexopathy
• Radiation myelopathy
• Hemangiomas, hematomas, neurofibromas, etc
Cord Compression
– treatment
• Treatment depends on histology, site of
disease, extent of epidural disease, extent of
other mets, neurologic status, and spinal
stability
• Treatment is nearly always palliative
• Aim to minimize pain, reduce/prevent neurologic
compromise, stabilize the spine
• When suspected, investigate and treat with
urgency
Cord Compression
– treatment
• Steroids
• 10-100mg iv, initial dose, followed by 16mg
daily in divided doses
• Higher the dose, more serious the side effect
profile, including insomnia, agitation, mania,
hyperglycemia
Cord Compression
– treatment
• Radiation therapy
• Treatment of choice for MSCC with or without
motor deficits and/or bone metastases, which
do not require immediate surgery
Cord Compression
– treatment
• Can be used post-surgery
• Radiosensitivity variable
• For poor prognosis patients, single fraction XRT
found to be as effective as multifraction XRT in
relieving pain
• Optimal dose/schedule of rads not yet
determined
Cord Compression
– treatment
• Stereotactic body radiation therapy (SBRT) can
be used for spinal oligometastases, radioresistant spinal mets, previously irradiated but
progressive spinal mets
Cord Compression
– treatment
• Surgery serves to decompress the cord and
stabilize the spine
• Followed by XRT more likely to regain ability to
walk and results in longer maintenance of
walking ability. Also associated with longer
survival
• Can work in select patients who are paraplegic
for up to 48 hours
• Typically not offered if survival <3months
Cord Compression
– treatment
• Surgery can include vertebroplasty or
kyphoplasty
• Can be combined with radiofrequency ablation
techniques to minimize pain
• Hormonal, chemotherapy, osteoclast inhibitors,
radiopharmaceuticals
• Rehabilitation shown to improve impaired
function and the associated depression
Cord Compression
– conclusion
• With improved cancer treatment and survival
extradural spinal cord compression is becoming
more common
• Early diagnosis and management reduces
complications, SCC diagnosis often delayed
• Sequelae of cord compression seriously reduce
quality of life
• High index of suspicion warranted in cancer
patient with new onset back pain
Cord Compression
– conclusion
• MRI investigative tool of choice
Cord Compression
– conclusion
• Once diagnosis confirmed treat aggressively
with steroids, XRT, + surgery
• Surgery followed by XRT can improve duration
of ambulation and survival
• As care providers for advanced cancer patients
palliative care doctors and clinical nurse
specialists are in a unique position to
RECOGNIZE symptoms early leading to earlier
diagnosis, and facilitate prompt referral of
these patients = better outcomes
Thank you