Download Spinal Cord Compression as an Oncological Emergency By Lisa

Spinal Cord Compression:
A Case Study
Angie Angeles-Lo, SN,
Kathy Berliner, SN
Anthony Bodestyne, SN
Lisa Warren, SN
Spinal Cord Compression:
Patient History

Pt Demographics: 55 year old female, diagnosed 1
year prior with metastatic colon cancer. This
patient had a section of colon removed in 11/02;
she now has a permanent transverse colostomy.
She was admitted to Kaiser South San Francisco
on 11/20/03 for Spinal Cord Compression with
paralysis of the lower extremities.
Spinal Cord Compression:
Patient History

History of Present Hospitalization: In 9/03,
multiple retroperitoneal nodes were discovered on
CT. On the advice of the physician, the pt flew to
El Salvador to visit family. On 11/19, pt awoke
with severe 10+/10 back pain accompanied by b/l
weakness of the lower extremities. She was seen
in the ER in El Salvador where she received
epidural analgesia in order to sit through the flight
back to the U.S. By the end of the flight, the pt
had no sensation or movement of the lower
extremities.
Spinal Cord Compression:
Diagnostic Tests

CT Scan: A scan of the thoracic spine done on 11/20. The
impression showed probable metastatic disease to the
thoracic spine. Air was seen within the epidural space at
the lower thoracic level. Exact etiology is unknown.

MRI: A follow up MRI was done of the thoracic and lower
spine that same day. The impression showed extensive
metastatic tumor involving the cervical, thoracic, lumbar
and sacral vertebrae, with evidence or spinal cord
compression at T2 and T9.
Spinal Cord Compression:
Pathophysiology

Definition: Spinal cord compression
damage occur when a tumor directly enters
the spinal cord or when the vertebral
column collapses from tumor entry. Tumors
may begin in the spinal cord but more
commonly spread from other areas of the
body such as the lung, prostate, breast,
colon.
Spinal Cord Compression:
Pathophysiology
 Direct compression or distortion of the spinal cord may
result from neoplastic infiltration of the vertebral bodies or
paravertebral spaces.

Rarely, cancerous growths may originate from structures
within the epidural space.

Nerve tracts most vulnerable to mechanical pressure
include the corticospinal and spinocerebellar tracts and the
posterior spinal columns.
Spinal Cord Compression:
Pathophysiology

Spinal cord compression usually follows hematogenous
dissemination of a malignancy to the vertebral bodies, with
subsequent expansion of an epidural mass. Generally,
metastatic seeding appears in the thoracic spine 70% of
with the lumbar spine being the next most involved
site.The cervical spine is affected in approximately 10% of
cases.Multiple spinal levels are affected in about 30% of
patients.

Systemic cancers with a tendency for spinal cord
metastasis include the following: breast, prostate, renal, or
lung neoplasms; lymphoma; sarcoma; and multiple
myeloma.
Spinal Cord Compression:
Pathophysiology

Spread into the epidural space may occur by
means of tumor extension through the
intervertebral foramina or hematogenous spread
by way of the Batson venous plexus. Additionally,
gastrointestinal and pelvic malignancies tend to
affect the lumbosacral spine; lung and breast
cancers are more likely to affect the thoracic spine.
Spinal Cord Compression:
Pathophysiology

Leptomeningeal metastases spread by means of
diffuse or multifocal seeding of the meninges from
systemic cancer (eg, lung or breast cancer,
melanoma, lymphoma). Consequent signs and
symptoms are referable to the brain, cranial
nerves, or spine. Evidence of spinal compromise
includes lower extremity weakness, paresthesias,
reflex asymmetry, and spinal pain.
Spinal Cord Compression:
Signs and Symptoms

Signs and Symptoms: Spinal cord compression causes
back pain, usually before neurologic deficits occur. Neurologic deficits
are related to the spinal level of compression and include the
following:

1. Numbness

2.

3. Loss of urethral, vaginal and rectal sensation

4. Muscle weakness

5. If paralysis occurs, it is usually permanent.

6. Valsalva maneuvers, such as coughing, sneezing, or straining, may
exacerbate radicular back pain.
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Spinal Cord Compression:
Treatment

Nurses caring for clients with spinal cord compression must recognize
the condition early. The nurses assesses the client for neurologic
changes consistent with spinal cord compression. The nurse also
teaches clients and families to recognize the symptoms of early spinal
cord compression and to seek medical assistance as soon as possible.

Treatment is largely palliative. High-doses radiation is usually
administered to reduce the size of the tumor in the area and relieve
compression. Radiation may be given in conjunction with
chemotherapy to treat the total disease. Surgery is occasionally
performed to remove the tumor from the area and rearrange the bony
tissue so less pressure is placed on the spinal cord. External back or
neck braces may be prescribed to reduce the weight borne by the spinal
column and to reduce pressure on the spinal cord or spinal nerves.
Spinal Cord Compression:
Patient Medications



Dexamethasone- Management of cerebral edema and spianal
compression .Potent, locally acting anti-inflammatory and immune
modifier.Action-suppresses inflammation and the normal immune
response. Dosage-0.75-9mg PO/IV/IM daily IM, IV (Adults):
Dexamethasone phosphate—10 mg initially IV, 4 mg q 6 hr, may be
decreased to 2 mg q 8–12 hr, then change to PO. Adverse reactionnausea, dizziness, HA Serious reaction -anapyhaxis. ImplicationAssess patient for changes in level of consciousness and headache
throughout therapy.
Protonix- For hypersecretory condition, GERD
Dosage 40-120mg PO BID Max:240 mg/d. Info:do not crush, cut
chew Action:Inhibits gastric parietal cell hydrogen-potassium ATPase
(proton pump inhibitr) Adverse RXN: HA, diarrhea Serious side
effect: Anaphylaxis Implication:monitor for and immediately report
S&S of angioedma or severe skin reaction
Spinal Cord Compression:
Patient Medications




Fentanyl Patch: For Chronic Pain
Dosage: 25-100 mcg/hr patch q72h Action: Binds to various opiate
receptors, producing analgesia and sedation. Adverse reaction: dry
mouth, euphoria. Serious side effect: respiratory depression, severe
HTN. Implication:evaluate pain relief. Monitor VS, O2 Sat, bladder
function.
Heparin-DVT Tx/prophylaxis
Dosage: 5000 U SC q8-12h Action: with antithrobin III and heparin
cofactor, inhibits thrombin and Factor Xa and inhibits conversion of
fibrinogen to fibrin Adverse reaction: Prolonged clotting time,
bleeding Serious reaction: hemorrhage Implication:Monitor patient
for hypersensitivity reactions (chills, fever, urticaria). Report signs to
physician.Monitor platelet count every 2–3 days throughout therapy.
Spinal Cord Compression:
Patient Medications

Insulin:Due to glucocorticoid administration.

Dosage: Sliding Scale before meals and bedtime Action:
Lower blood glucose by increasing transport into cells and
promoting the conversion of glucose to glycogen Adverse
reaction: rebound hyperglycemia (Somogyi effect),
hypoglycemia Serious reaction-anaphylaxis
Implications: Check type, species source, dose, and
expiration date with another licensed nurse. Do not
interchange insulins without consulting physician or other
health care professional.
Spinal Cord Compression:
Radiation Therapy

Radiation treatment to areas of tumor compression should
be pursued after appropriate imaging and consultation.

Cord compression from an epidural tumor is considered
one of the few emergencies in radiation oncology.

Spinal cord tolerance to radiation depends on the fraction
size and cumulative dose.
Spinal Cord Compression:
Radiation Therapy

Radiation treatment affects normal cells while damaging cancer cells.
Sometimes this effect on normal cells and tissues can cause pain and
discomfort.

Skin dryness, difficulty in swallowing or skin sores may occur. The
radiation therapy specialist can recommend a program to care for the
skin to alleviate these side effects.

Fatigue can be a disabling side effect of cancer, cancer treatments and
dealing with pain. It restricts a person's ability to manage their usual
activities.

This patient was receiving external beam radiation for 8 days as
palliative treatment to shrink the tumor that invaded the spinal
column.
Spinal Cord Compression:
Nursing Assessments and Interventions

Monitor and document vital signs.Rationale: Obtain info
on patient’s overall condition

Assess neurological status including limb strength,
sensation, bladder and bowel functionRationale:
Establish patient’s level of consciousness. Ascertain any
evidence of increasing spinal cord compression as
indicated by motor dysfunction, weakness, ataxia,
sensory loss, numbness, tingling, loss of sensation to pain
and temperature, constipation and urinary retention.
Spinal Cord Compression
Nursing Assessment

Monitor blood chemistry and patient for signs of hypercalcemia, such
as confusion, drowsiness and lethargy. Rationale: Elevated calcium
levels may be associated with bone mets causing spinal cord
compression

Assess alterations in elimination of urine and feces in terns of urgency,
frequency, level of control over function, retention, constipation and
incontinence. Rationale: Early autonomic and nervous system
involvement results in constipation and urinary retention. Bowel
and bladder incontinence develop with advanced autonomic nervous
system involvement.
Spinal Cord Compression:
Nursing Assessment

Assess patient’s pain level. Assess for duration, location,
type, intensity and quality. Assess pain interventions.
Consider non-pharmacological interventions such as
relaxation, therapeutic massage and adjustment of
patient’s position.

Assess patient’s skin as there are at risk for impaired skin
integrity. Rationale: Maintain good body alignment at all
times to decrease the risk of further injury to spine.
Spinal Cord Compression:
Nursing Assessment

Assess for signs and symptoms of deep venous thrombosis due to
activity. This can lead to pulmonary embolism, which can be a lethal
complication. Many die within one hour of onset of symptoms or
before it has been suspected.

For a DVT assess for calf and groin tenderness, pain, sudden onset of
unilateral swelling of leg and positive Homan’s sign. Symptoms of
pulmonary embolism include dyspnea, chest pain, restlessness, cough
and hemoptysis. Signs include tachypnea, crackles, pleural friction
rub, tachycardia, diaphoresis, fever and petechiae over chest and axilla.
Spinal Cord Compression:
Nursing Assessment

Assess and monitor patient and family’s psychological
status and adaptation to diagnosis and implication on
lifestyle. Feelings of helplessness, hopelessness and
depression are common. Bed bound patients become
withdrawn and lose motivation.
Spinal Cord Compression:
Nursing Diagnoses and Interventions


Impaired physical mobility related to neuromuscular
impairment. Interventions include: maintain proper body
alignment, ROM exercises, adequate nutrition, teach
patient how to move in bed, monitor skin area over
pressure areas.
Risk for falls related to decreased or absent lower
extremity sensation and strength. Interventions include:
bed in low position, side rails up, keep frequently used
items within patient’s reach, provide assistance with
ambulation.
Spinal Cord Compression:
Nursing Diagnoses and Interventions


Risk for impaired skin integrity related to physical
immobilization and loss of bladder and bowel control.
Interventions include: Active or passive range of motions,
ambulate to the extend possible, change positions every 2 hours,
reduce pressure using things like pillows, air mattresses and bed
cradles, maintain good body hygiene, encourage adequate fluid
and nutritional intake.
Bowel incontinence related to loss of rectal sphincter control.
Interventions include: Keep area clean and dry. Monitor anal
and genital skin integrity. Record each episode including when
it occurs, amount, color and consistency. Provide emotional
support for patient.
Spinal Cord Compression:
Nursing Diagnoses and Interventions

Ineffective Individual Coping related to inadequate
level of confidence in ability to cope. Interventions
include: maintain consistency in approach and teaching
whenever interacting with patient, monitor for and
reinforce behavior suggesting effective coping
continuously, assist patient to identify and use available
support systems before discharge from hospital and help
patient evaluate which methods he or she have used that
have not been successful or have been only partially
successful.