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Handbook of Palliative Medicine

Malignant spinal cord compression

This is an emergency presentation and needs to be diagnosed and treated as rapidly as possible as once paralysis is established only 5% of patients will walk again. Prompt recognition and treatment improves outcomes. It will occur in between 5 and 10% of patients with a malignant diagnosis. It most commonly occurs in the thoracic spine (70% of cases) followed by lumbar and then cervical. There are non-malignant causes of spinal cord compression, but their treatment will depend on the specific pathology and whilst many principles of treatment will be the same there is less likely to be a role for steroids.

Causes

  • The most common primary sites are breast, prostate, lung, and renal cancers. 
  • Multiple myeloma
  • Bony deformity and vertebral body collapse
  • Epidural invasion of a vertebral body metastasis
  • Paravertebral node infiltration

Signs and symptoms

  • When suspecting spinal cord compression, do not wait for worsening signs and symptoms, investigate, and intervene early
  • Usual history is back pain with or without radiation
  • This is then followed by sensory changes, bowel and bladder dysfunction, and leg weakness. These may be present individually or in combination 
  • Thoracic cord compression often presents with a sensory level and brisk reflexes
  • In cauda equina (Below L2) reflexes are likely to be diminished

Management essentials

  • Does depend on treatment plan, comorbidity and functional status, goals of care, prognosis, and patient choice
  • Commence high dose steroids (Dexamethasone 8-16mg oral/IV/SC)
  • Advise bed rest, potentially including log rolling, while investigation pending
  • Ensure being nursed in an appropriate clinical area with appropriately trained staff
  • Arrange urgent MRI scan
  • Alert oncology as radiotherapy is the definitive treatment

Non-drug treatment

  • Pressure area care
  • Catheter if urinary retention/problematic incontinence
  • Bowel care
  • Physiotherapy and occupational therapy

Drug treatments

  • High dose dexamethasone via the most appropriate route. This will reduce oedema of the spinal cord and may result in symptomatic improvement. This is especially important during radiotherapy when oedema may temporarily worsen
  • Consider gastric protection alongside steroids with PPI
  • Monitor blood sugars and treat accordingly (see page…)
  • Once radiotherapy complete steroid dose can be weaned down gradually to a stop
  • Opioid analgesia for back pain is likely to be required
  • Neuropathic agents (e.g. gabapentin) may also be required
  • SC heparin as venous thromboembolism prophylaxis, if not contraindicated, is essential