Spinal Cord Compression (SCC)

Clinical Description

• This is the initial presentation of cancer in 20-30% of SCC. Common cancers to present with SCC are lung, Cancer of unknown primary, Breast, Prostate, NHL, Multiple myeloma. Mostly in the thoracic spine (60-80%), Lumbar spine (15 – 30%), Cervical spine (4-13%).

Signs and Symptoms

• Back pain (95%)
• Weakness (60-80%)
• Sensory deficits (40-90%)
• Autonomic dysfunction (50%)
• Ataxia (5%)

Investigations

High index of suspicion in cancer patient with new back pain or change in character of preexisting back pain

• Immediate imaging and consultation with oncologist and a neurosurgeon
• Careful documentation of neurology
• NOMS criteria to decide treatment
• MRI- whole spine (contrast-enhanced) is the gold standard
• CT scan is useful in assessing the degree of bone destruction, and differentiating bone vs. tumor

Treatment

Supportive

• Pain is mostly resistant to standard analgesics, therefore opioids are indicated
• Steroids lessen pain, reduce vasogenic cord oedema and avoid radiation induced spinal oedema
• High dose if establishes paraparesis or paraplegia vs. low dose steroids if pain with minimal fallout

Dexamethasone 40-96 mg loading dose then 16-24 mg over next 3 days. Decrease dose and increase time (taper) discontinue after 10days.

Radiotherapy

• Preferred treatment for metastatic SCC
• First-line therapy if surgery is contraindicated
• Radiosensitive tumors are lymphoma, multiple myeloma, breast, prostate and lung

Surgery

• Spinal instability, paraplegia at diagnosis
• No tissue diagnosis hence decompression & biopsy
• Retropulsion of bones within the vertebral canal
• Radio-resistant tumors
• Deterioration during RT
• Prior radiation in the same areas

Chemotherapy

• Chemo-sensitive tumors e.g., Lymphoma