Spinal cord compression occurs when there is compression of the spinal cord or cauda equina at any level secondary to the effects of a malignancy. This can include metastatic infiltration to the vertebral column causing instability or pathological fractures as well as direct pressure from malignancy to the spinal cord. This condition affects around 5-10% of all patients with a malignancy and is more common in lung, prostate and breast cancer. Up to 20% of MSCC occurs in patients not previously diagnosed with cancer.

Symptoms and Signs

• Pain is the earliest sign (predating neurological symptoms by 7 weeks) & is present in around 90%
  • Usually, it is in the thoracic region, but it can affect any part of the spine & can be more radicular affecting the limbs due to referred pain
  • Pain does not always correspond to the exact spinal level, therefore, it is best to always request an MRI of the full spine
  • Usually, it is progressively worsening, continuous in nature & is worse at night
  • Pain is classically worse when lying flat and worse when coughing or straining or on movement
• Numbness and sensory disturbance
• Motor weakness (this is a late sign!)
• Bladder and bowel dysfunction (always ask about back pain & red flags, if a patient comes in complaining of these symptoms!)

As expected symptoms will vary depending on the level but given the difficulty in differentiating it clinically it is best to be thorough & systematic. Spinal cord compression is more likely to be thoracic with neurology in the upper limbs with bladder & bowel changes being a very late sign. Whereas in cauda equina, the lower limbs are classically affected with earlier bladder & bowel dysfunction and saddle anaesthesia.

Examination

• Give analgesia as necessary to do a full neurological examination of the upper & lower limbs 
• PR examination to check for sensation and anal tone
• Bladder scan (pre and post void) to look for evidence of urinary retention

Investigations

• MRI whole spine is the gold standard – it is sensitive and specific & must be done within 24 hours. You must discuss this with seniors & radiology to obtain this urgently. 
• CT scans can be considered if an MRI is contraindicated but can be falsely reassuring

Management

• If spinal cord compression is suspected
  • High dose dexamethasone is given straight away usually for patients with neurological deficits unless there are good contraindications
    • Dosing should be confirmed with seniors/oncology/neurosurgery but a classic regime might be 10mg stat followed by 16mg daily (8mg at morning & lunch) with PPI cover
  • Analgesia
  • VTE prophylaxis (up to 10% might have a DVT given advanced cancer & immobility being major risk factors)
• If spinal cord compression is confirmed
  • Inform (or refer) to their local oncology centre
  • Usually, patients have a contact number card on them
  • You want to know what their prognosis & treatment has been
  • Whether they would be for radiotherapy
  • To confirm immediate management including dexamethasone
  • To confirm whether transfer to their care would be beneficial 
• Refer to neurosurgery 
  • Often referrals are via: https://www.referapatient.org/
  • You will want to transfer the images (ask the radiographers how to do this)
  • You want to know is the lesion amenable to spinal surgery?
  • Would they accept an urgent transfer (if it is)?
• Palliative care input should be considered especially if the patient is unable to have radiotherapy

References & Further reading

• Palliative Care Guidelines (Scotland) – MSCC
• Oxford Medical Education – Oncology – MSCC
• UpToDate – Clinical Features & Diagnosis of MSCC
• UpToDate – Treatment & Prognosis of MSCC

Written by Dr Shamilah Rahman (GP trainee)
Edits by Dr Akash Doshi (CT2)