Malignant spinal cord compression

BY DR.SOUMYADIP ROY (1ST YEAR JUNIOR
RESIDENT , RADIATION ONCOLOGY ,
JIPMER , PUDUCHERRY)
MALIGNANT SPINAL CORD COMPRESSION

OVERVIEW
 EPIDEMIOLOGY
 PATHOGENESIS
 CLINICAL FEATURES
 INVESTIGATIONS
 MANAGEMENT
 SUMMARY

EPIDEMIOLOGY
 Affects 5-10% of the cancer patients (ByrneTN , N Eng J Med,1992)
 Majority of the patients are older than 50 years of age ,but
cumulative incidence decreases with age
 25 %, 16%, 11% and 7% of the MSCC are caused by lung ,
prostate, MM , breast respectively (Prasad et al,LancetOncology , 2005).
 20 % patients lack a history of cancer (Bach et al ,Acta Neurochir (Wien)
1990 )

Tumour extension into
epidural space
Compression of Batson’s
venous plexus
Increase in vascular
permeability and edema
Infarction of cord structure
in longstanding situation
Occlusion of the small
arterioles
Increase pressure on small
arterioles
Pathophysiology : Mainly vascular rather than mechanic

Method of spread
Any of these four mechanisms:
1)Expansion of a vertebral bone
metastasis into epidural space
2)Neural foramina extension of a
paraspinal mass
3)Displacement of a bony fragment
into neural foramina following
destruction of a vertebra
4)Rarely primary hematogenous
seeding into epidural space

Clinical Presentation
 Common symptoms in decreasing order of frequency (Prasad et
al,Lancet Oncol 2005):
1)Back pain (70-90%) – precedes neurologic deficits by 7 weeks
2)Motor deficits (60-90%)
3)Sensory deficits (45-900%)
4)Autonomic dysfunction (40-75%)
 Pain is aggravated by lying down
 New onset back pain in cancer patients : RED FLAG SIGN
 Common cancers causing MSCC : breast , lung and prostate:
accounting to 20 % of all cases (Prasad et al).

Cont.
 Pain types of spine metastasis:
Biologic Irritation/destruction of vertebral
periosteum , PCL , facet joints
Night or morning pain ,
present even when lying
down
Mechanical Spinal instability Movement related pain
Radicular Compression/infiltration of nerve
root
Radiation along the
distribution of nerve and
positional in nature
Funicular Irritation of long tracts of spinal
tracts
Constant and diffuse pain
regardless of position
Types of pain Cause Features

Clinical examination
 Motor: Power , tone , deep
tendon reflexes , clonus
 Sensory: sensory level , at
this level a band like
sensation is present
 Sensations from sacral area
and anal sphincter tone

Cont.
 Beevor’s sign: present in lower
thoracic cord injury which
causes paralysis of muscles in
lower abdomen resulting in
upward movement of umbilicus
while attempting raising head
from supine posture due to
unopposed action of upper
abdominal muscles

Investigation(s):
 MRI of whole spine as synchronus
multifocal lesion are present in
different spinal level in one third of the
cases (Hardy JR, Huddart R. Spinal cord
compression: what are the treatment standards? Clin
Oncol 2002;14(2):132–134 )
,T2 weighted images to look for thecal
sac indentation(s).
Compression by vertebral mass
extending into epidural space

Cont.
 Tissue diagnosis is necessary when the
primary is unknown
 HRCT or CT myelogram in whom MRI is
contraindicated (with cardiac
pacemakers , metallic implants
,claustrophobia etc).In CT myelogram 1
ml radioopaque dye is injected into
subarachnoid space before taking CT
 Hypercalcemia may be present with
extensive vertebral metastasis.
CT myelogram

Different forms of cord compression
Compression by bony
fragment
Compression by paraspinal mass

Grading
 Bilsky MSCC grading scale (Bilsky et al):
 Two scales are present: a 4 point (more
preferred due to easiness of use) and a 6 point
 0-only bony vertebral lesion
 1-o+epidural extension (1a) and thecal sac
indentation (1b) and touching cord(1c)
 2-1+spional cord compression without
blocking CSF
 3-2+ blockage of CSF flow
Bilsky MH, Laufer I, Fourney DR, et al. Reliability analysis of the
Epidural Spinal Cord Compression Scale. J
Neurosurg Spine 2010;13(3):324–328

Management
 Overview:
THIS IS AN ONCOLOGIC EMERGENCY
 Treatment objectives: pain control , avoidance of
complications , preserve or improve neurological function
 Patient should be kept on bed rest
 Provide adequate analgesia

Cont.
3)Things to consider:
a) STEP1 histologic diagnosis : necessary to get biopsy from
the spinal cord lesion when the primary in unclear (unknown
or lower stage tumour diagnosed long back) before starting
radiotherapy/chemotherapy /steroids.
b)STEP 2 Initiation of corticosteroids

Cont.
2)Two regimens present : a)High dose : 96 mg loading dose f/b 96 mg daily
divided in 4 doses and b) Low dose: 10 mg loading dose f/b 16 mg daily
divided in 4 doses. Superiority of one regimen over is unclear.( Sørensen P,
Helweg-Larsen S, Mouridsen H, et al. Effect of high-dose dexamethasone in carcinomatous metastatic
spinal cord compression treated with radiotherapy: a randomised trial. Eur J Cancer
1994;30A(1):22–27)
3)One PPI is always used for gastric protection.
c)STEP 3 Evaluate ,life expectancy, performance status, extent of disease,
systemic treatment options

Cont.
d) STEP 4 MNOP algorithm:
M, mechanical instability of spine when present consider for
up front surgery to stabilize spine first
N, neurologic deficit whether present and for how long
O, Oncologic : choose radiation dose as per tumour biology (4
Gy/1# is sufficient for lymphoma),whether treatment is
curative (For macroscopic disease 60 Gy and for microscopic
disease 30 Gy @ 2 Gy equivalent) or palliative (15-36 Gy @ 2
Gy equivalent).

Cont.
P,Preferred treatment
 Surgery:
 Patchel et al study (LANCET
, 2005):It was the first phase
III RCT that compared
decompressive surgery and
spinal stabilization within
24 hr of diagnosis f/b RT
(30Gy/10#) vs RT (same
dose) alone in MSCC.

Cont.
 Surgery:
1)Indications: KPS at least 4o +(unstable spine/at least 3 or(PEREZ)
2 (DEVITA)months life expectancy/duration of paraplegia less than
24 hours/intractable pain/rapid progression in spite of RT/unknown
primary tumour/relapse post RT/relatively radioresistant
cancer/bony fragment impinging on cord)

2)Traditionally used posterior laminectomy
is now obsolete due to high rate of
complication.360 degree decompression
and concomitant stabilization done with
modern techniques has best outcomes
(Patchell RA,Tibbs PA, RegineWF, et al. Direct decompressive
surgical resection in the treatment of spinal cord
compression caused by metastatic cancer: a randomised trial.
Lancet 2005;366(9486):643–648)
3)Kyphoplasty or vertebroplasty are
relatively contraindicated in MSCC
(NCCN)

Radiation
 Surgery f/b RT is better (in terms of regaining and maintenance of
motor function , maintenance of continence , pain control ,
overall survival , maintenance of ASIA and FRANKEL score) than
RT alone
 Several schedules are present: 37.5 Gy/15# ,40 Gy/20#,30
Gy/10#,20 Gy/5#, 8 Gy/1#
 Short course RT schedules are associated with more retreatment
rates because high incidence of local recurrences , requirement of
higher dose of analgesics afterwards (Rades et al study;IJROBP 2011 ,Wu JS et
al study; IJROBP 2003)
 Shorter course RT schedules are used in patients with short life
expectancy.

Cont.
 Field size: involved segment + 1 (for MRI based
planning) or 2 (for CT or Xray based planning)
vertebra above and below; AP PA field for
thoracic and lumbar region and laterally
opossed field for cervical region
 SBRT: important for radical treatment , in
case of radioresistant tumours to escalate
dose,reirradiation for a recurrent lesion; at
least 6 months gap between the treatments is
recommended (ACR Journal of Palliative Medicine 2015).

Cont.
 Radiosensitivity of the tumour as per histology
Very good unfavourable resistant
Lymphoma
Germ cell tumour
MM
Breast
Prostate
HPV positive SCC
HPV negative SCC
NSCLC
GI tumours
Melanoma
Sarcomas
RCC

Cont.Chemotherapy
 Useful in :
1. germ cell tumours ,
2. lymphomas ,
3. neuroblastoma ,
4. breast and prostate (hormonal manipulation)

Cont.Supportive care and
Rehabilitation
 Braces and collars : Physical medicine opinion
 For paraplegic patients offer thigh length compression
stockings.
 Who has been treated by surgery are at high risk of
thromboembolism. LMWH should be used prophylactically.
Dose :Enoxaparin 40 mg S.C. OD.
 Paraplegic patients should be provided with air mattresses or
cushions with every 2-3 hourly posture changing to prevent
decubitus ulcer.

Cont.Supportive care and
Rehabilitation
 Catheterization of urinary bladder for bladder dysfunction.Foley’s
catheter is to be changed once every 3 weekly. Siliconized catheter
can be kept in-situ for a maximum of 3 month. If long term bladder
dysfunction is present then Intermittent catheterization or
suprapubic catherization may be done.
 Judicious use of laxatives for constipation.
 Psychological support

PROGNOSIS
 MSCC has a median servival of 6 months and only one third of the
patient are alive beyond 1 year (sorensen et al study .Cancer 1990)
 Rapidity of symptoms onset (most important) (Rades et al Int J Radiat Oncol
Biol Phys 2002) : rapidly evolving compression carries worst prognosis
 Radiosensitivity of the tumour
 Pretreatment ambulatory function : ambulatory patients at
diagnosis have best prognosis
 Overall tumour burden

Cont.Prognosis
 Rades prognistic
scoring
The first score predicting
overall survival in patients
with metastatic spinal cord
compression (Rades et al , Cancer
2008 Jan 1, 112(1)157-61)

PAEDIATRIC MSCC
 Tumour biology is different from adults
 Mostly neuroblastomas (commonest),Ewing’s sarcoma,
Wilm’s tumour
 Pathogenesis:Tumour extension to the epidural space through
the neural foramina , so called “dumbell tumour”
 Usually chemotherapy plays main role in treatment (French
Society of Pediatric Oncology Protocol NBL-90).
 Tumours rapidly progressing despite chemotherapy should be
operated
 RT is used for palliation when all modalities fail.

Summary
 MSCC affects arround 10 % of cancer patients
 Suspect in known cancer patients with new onset back pain
and in patients without h/o cancer with progressively
worsening back pain
 Do MRI whole spine , look for hypercalcemia
 Don’t start steroid when tissue diagnosis is unclear or when
there is suspicion of lymphoma
 Use low dose steroid regimen as high dose regimen cause
more adverse effects without clear benefit

SUMMARY
 Do upfront surgical decompression f/b adjuvant RT (30
Gy/10#) in patients with life expectancy >2-3 month , systemic
burden of disease is less , where spine is unstable
 For curative treatment SBRT has a role where dose escalation
is needed
 Use short course RT schedules in others
 Adequate rehabilitation measures

Malignant spinal cord compression

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