Spinal Cord Compression Lecture Notes- By Carol Viele RN, MS, CNS, OCN.ppt
1. Spinal Cord Compression
Spinal Cord Compression
Carol S. Viele RN MS OCN
Carol S. Viele RN MS OCN
Clinical Nurse Specialist
Clinical Nurse Specialist
Heme-Onc-BMT
Heme-Onc-BMT
University of California San Francisco
University of California San Francisco
Associate Clinical Professor
Associate Clinical Professor
Dept of Physiological Nursing
Dept of Physiological Nursing
UCSF
UCSF
School of Nursing
School of Nursing
2. Objectives
Objectives
At the completion of this presentation
At the completion of this presentation
the participant will be able to:
the participant will be able to:
– Describe the most common cancers
Describe the most common cancers
associated with cord compression
associated with cord compression
– Identify at least 2 symptoms associated
Identify at least 2 symptoms associated
with cord compression
with cord compression
– Describe the most appropriate nursing
Describe the most appropriate nursing
interventions for cord compression
interventions for cord compression
3. Definition/Frequency
Definition/Frequency
A mass effect from the tumor with
A mass effect from the tumor with
associated edema which results
associated edema which results
in ischemia and neural damage to
in ischemia and neural damage to
the spinal cord
the spinal cord
10% of all patients with cancer
10% of all patients with cancer
will develop this complication
will develop this complication
5. Occurrence
Occurrence
The most common source of cord
The most common source of cord
compression is metastasis to the epidural
compression is metastasis to the epidural
space with or without bony involvement
space with or without bony involvement
Tumors can also through the reach the
Tumors can also through the reach the
epidural space by direct extension through
epidural space by direct extension through
the intervertebral foramen
the intervertebral foramen
Some tumors occur in the cord itself
Some tumors occur in the cord itself
7. Level of Involvement
Level of Involvement
Cervical area 10%
Cervical area 10%
Thoracic area 70%
Thoracic area 70%
Lumbosacral 20%
Lumbosacral 20%
8. Symptoms
Symptoms
Back pain is usually the first symptom
Back pain is usually the first symptom
95% of patients with a cord compression
95% of patients with a cord compression
experience back pain
experience back pain
Pain will precede other symptoms by
Pain will precede other symptoms by
weeks to months
weeks to months
Early cord compression may be
Early cord compression may be
asymptomatic
asymptomatic
12. Diagnosis
Diagnosis
Thorough physical examination
Thorough physical examination
– Palpation
Palpation
– Gentle percussion over bony areas
Gentle percussion over bony areas
– Neurologic exam
Neurologic exam
Laboratory data – Increased alkaline
Laboratory data – Increased alkaline
phosphatase may indicate bony
phosphatase may indicate bony
involvement
involvement
13. Diagnosis
Diagnosis
Radiographs- may reveal erosion of the
Radiographs- may reveal erosion of the
pedicle,
pedicle,
– Lytic lesions of the vertebral body
Lytic lesions of the vertebral body
– Collapse of the vertebral body
Collapse of the vertebral body
Bone scan- 20% of scans reveal lesions
Bone scan- 20% of scans reveal lesions
missed on plain films
missed on plain films
CT
CT
– Used to determine extent of tumor
Used to determine extent of tumor
14. Diagnosis
Diagnosis
MRI ( Tool of choice)
MRI ( Tool of choice)
– Able to determine prevertebral, vertebral,
Able to determine prevertebral, vertebral,
extradural, intradural, extramedullary and
extradural, intradural, extramedullary and
intramedullary lesions
intramedullary lesions
– Provides better anatomic visualization with
Provides better anatomic visualization with
sagittal and axial images of the spinal cord
sagittal and axial images of the spinal cord
Fine needle aspiration
Fine needle aspiration
– May provide tissue confirmation
May provide tissue confirmation
16. Treatment
Treatment
Surgery
Surgery
– Radical resection if an a candidate
Radical resection if an a candidate
– Complete block
Complete block
– Single lesion where complete removal is
Single lesion where complete removal is
possible
possible
– Diagnosis is uncertain
Diagnosis is uncertain
– Mild deficits
Mild deficits
– New data supports surgery over treatment
New data supports surgery over treatment
with RT if patient is a good surgical candidate
with RT if patient is a good surgical candidate
17. Treatment
Treatment
Radiation therapy
Radiation therapy
– If not a surgical candidate
If not a surgical candidate
– Incomplete block
Incomplete block
– Severe deficits
Severe deficits
– Relapse in area of prior radiation if short
Relapse in area of prior radiation if short
survival is expected
survival is expected
18. Treatment
Treatment
Radiation- often initiated as an emergency if
Radiation- often initiated as an emergency if
not a surgical candidate
not a surgical candidate
– Therapy
Therapy
Treatment field extends 1-2 vertebral
Treatment field extends 1-2 vertebral
bodies above and below level of
bodies above and below level of
compression
compression
3000-4000 cGy over 2-4 weeks
3000-4000 cGy over 2-4 weeks
2/3 of patients remain stable or improve
2/3 of patients remain stable or improve
65-75% achieve pain relief
65-75% achieve pain relief
19. Treatment
Treatment
Steroids
Steroids
– Dexamethasone
Dexamethasone
Bolus IV 10 mg
Bolus IV 10 mg
Oral 4-6 mg q 6 hours for 2 days then a slow taper
Oral 4-6 mg q 6 hours for 2 days then a slow taper
25% of patients with cord compression require
25% of patients with cord compression require
maintenance to maintain neurologic function
maintenance to maintain neurologic function
Steroid related side effects may occur
Steroid related side effects may occur
– Hyperglycemia
Hyperglycemia
– GI bleeding
GI bleeding
– Psychosis
Psychosis
21. Outcome
Outcome
Pretreatment ambulatory ability is the
Pretreatment ambulatory ability is the
main determinant of post treatment
main determinant of post treatment
ambulatory ability
ambulatory ability
90% of patients ambulatory before
90% of patients ambulatory before
therapy are after
therapy are after
Only 10% of paraplegics become
Only 10% of paraplegics become
ambulatory after therapy
ambulatory after therapy
22. Prognosis
Prognosis
Median survival is 6 months if patient
Median survival is 6 months if patient
presents as a paraplegic
presents as a paraplegic
50% of patients who walk in with a cord
50% of patients who walk in with a cord
compression are alive at 1 year
compression are alive at 1 year
If patient was ambulatory prior to RT
If patient was ambulatory prior to RT
survival is 8-10 months
survival is 8-10 months
23. Recurrent Disease
Recurrent Disease
Options
Options
– If RT given may be a surgical candidate
If RT given may be a surgical candidate
if survival of > 12 months predicted
if survival of > 12 months predicted
– Repeat RT
Repeat RT
Risks of repeat RT
Risks of repeat RT
–Radiation myelopathy
Radiation myelopathy
–Collateral damage
Collateral damage
24. Nursing Interventions
Nursing Interventions
Thorough assessment and early
Thorough assessment and early
MD/Provider notification of changes in
MD/Provider notification of changes in
– Pain
Pain
– Sensory function
Sensory function
– Motor function
Motor function
– Urinary function
Urinary function
– Bowel function
Bowel function
25. Nursing Interventions
Nursing Interventions
Maintenance of functional status
Maintenance of functional status
– Bowel program
Bowel program
– Bladder program
Bladder program
– Skin care
Skin care
– Rehabilitation services
Rehabilitation services
PT
PT
OT
OT
29. References
References
Schulmeister, L., Gatlin, C.,( 2008) Spinal cord
Schulmeister, L., Gatlin, C.,( 2008) Spinal cord
compression in
compression in Oncology Nursing Secrets,
Oncology Nursing Secrets,
Gates, R. and Fink, R. (eds) Hanley and Belfus,
Gates, R. and Fink, R. (eds) Hanley and Belfus,
Philadelphia, 546-550
Philadelphia, 546-550
Quinn, J., De Angelis, L.(2000) “Neurologic
Quinn, J., De Angelis, L.(2000) “Neurologic
emergencies in the cancer patient”,
emergencies in the cancer patient”, Semin
Semin
Oncol,
Oncol, 27: 311- 321
27: 311- 321
Tan, S. Recognition and Treatment of Oncologic
Tan, S. Recognition and Treatment of Oncologic
Emergencies (2002),
Emergencies (2002), Journal of Infusion
Journal of Infusion
Nursing
Nursing,25:3, 182-188
,25:3, 182-188
