malignant spinal cord compression-- dealing the most common --mets
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Maliganant Spinal CordCompression
Dr Sasikumar Sambasivam
Dept. Of Palliative Medicine
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Compressive Myelopathy
Intra medullary
Intradural
Extradural
Extramedullary
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Extramedullary Intramedullary
Motor
a)UMN signs Common Late
b)LMN signs 1or2segments at the site ofroot compression wide (Ant horn cell)
Sensory
a)Pain Root pain Funicular pain
b)Dissociated sensory loss Absent present
c)Sacral sensation Lost Preserved
d)Joint sensation Lost Late involvement
e)Lhermitte`s sign present absent
Autonomic involvement
Bowel and Bladder
Late Early
Intradural Extradural
Mode of onset Asymmetrical ,
acute,rapid
Symmetrical,slow,
progressive
Vertebral No Pain and gibbus Pain and Gibbus
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Extradural Intradural Intramedullary
SpondylosisDisc prolapse
Trauma
Tumor-Metastasis,multiple
myeloma
CVJ anomalies
FluorosisTB spine
Epidural abscess
Epidural haematoma
Tumor-NF,meningioma,lipoma,sarcoma
metastasis
Arachonoiditis
Sarcoidosis
Cervical menigitis
AVMLeukemic infiltration
Arachonoid cyst
SyrinxTumor ependymoma
astrocytoma
Haemagioblastoma
Haematomyelia
COMPRESSIVE MYELOPATHY CAUSES
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METASTASIS:
Metastasis is the most common tumor.
Epidural type of compression
Throacic is common; Lumbar&Sacral Prostate and
ovarian
Breast>Lung>Prostate>Kidney>Lymphoma>
Plasmacell dyscrasia
MRI hypodense in T1;doesnot cross the adjacent
disc space
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Site of Spinal Cord Syndrome
60-80 percent of cases occur in the thoracic
spine
15-30 percent in the lumbosacral spine
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Intradural : Benign and slow growing ; progressive compression signs
Meningioma,Neurofibroma,chordoma,lipoma
dermoid,sarcoma
MENINGIOMA: benignthrocic cord level or near foramen magnum
from arachonoid cells
forms Psammoma bodies
Radiation therapy- Gammma Knife, proton beam treatment
external beam
NEUROFIBROMA: from schwwan cells
arises near posterior root
begins with radicular symptoms
asymetric progressive spinal cord syndrome
need surgical treatment
INTRAMEDULLARY: uncommon
cervical commonly
central cord syndrome or hemicord syndrome
Ependymoma,Haemangioblastoma,secondaries
astrocytoma(lowgrade)
Microsurgical debulking can be tried
RT is not useful
Primary tumors of spinal cordcommon in cervical
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Spinal Cord Syndrome
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Spinal Cord Syndrome
Making the diagnosis early
Imaging studies
Conventional Therapy
Radiation approaches
Surgical techniques
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Compression of the spinal cord is due
predominantly to extradural metastases
(95%) and usually results from tumorinvolvement of the vertebral column. A
tumor may occasionally metastasize to
the epidural space without bony
involvement.
Metastatic spinal cord compression
affects 5 to 14% of all cancer patients.
Although spinal cord compression
occurs in a variety of malignancies, the
most common are lung, breast,
unknown primary, prostate, and renalcancers, as well as lymphoma and
myeloma.
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Symptoms of Spinal Cord Syndrome
Pain
Motor
Sensory Autonomic
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Painusually the first symptom being present in 83 to 95 percent of
patients at the time of diagnosis.
On average, pain precedes other neurologic symptoms of ESCC by
seven weeks.
Affected patients usually notice a severe local back pain which
progressively increases in intensity.
Pain is often worse with recumbency, a feature attributed to distension
of the epidural venous plexus.
Over time, the pain may develop a radicular quality.
Radicular pain is more common in lumbosacral lesions than thoracic
lesions.
Thoracic radicular pain is commonly bilateral and wraps around
anteriorly in a band like fashion.
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Odds of finding epidural metastases based onsymptoms in patients with bone metastases in spine
myelopathy 78%
radicular pain 61%
back pain 36%
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Motor findingsWeakness is present in 60 to
85 percent of patients.
o When the lesion is at or above the conus
medullaris, weakness is from corticospinal
dysfunction and has the typical pyramidal
pattern, preferentially affecting the flexors in
the lower extremities and,
o if above the thoracic spine, the extensors ofthe upper extremities.
o Hyperreflexia below the level of the
compression and extensor plantar responses
may be seen.
o The progression of motor findings untildiagnosis typically consists of increasing
weakness followed sequentially by loss of
gait function and paralysis
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Sensory findingsSensory findings
are a little less common than motor
findings but are still present in a
majority of patients at diagnosis.
Patients frequently report ascending
numbness and paresthesias .
When a spinal sensory level is present,
it is typically one to five levels belowthe actual level of cord compression.
Saddle sensory loss is commonly
present in cauda equina lesions, while
lesions above the cauda equinafrequently result in sparing of sacral
dermatomes to pinprick.
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Loss of bladder and bowel functionBladder and bowel dysfunction due to ESCC is
generally a late finding that may be present in as many as one-half of patients. The
autonomic neuropathy most commonly presents as urinary retention and is rarely the
sole symptom of ESCC
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The median delay to treatment in those with
known malignancy was two months from the
onset of back pain and ten days from the onsetof symptoms of spinal cord compression
Most importantly, the majority of patients
deteriorated by at least one grade in motor or
bladder function during the delay from initialsymptoms of ESCC. The net effect of delayed
recognition and therapy is that the majority of
patients with ESCC are not ambulatory at
diagnosis
Even in recent series, between 48 and 77
percent of patients with newly diagnosed
ESCC are non-ambulatory
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RadiographyPlain spinal radiographs in a cancer patient with back pain,
either major vertebral body collapse or pedicle erosion with a matching
radiculopathy predicts a 75 to 83 percent chance of ESCC when a definitive
study is performed .
False negativeplain spinal radiographs --10 to 17percent of patients.
Three factors are primarily responsible for the false negative results: 50 percent
of bone must be destroyed before a radiograph becomes abnormal; metastatic
involvement of multiple vertebrae may obscure the clinically relevant lesion;
and paraspinal tumor invading through the neural foramen may produce noradiographic abnormality.
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MRI
BONE SCAN
PET SCAN
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Estimated Life Expectancy
Median Survival , n= 1,157, radiation for painful bone mets
breast cancer 16 months(14.2 to 18.5 months)
prostate cancer 9.5 months (7.8 to 11 months)
lung
cancer 3.2 months (2.8 to 3.5 months)
One criterion to consider a patient eligible forsurgery isan expected
survival of at least 3 months. Forradiotherapy,a minimum life
expectancy of at least a month is consideredappropriate since most
beneficial effects are expected to occurafter 3 to 4 weeks.
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Survival is based on several considerations:
- responders live longer (9.5 months versus 2 months)
- ambulatory patients live longer than paralyzed (10 monthsversus 1 month)
-favorable histologies (myeloma, breast, lymphoma) live
longer than other types (12 months versus 4 months)
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Early Detection Inform patients at high risk of developing bone
metastases
Ensure that patients with MSCC and their families andcarers know who to contact if their symptoms progresswhile they are waiting for urgent investigation of
suspected compression.
MRI investigation of choice, CT Scan with 3Dreconstruction for spinal stability.
No role of routine MRI in asymptomatic pts.
Bone scan to rule out other sites of mets
f i l d
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Treatment of spinal metastases and MSCC Treatment is primarily to relieve pain and/or preventvertebral collapse and spinal cord compression.
Definitive treatment of bony instability and/orneurological disability.
Surgery is increasingly the treatment of choice forpatients with MSCC, but the two aims of preserving
neurological function and also achieving spinalcolumn reconstruction that will remain stable duringthe patients remaining life, are not alwaysattainable.
It is important to remember that:
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It is important to remember that:
MSCC is only one manifestation of the underlying malignant diseasewhich itself may need speficic treatment by the primary tumour site
specialist-- ongologist or haemotologist.
The majority of patients with MSCC have metastases in other bonysites or viscera.
Even when a solitary metastasis has progressed to the point thatMSCC has developed, it is unlikely that extralesional excision willeradicate the cancer.
Only about 20% of patients with MSCC will survive more than a year.
Treatment of MSCC is primarily to improve the quality of remaininglife in most cases.
Some epidural tumours (including haemotological malignancies)respond to treatments other than surgery or require only limitedsurgery.
Treatment planning must therefore take account of:
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Treatment planning must therefore take account of: the degree of neurological disability
the general health of the patient
the primary site of tumour
the presence of other spinal and extraspinal metastases the likely response of the tumour to radiotherapy or other adjuvant
therapy.
All of these factors as well as the likely time taken to be treated
and rehabilitated must be balanced against the likelihood of agood functional outcome and long-term survival.
There are some patients who are too unwell for anyintervention and will be given supportive care only.
Surgical procedures need proper patient selection and the bestsuited surgical procedure
Treatment for painful spinal metastases
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Treatment for painful spinal metastases
and prevention of MSCC
Ideally all patients with MSCC should be fully staged beforesurgery but if spinal cord function is deteriorating rapidlythis may not be possible.
Non-mechanical pain -non-invasive methods--analgesics,radiotherapy, drugs including bisphosphonates, andoccasionally chemotherapy as part of the generaltreatment of chemosensitive disease.(Some pts only)
Mechanical painspine support---corsets or braces for thetrunk, and collars or halo jackets.
Internal supportvertebroplasty, kyphoplasty
Treatments
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Bisphosphonates: (Level 1 Evidence)
Offer patients with vertebral involvement from
myeloma or breast cancer bisphosphonates to
reduce pain and the risk of vertebral
fracture/collapse
Offer patients with vertebral metastases fromprostate cancer bisphosphonates to reduce pain
only if conventional analgesia fails to control pain.
Should not be used to treat spinal pain in patientswith other than myeloma, breast cancer or
prostate cancer (if conventional analgesia fails) or
with the intention of preventing MSCC, except as
part of a randomised controlled trial.
Treatments
for painful
spinal
metastases
and
preventionof MSCC
R di th (L l 1)Treatments
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Radiotherapy (Level 1)
30Gy/10 fr; 20Gy/5 fr; 8 Gy /1fr based
on the performace scale.
No role of Prophylactic RT.
for painful
spinal
metastases
and
preventionof MSCC
Vertebroplasty and kyphoplastyTreatments
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Vertebroplasty and kyphoplasty
Consider for patients who have vertebral metastases and no
evidence of compression or spinal instability if they have:
mechanical pain resistant to conventional analgesia, or
vertebral body collapse.
Vertebroplasty or kyphoplasty for spinal metastases should onlybe performed after agreement between appropriate specialists.
There is no health economic evidence regarding vertebroplasty
and kyphoplasty for their use in pain control.
However, there is evidence of cost effectiveness for
vertebroplasty as a definitive treatment for MSCC.
for painful
spinal
metastases
and
preventionof MSCC
Surgery Treatments
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Surgery
Urgent consideration in -- spinal metastases and imaging
evidence of structural spinal failure
If mechanical pain is resistant to conventional analgesia ---
stabilisation surgery even if completely paralysed.
Pts with severe mechanical pain and/or imaging evidence
of spinal instability, but who are unsuitable for surgery are
considered for external spinal support (for example, a halo
vest or cervico-thoraco-lumbar orthosis).
Pts without pain or instability should not be offered
surgery
for painful
spinal
metastases
and
preventionof MSCC
f
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Care of the threatened spinal cord in
patients with MSCC
Immobilisation:
Nursed with flat with neutral spinealignment
close monitoring and intervalassessment during gradual sittingfrom supine to 60 degrees over aperiod of 34 hours.
continue to unsupported sitting ifBP is stable
C ti t idCare of the
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Corticosteroids
Believed to reduce tumour bulk or spinal cord
swelling, relieve spinal cord pressure and improvetreatment outcomes.
Rapid improvement of neurological function butlong term benefit is limited, and there is no
evidence that survival is improved.
Significant side effects on longterm use hencedefinitive therapy.
Loading dose of at least 16 mg of dexamethasoneas soon as possible after assessment, followed bya short course of 16 mg dexamethasone dailywhile treatment is being planned.
threatened
spinal cord
in patients
with MSCC
C ti d th 16 d il iCare of the
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Continue dexamethasone 16 mg daily inpatients awaiting surgery or radiotherapy
After surgery or the start of radiotherapythe dose should be reduced graduallyover 57 days and stopped.
If neurological function deteriorates atany time the dose should be increasedtemporarily.
If no treatment is planned , taper thedose gradually.
Monitor Blood glucose
threatened
spinal cord in
patients with
MSCC
-Corticosteroids
C l i f d fi i i
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Case selection for definitive treatment
Start before any further neurological deterioration
and ideally within 24 hours
establish the primary histology of spinal metastases(by tumour biopsy, if necessary)
Stage the tumours to determine the number,anatomical sites and extent of spinal and visceral
metastases.
Age but PS is an independent predictor of outcome
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Summary of prognostic indicators
Good prognosis Breast cancer as the
primary site
Solitary or few spinalmetastases
Absence of visceralmetastases
Ability to walk aided orunaided
Minimal neurologicalimpairment
No previous radiotherapy.
Poor prognosis Lung or melanoma
primary
Multiple spinal
metastases Visceral metastases
Unable to walk
Severe weakness
Recurrence afterradiotherapy.
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Surgery for the definitive treatment
If surgery is appropriate, attempt to
achieve both spinal corddecompression and durable spinalcolumn stability.
Options: decompression and the spinal column is
stabilised by rods connected to pediclescrews in the healthy vertebra above andbelow the diseased level with or withoutpostero- lateral inter-transverse grafts.
Alternatively, or additionally, the diseasedvertebral body can be resected andreplaced with bone graft and/or metalcages or cement
Surgery for the
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Neurological ability and timing:
Surgery done-- before they lose the ability to walk.
Residual distal sensory or motor function and a
good prognosis --offered surgery in an attempt to
recover useful function, regardless of their ability towalk.
completely paraplegic or tetraplegic for more than
24 hours --should only be offered surgery if spinalstabilisation is required for pain relief
definitive
treatment
Posterior decompression alone should not bef d i i i h MSCC i h
Surgery for the
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performed in patients with MSCC except in therare circumstances of isolated epidural tumouror neural arch metastases without bonyinstability.
Vertebral inv. Or threatened spinal stability,consider posterior decompression withinternal fixation with or without bone grafting.
Consider vertebral body reinforcement withcement for patients with MSCC and vertebralbody involvement who are suitable forinstrumented decompression and lifeexpectancy < 1 yr
Consider vertebral body reconstruction withanterior bone graft for patients with MSCC andvertebral body involvement who are suitablefor instrumented decompression, if life expect>1 yr
definitive
treatment-
Recommendations
Radiotherapy for the definitive treatment
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Radiotherapy for the definitive treatment
Ensure urgent (within 24 hours) access to and availability of
radiotherapy.
Offer fractionated radiotherapy as the definitive treatment ofchoice to patients with epidural tumour without neurologicalimpairment, mechanical pain or spinal instability.
Fractionatedgood prognosis who are having radiotherapy astheir first-line treatment
No role of preop RT if surgery is planned
Postop RT recommended for better outcome
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Offer urgent radiotherapy (within 24 hours) to
all patients with MSCC who are not suitable
for spinal surgery unless:
they have had complete tetraplegia or
paraplegia for more than 24 hours and their
pain is well controlled; or
their overall prognosis is judged to be too poor
Recent Advances in
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Recent Advances in
relation to RT Improving radiation
technology from radiumand cobalt to imageguided IMRT /Tomotherapy andstereotactic radiosurgery(Cyberknife)
Health economic evaluation
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Health economic evaluation
Consider further radiotherapy or surgery for patients who have
responded well to previous radiotherapy and develop recurrentsymptoms after at least 3 months.
If patients have further radiotherapy, the total dose should be
below a biologically equivalent dose of 100 Gy where possible.
Discuss the possible benefits and risks with the patient before
agreeing a treatment plan.
Further research is required into the tolerance of the spinal cord
to radiation damage and its ability to recover and tolerate
repeated courses.
S ti d h bilit ti
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Supportive care and rehabilitation
Bed rest--thigh-length graduated
compression/anti-embolism stockings unless
contra-indicated
high risk of venous thromboembolismlow
molecular weight heparin + mechanical
thromboprophylaxis
Supportive care
d
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Management of
pressure ulcers
Bladder and bowel
continence
management
Maintainingcirculatory and
respiratory functioning
Access to specialistrehabilitation and
transition to care at
home
and
rehabilitation
Tokuhashi scoring system: A revised scoring system for
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Tokuhashi scoring system: A revised scoring system for
preoperative evaluation of metastatic spine tumor prognosis
Spine 2005, 30 (19), 21862191
General condition (performance status) Poor (PS 1040%) 0
Moderate (PS 5070%)1
Good (PS 80100%)2
Number of extraspinal bone metastases foci
3 0
1-2 1
0 2
Number of metastases in the vertebral body
3 0
2 1
1 2
Metastases to the major internal organs
Unremovable 0
Removable 1
No metastases 2
Primary site of the cancer Lung, osteosarcoma, stomach, bladder,
esophagus, pancreas 0
Liver, gall bladder, unidentified 1
Others 2
Kidney, uterus 3
Rectum
4 Thyroid, breast, prostate, carcinoid tumor
5
Palsy
Complete (Frankel A, B)0
Incomplete (Frankel C, D)1
None (Frankel E) 2
Criteria of predicted prognosis:
Total Score (TS) 08 < 6 months,
TS 911 6 months,
TS 1215 1 year
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Thank you.