Malignant Spinal Cord Compression(Metstatic aspects in detail)

1. Maliganant Spinal Cord
Compression
Dr Sasikumar Sambasivam
Dept. Of Palliative Medicine

2. Intra medullary
Intradural
Extramedullary
Extradural
Compressive Myelopathy
Compressive Myelopathy

3. Extramedullary
Intramedullary
a)UMN signs
Common
Late
b)LMN signs
1or2segments at the site of wide (Ant horn cell)
root compression
Motor
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

4. COMPRESSIVE MYELOPATHY – CAUSES
Extradural
Intradural
Intramedullary
Spondylosis
Disc prolapse
Trauma
Tumor-Metastasis,multiple
myeloma
CVJ anomalies
Fluorosis
TB spine
Epidural abscess
Epidural haematoma
Tumor-NF,meningioma,
lipoma,sarcoma
metastasis
Arachonoiditis
Sarcoidosis
Cervical menigitis
AVM
Leukemic infiltration
Arachonoid cyst
Syrinx
Tumor – ependymoma
astrocytoma
Haemagioblastoma
Haematomyelia

5. 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

6. Site of Spinal Cord Syndrome
<10 percent in the cervical spine
60-80 percent of cases occur in the thoracic
spine
15-30 percent in the lumbosacral spine

7. Primary tumors of spinal cord common in cervical
Intradural : Benign and slow growing ; progressive compression signs
Meningioma,Neurofibroma,chordoma,lipoma
dermoid,sarcoma
MENINGIOMA: benign
throcic 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

8. Spinal Cord Syndrome

9. Spinal Cord Syndrome
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Making the diagnosis early
Imaging studies
Conventional Therapy
Radiation approaches
Surgical techniques

10. Compression of the spinal cord is due
predominantly to extradural metastases
(95%) and usually results from tumor
involvement 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 renal
cancers, as well as lymphoma and
myeloma.

14. Symptoms of Spinal Cord Syndrome
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•
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•
Pain
Motor
Sensory
Autonomic

15.  Pain — usually 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.

16. Odds of finding epidural metastases based on
symptoms in patients with bone metastases in spine
myelopathy
78%
radicular pain
61%
back pain
36%

17. Motor findings — Weakness is present in 60 to
85 percent of patients.
oWhen 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 of
the upper extremities.
o Hyperreflexia below the level of the
compression and extensor plantar responses may
be seen.
oThe progression of motor findings until
diagnosis typically consists of increasing
weakness followed sequentially by loss of gait
function and paralysis

18. Sensory findings — Sensory 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 below
the actual level of cord compression.
Saddle sensory loss is commonly
present in cauda equina lesions, while
lesions above the cauda equina
frequently result in sparing of sacral
dermatomes to pinprick.

19. Loss of bladder and bowel function — Bladder 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

20. The median delay to treatment in those with
known malignancy was two months from the
onset of back pain and ten days from the onset
of 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 initial
symptoms 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

21. Radiography — Plain 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 negative plain spinal radiographs --10 to 17 percent 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 no
radiographic abnormality.

22. MRI
BONE SCAN
PET SCAN

30. Estimated Life Expectancy
Median Survival , n= 1,157, radiation for painful bone mets
breast cancer
prostate cancer
lung cancer
16 months (14.2 to 18.5 months)
9.5 months (7.8 to 11 months)
3.2 months (2.8 to 3.5 months)
One criterion to consider a patient eligible for surgery is an expected
survival of at least 3 months. For radiotherapy, a minimum life
expectancy of at least a month is considered appropriate since most
beneficial effects are expected to occur after 3 to 4 weeks.

31. Survival is based on several considerations:
- responders live longer (9.5 months versus 2 months)
- ambulatory patients live longer than paralyzed (10 months
versus 1 month)
-favorable histologies (myeloma, breast, lymphoma) live
longer than other types (12 months versus 4 months)

36. Early Detection
• Inform patients at high risk of developing bone
metastases
• Ensure that patients with MSCC and their families and
carers know who to contact if their symptoms progress
while they are waiting for urgent investigation of
suspected compression.
• MRI investigation of choice, CT Scan with 3D
reconstruction for spinal stability.
• No role of routine MRI in asymptomatic pts.
• Bone scan to rule out other sites of mets

37. Treatment of spinal metastases and MSCC
• Treatment is primarily to relieve pain and/or prevent
vertebral collapse and spinal cord compression.
• Definitive treatment of bony instability and/or
neurological disability.
•Surgery is increasingly the treatment of choice for
patients with MSCC, but the two aims of preserving
neurological function and also achieving spinal column
reconstruction that will remain stable during the
patient’s remaining life, are not always attainable.

38. • It is important to remember that:
– MSCC is only one manifestation of the underlying malignant disease
which itself may need speficic treatment by the primary tumour site
specialist-- ongologist or haemotologist.
– The majority of patients with MSCC have metastases in other bony
sites or viscera.
– Even when a solitary metastasis has progressed to the point that
MSCC has developed, it is unlikely that extralesional excision will
eradicate 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 remaining
life in most cases.
– Some epidural tumours (including haemotological malignancies)
respond to treatments other than surgery or require only limited

39. • 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 a good functional outcome and long-term
survival.
• There are some patients who are too unwell for any
intervention and will be given supportive care only.
• Surgical procedures need proper patient selection and the best
suited surgical procedure

40. Treatment for painful spinal metastases
and prevention of MSCC
• Ideally all patients with MSCC should be fully staged
before surgery but if spinal cord function is deteriorating
rapidly this may not be possible.
• Non-mechanical pain -non-invasive methods--analgesics,
radiotherapy, drugs including bisphosphonates, and
occasionally chemotherapy as part of the general
treatment of chemosensitive disease.(Some pts only)
• Mechanical pain—spine support---corsets or braces for the
trunk, and collars or halo jackets.
• Internal support—vertebroplasty, kyphoplasty

41. • 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 from
prostate cancer bisphosphonates to reduce pain
only if conventional analgesia fails to control pain.
 Should not be used to treat spinal pain in patients
with 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
prevention
of MSCC

42. Radiotherapy (Level 1)
•30Gy/10 fr; 20Gy/5 fr; 8 Gy /1fr– based
on the performace scale.
•No role of Prophylactic RT.
Treatments
for painful
spinal
metastases
and
prevention
of MSCC

43. Treatments
for painful
spinal
Consider for patients who have vertebral metastases and no metastases
and
evidence of compression or spinal instability if they have: prevention
of MSCC
− mechanical pain resistant to conventional analgesia, or
Vertebroplasty and kyphoplasty
•
− vertebral body collapse.
• Vertebroplasty or kyphoplasty for spinal metastases should only
be 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.

44. 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
Treatments
for painful
spinal
metastases
and
prevention
of MSCC

45. Care of the threatened spinal cord in
patients with MSCC
• Immobilisation:
• Nursed with flat with neutral spine
alignment
• close monitoring and interval
assessment during gradual sitting
from supine to 60 degrees over a
period of 3–4 hours.
• continue to unsupported sitting– if
BP is stable

46. Corticosteroids
• Believed to reduce tumour bulk or spinal cord
swelling, relieve spinal cord pressure and improve
treatment outcomes.
• Rapid improvement of neurological function but
long term benefit is limited, and there is no
evidence that survival is improved.
• Significant side effects on longterm use… hence
definitive therapy.
• Loading dose of at least 16 mg of dexamethasone
as soon as possible after assessment, followed by
a short course of 16 mg dexamethasone daily
while treatment is being planned.
Care of the
threatened
spinal cord
in patients
with MSCC

47. • Continue dexamethasone 16 mg daily in
patients awaiting surgery or radiotherapy
• After surgery or the start of radiotherapy
the dose should be reduced gradually
over 5–7 days and stopped.
• If neurological function deteriorates at
any time the dose should be increased
temporarily.
• If no treatment is planned , taper the
dose gradually.
• Monitor Blood glucose
Care of the
threatened
spinal cord in
patients with
MSCC
-Corticosteroids

48. 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

49. Summary of prognostic indicators
• Good prognosis
• Breast cancer as the
primary site
• Solitary or few spinal
metastases
• Absence of visceral
metastases
• Ability to walk aided or
unaided
• Minimal neurological
impairment
• No previous
radiotherapy.
• Poor prognosis
• Lung or melanoma
primary
• Multiple spinal
metastases
• Visceral metastases
• Unable to walk
• Severe weakness
• Recurrence after
radiotherapy.

50. Surgery for the definitive treatment
• If surgery is appropriate, attempt to
achieve both spinal cord
decompression and durable spinal
column stability.
• Options:
– decompression and the spinal column is
stabilised by rods connected to pedicle
screws in the healthy vertebra above and
below the diseased level with or without
postero- lateral inter-transverse grafts.
– Alternatively, or additionally, the
diseased vertebral body can be resected
and replaced with bone graft and/or
metal cages or cement

51. • 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
to walk.
• completely paraplegic or tetraplegic for more than
24 hours --should only be offered surgery if spinal
stabilisation is required for pain relief
Surgery for the
definitive
treatment

52. • Posterior decompression alone should not be
performed in patients with MSCC except in the
rare circumstances of isolated epidural tumour
or neural arch metastases without bony
instability.
• Vertebral inv. Or threatened spinal stability,
consider posterior decompression with
internal fixation with or without bone grafting.
• Consider vertebral body reinforcement with
cement for patients with MSCC and vertebral
body involvement who are suitable for
instrumented decompression and life
expectancy < 1 yr
• Consider vertebral body reconstruction with
anterior bone graft for patients with MSCC and
vertebral body involvement who are suitable
for instrumented decompression, if life expect
>1 yr
Surgery for the
definitive
treatmentRecommendations

53. Radiotherapy for the definitive treatment
• Ensure urgent (within 24 hours) access to and availability of
radiotherapy.
• Offer fractionated radiotherapy as the definitive treatment of
choice to patients with epidural tumour without neurological
impairment, mechanical pain or spinal instability.
• Fractionated—good prognosis who are having radiotherapy
as their first-line treatment
• No role of preop RT if surgery is planned
• Postop RT recommended for better outcome

54. • 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

55. Recent Advances in
relation to RT
• Improving radiation
technology from radium
and cobalt to image
guided IMRT /
Tomotherapy and
stereotactic radiosurgery
(Cyberknife)

56. Health economic evaluation
• Consider further radiotherapy or surgery for patients who have
responded well to previous radiotherapy and develop recurrent
symptoms 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.

57. Supportive care and rehabilitation
• Bed rest--thigh-length graduated
compression/anti-embolism stockings unless
contra-indicated
• high risk of venous thromboembolism—low
molecular weight heparin + mechanical
thromboprophylaxis

58. • Management of
pressure ulcers
• Bladder and bowel
continence
management
• Maintaining
circulatory and
respiratory functioning
• Access to specialist
rehabilitation and
transition to care at
home
Supportive care
and
rehabilitation

59. Tokuhashi scoring system: A revised scoring system for
preoperative evaluation of metastatic spine tumor prognosis
Spine 2005, 30 (19), 2186–2191
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General condition (performance status)
Poor (PS 10–40%)
0
Moderate (PS 50–70%)
1
Good (PS 80–100%)
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
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•
•
•
•
•
•
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•
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) 0–8
< 6 months,
TS 9–11
≥ 6 months,
TS 12–15
≥ 1 year

60. Thank you.