Malignant Spinal Cord Compression (MSCC)
N.B. The West of Scotland guideline on MSCC is available on the WoSCAN intranet site (NHS network access required) at http://www.intranet.woscan.scot.nhs.uk/, in the Guidelines and Protocols section, then Acute Oncological Guidelines subsection.
MSCC is most common in, but not exclusive to, patients with lung cancer, breast cancer, prostate cancer and myeloma, as well as patients with known bony metastases. For patients not known to have cancer, MSCC can be the first presentation. Early identification and referral of patients with MSCC is crucial for optimal patient outcomes.
MSCC is an oncological emergency and should be suspected in any patient with a known cancer diagnosis and suggestive symptoms (as described below). It should be discussed with a Registrar immediately, and with on-call Oncology Registrar as soon as possible (see Appendix 6 for contact details of the Acute Oncology Team).
Signs and Symptoms
- Pain is usually the first presenting symptom and has often been present for a number of weeks before MSCC is diagnosed.
- Pain may be new, or may present as a significant change in the character of longstanding pain. Pain is usually in the back but can be radicular, often described as a tight band around the chest or abdomen.
- Later presenting symptoms are motor deficits (e.g. muscle weakness, loss of coordination, paralysis), sensory deficits (e.g. paraesthesia, loss of sensation) or autonomic dysfunction (bladder or bowel problems). You should always enquire about bowel and bladder dysfunction in patients presenting with leg weakness.
Assessment / Monitoring
If MSCC is suspected:
- Clinical assessment and examination, including full neurological examination and assessment for a sensory level. A spastic paraparesis is the typical finding but it is not always clear cut.
- Contact the oncall Oncology Registrar ASAP (see Appendix 6 for contact details).
- Urgent MRI of the whole spine (within 24 hours).
- Consider Neurosurgical referral (e.g. unstable or high spinal lesion, unknown primary).
- For patients without a cancer diagnosis, a biopsy is likely to be required. Tissue may be obtained at the time of surgical intervention. If the patient is for oncological treatment, then the question is whether a biopsy is performed before or after radiotherapy and this can be discussed with oncology. Chemotherapy is unlikely to be considered without tissue, unless there are tumour markers supporting a diagnosis (e.g. PSA for prostate cancer, Ig for myeloma).
- Give dexamethasone oral 8mg as a single dose as soon as MSCC is suspected, and whilst waiting for MRI, followed by dexamethasone 8mg twice daily (morning and lunchtime). Use IV route if oral contraindicated.
- Consider prophylactic gastroprotection whilst patient on high dose steroids (omeprazole oral 20mg daily or lansoprazole oral 30mg daily).
- Pain control.
- Keep flat until stability of spine is known (following MRI).
- Urgent radiotherapy (within 24 hours of MRI diagnosis), chemotherapy (and/or surgery) depending on radiosensitivity / chemosensitivity of the culprit tumour. Most common treatment is radiotherapy. Contact on-call Oncology Registrar (see Appendix 6 for contact details).
- Thromboprophylaxis (if appropriate)
When patient is stabilised:
- Physiotherapy and occupational therapy referral – on day of admission
- Palliative care referral
- Patient / care / family information and psychological care.
Guideline reviewed and content updated August 2020