# CIM Case: Spinal Cord Compression - Oncology ## Clinical Scenario **Patient:** 68-year-old man **Presentation:** 2-week history of progressive back pain, 3-day history of bilateral leg weakness, urinary hesitancy since yesterday **Relevant history:** Metastatic prostate carcinoma diagnosed 3 years ago (hormone-sensitive initially, now castration-resistant), known bone metastases (ribs, pelvis), recent PSA rise from 4 to 85 ng/mL, back pain worsening despite analgesia, weight loss 6kg over 2 months **Examination findings:** - Pain score 8/10, pain with percussion over T8-T10 - Bilateral lower limb weakness (MRC grade 3/5 hip flexion, 4/5 knee extension) - Brisk knee and ankle reflexes bilaterally - Upgoing plantars bilaterally (Babinski positive) - Sensory level at T10 (reduced pinprick and light touch below) - Distended bladder (1200mL on catheterisation) - Anal tone reduced - Upper limb neurologically normal - Mild hypotension (BP 105/65) --- ## Investigations Provided ### Laboratory Results | Test | Result | Normal Range | Interpretation | |------|--------|--------------|----------------| | Hb | 102 g/L | 130-170 g/L | ↓ Anaemia of chronic disease | | WCC | 8.5 ×10⁹/L | 4-11 ×10⁹/L | Normal | | Platelets | 195 ×10⁹/L | 150-400 ×10⁹/L | Normal | | CRP | 45 mg/L | <5 mg/L | ↑ Elevated | | ESR | 65 mm/hr | <20 mm/hr | ↑ Elevated | | PSA | 85 ng/mL | <4 ng/mL | ↑↑ Markedly elevated | | ALP | 380 U/L | 30-120 U/L | ↑ Elevated (bone turnover) | | Calcium | 2.65 mmol/L | 2.2-2.6 mmol/L | ↑ Mildly elevated | | Albumin | 32 g/L | 35-50 g/L | ↓ Low | | Creatinine | 118 μmol/L | 60-110 μmol/L | ↑ Mildly elevated | ### Imaging **Image 1: MRI Whole Spine with Contrast** **Findings:** - T9 vertebral body: near-complete replacement with tumour - Posterior cortex breached with epidural extension - Spinal cord compression at T9 level (>50% canal compromise) - Cord signal change (oedema visible on T2) - Additional vertebral body metastases at T4, L2, L4 (no cord compression) - Paraspinal soft tissue mass at T9 - No intraspinal haematoma **Image 2: CT Thorax/Abdomen/Pelvis** **Findings:** - Multiple blastic and mixed bone metastases (typical prostate pattern) - No visceral metastases - Moderate prostatic enlargement - No lymphadenopathy - No lung metastases --- ## Questions & Model Answers **Diagnosis: Metastatic Spinal Cord Compression (MSCC) at T9** Secondary to metastatic prostate carcinoma (castration-resistant) **This is an ONCOLOGICAL/SURGICAL EMERGENCY:** | Clinical Feature | Significance | |------------------|--------------| | Bilateral leg weakness | Upper motor neuron signs = cord compression | | Sensory level at T10 | Localises level of compression | | Urinary retention | Bladder dysfunction = poor prognostic sign | | Reduced anal tone | Cauda/conus involvement | | Upgoing plantars | Confirms cord involvement | **Urgency Timeline:** | Time Frame | Significance | |------------|--------------| | <24 hours | Treatment within 24 hours gives best neurological outcome | | <48 hours | Still reasonable outcomes if some function preserved | | >48 hours | Irreversible damage likely if complete paralysis | **Key Principle:** Neurological status at time of treatment is the strongest predictor of outcome. Patients who are ambulatory have 80-90% chance of remaining ambulatory; those paraplegic have <30% chance of walking again. > **Consultant Tip:** MSCC is an emergency. The patient who can walk pre-treatment will likely walk post-treatment. The paraplegic patient rarely regains function. Treat URGENTLY. **SINS Score (Spinal Instability Neoplastic Score):** | Component | Options | Score | This Patient | |-----------|---------|-------|--------------| | **Location** | Junctional (0-3, C2, C7-T2, T11-L1, L5-S1) = 3; Mobile (C3-6, L2-4) = 2; Semi-rigid (T3-10) = 1; Rigid (S2-5) = 0 | 1 | T9 (semi-rigid) = 1 | | **Pain** | Mechanical = 3; Non-mechanical = 1; None = 0 | 3 | Mechanical (worse with movement) = 3 | | **Lesion type** | Lytic = 2; Mixed = 1; Blastic = 0 | 1 | Mixed = 1 | | **Alignment** | Subluxation = 4; Kyphosis/scoliosis = 2; Normal = 0 | 0 | Normal = 0 | | **Vertebral body collapse** | >50% = 3; <50% = 2; None = 1; None but >50% involved = 1 | 2 | <50% collapse = 2 | | **Posterolateral involvement** | Bilateral = 3; Unilateral = 1; None = 0 | 1 | Unilateral = 1 | **SINS Total: 8 (Indeterminate - surgical consultation recommended)** - 0-6: Stable - 7-12: Indeterminate (surgical consultation) - 13-18: Unstable (surgical stabilisation recommended) **Tokuhashi Score (Survival Prediction):** | Component | Score | This Patient | |-----------|-------|--------------| | General condition (Karnofsky) | Poor=0, Moderate=1, Good=2 | 1 (moderate) | | Extraspinal bone metastases | ≥3=0, 1-2=1, 0=2 | 0 (multiple) | | Visceral metastases | Unresectable=0, Resectable=1, None=2 | 2 (none) | | Primary site | Lung/stomach=0; Kidney/liver/uterus=1; Others=2; Thyroid/prostate=3; Breast/rectum=4; Kidney/slow-growing=5 | 3 (prostate) | | Neurological status | Complete=0; Incomplete=1; None=2 | 1 (incomplete) | | Spinal metastases | ≥3=0, 2=1, 1=2 | 0 (4 levels involved) | **Tokuhashi Total: 7** - 0-8: Predicted survival <6 months (conservative or palliative surgery) - 9-11: Predicted survival 6-12 months (consider palliative surgery) - 12-15: Predicted survival >12 months (consider excisional surgery) > **Consultant Tip:** SINS tells you about stability (need for surgery). Tokuhashi tells you about survival (extent of surgery). Both guide the MDT discussion. **Immediate Management (Within First Hour):** **Step 1: High-Dose Corticosteroids** | Regimen | Dose | Purpose | |---------|------|---------| | **Dexamethasone loading** | 16mg IV stat | Reduce cord oedema | | **Maintenance** | 4mg IV/PO QID | Continue until surgery or RT | | **Gastroprotection** | Pantoprazole 40mg daily | Prevent stress ulcer | **Step 2: Analgesia** - Opioid analgesia (morphine titrated) - Avoid NSAIDs initially (bleeding risk if surgery) - Consider neuropathic agents (gabapentin) **Step 3: Urgent Referrals** | Specialty | Purpose | |-----------|---------| | Spinal Surgery | Assessment for decompression ± stabilisation | | Radiation Oncology | Planning for radiotherapy | | Medical Oncology | Systemic treatment options | | Urology | Prostate cancer management input | | Palliative Care | Symptom management, goals of care | **Step 4: Nursing Care** - Catheterise (already done - 1200mL) - Pressure area care - DVT prophylaxis (mechanical initially) - Bowel care (aperients) **Step 5: Imaging Review** - Ensure whole spine MRI (done) - CT for surgical planning if surgery considered > **Consultant Tip:** Dexamethasone is the single most important immediate intervention. Start it NOW while arranging definitive treatment. **Treatment Options:** | Option | Indication | Technique | |--------|------------|-----------| | **Surgery + post-op RT** | Single/dominant level, unstable (SINS ≥13), neurological deterioration, radioresistant tumour, histological diagnosis needed | Decompression ± stabilisation, followed by RT | | **Radiotherapy alone** | Multiple levels, stable spine, radiosensitive tumour, poor prognosis, medically unfit | External beam RT (20-30 Gy) | | **Best supportive care** | Very poor prognosis (<3 months), complete paraplegia >48h, patient preference | Steroids, analgesia, comfort care | **Patchell Trial Evidence (2005):** - Surgery + RT vs RT alone for single-level MSCC - Surgery group: 84% ambulatory vs 57% (RT alone) - Maintained ambulation longer (122 vs 13 days) - Surgery favoured for appropriate candidates **Surgical Options:** | Approach | Indication | |----------|------------| | **Posterior decompression + stabilisation** | Most common; laminectomy with pedicle screw fixation | | **Anterior corpectomy + reconstruction** | Predominantly anterior compression, good prognosis | | **Combined (staged)** | Circumferential disease, need for complete excision | | **Separation surgery** | Create space between tumour and cord for stereotactic RT | **For This Patient:** - Single dominant level (T9) with significant cord compression - Incomplete neurological deficit (some function preserved) - SINS 8 (indeterminate) but progressing - Tokuhashi 7 (poor prognosis, but still ambulatory potential) - **Recommendation: Posterior decompression + stabilisation + post-operative radiotherapy** > **Consultant Tip:** The goal is to maintain or restore ambulation and continence. Even in patients with limited survival, maintaining independence is invaluable for quality of life. **Posterior Decompression and Stabilisation:** **Positioning:** - Prone on Jackson frame or bolsters - Minimise abdominal pressure (reduces bleeding) - Arms abducted, head neutral - Neuromonitoring in place (SSEPs, MEPs) **Surgical Steps:** | Step | Technique | |------|-----------| | 1 | Midline incision centred on affected level (extend 2 levels above/below) | | 2 | Subperiosteal dissection to expose posterior elements | | 3 | Identify levels with fluoroscopy | | 4 | Place pedicle screws at least 2 levels above and 2 below (4-6 screws each side) | | 5 | Decompressive laminectomy at affected level(s) | | 6 | Carefully remove tumour compressing dura (aim for circumferential decompression) | | 7 | Send tumour for histology (confirms diagnosis) | | 8 | Contour and place rods | | 9 | Consider crosslink for stability | | 10 | Assess spinal cord (pulsatility indicates decompression) | | 11 | Haemostasis, drain, layered closure | **Intraoperative Considerations:** - Tumour may be vascular (embolisation considered for renal/thyroid primaries) - Blood products available (cross-match 4 units) - Cell saver may be used (controversial in oncology) - Do NOT sacrifice nerve roots unless necessary **Instrumentation Principles:** - Minimum 2 levels above and below (more if bone quality poor) - Consider cement augmentation of screws (PMMA or calcium phosphate) - Avoid ending construct at junctional levels (T12-L1) > **Consultant Tip:** The goal is circumferential decompression of the cord. You don't need to remove all tumour - just enough to decompress the neural elements and stabilise the spine. **Prognostic Factors for Neurological Recovery:** | Factor | Better Outcome | Worse Outcome | |--------|----------------|---------------| | **Pre-treatment neurological status** | Ambulatory | Non-ambulatory | | **Speed of onset** | Gradual (days-weeks) | Rapid (<24-48 hours) | | **Duration of deficit** | <24-48 hours | >48 hours | | **Radiosensitivity** | Prostate, breast, myeloma | Renal, melanoma, lung | | **Number of levels** | Single level | Multiple levels | | **Degree of cord compression** | Partial | Complete block | | **Sphincter function** | Preserved | Lost | **Neurological Outcomes by Pre-treatment Status:** | Pre-treatment Status | Post-treatment Ambulation Rate | |----------------------|--------------------------------| | Ambulatory | 80-90% | | Paraparetic (some power) | 50-60% | | Paraplegic (<48 hours) | 10-30% | | Paraplegic (>48 hours) | <5% | **This Patient's Prognosis:** - Incomplete deficit (grade 3-4/5 power) = still has function - Urinary retention = concerning but may recover - Prostate cancer = radiosensitive - If treated urgently, reasonable chance of maintaining/improving function **Long-term Outcomes:** - Local control with surgery + RT: 70-80% - Median survival for prostate with MSCC: 9-12 months - Pain relief achieved in 80-90% > **Consultant Tip:** Pre-treatment neurological status is the single most important predictor. A patient who comes in walking has excellent prognosis. A paraplegic patient rarely walks again. Treat emergently while function remains. --- ## Key Teaching Points ### Pattern Recognition **This pattern suggests Metastatic Spinal Cord Compression:** - Known malignancy + progressive back pain - Bilateral lower limb weakness (upper motor neuron pattern) - Sensory level on examination - Bladder/bowel dysfunction (late sign, poor prognostic) - Pain worse at night or with recumbency - Progressive over days to weeks **Red Flags for Spinal Metastases (CES-M):** | Red Flag | Significance | |----------|--------------| | Known cancer | High pre-test probability | | Age >50 with new back pain | Increased malignancy risk | | Night pain | Suggests malignancy | | Weight loss | Constitutional symptom | | Progressive neurological deficit | EMERGENCY | | Bladder/bowel dysfunction | EMERGENCY | ### Critical Management Points 1. **Dexamethasone 16mg STAT** - reduce cord oedema immediately 2. **MRI whole spine** - multiple levels in 30% of cases 3. **Treat within 24-48 hours** - neurological outcome depends on timing 4. **MDT discussion** - oncology, spine surgery, radiation oncology 5. **SINS for stability** - guides surgical decision 6. **Tokuhashi for prognosis** - guides extent of intervention 7. **Goals of care** - maintain/restore function, not necessarily cure --- ## Common Examiner Follow-ups **Q: "What tumours are radiosensitive vs radioresistant?"** | Radiosensitive | Radioresistant | |----------------|----------------| | Prostate carcinoma | Renal cell carcinoma | | Breast carcinoma | Melanoma | | Multiple myeloma | Sarcoma | | Lymphoma | Non-small cell lung cancer | | Small cell lung cancer | Colorectal cancer | | Seminoma | Thyroid carcinoma | Radiosensitive tumours may be treated with RT alone. Radioresistant tumours often require surgery for local control. --- **Q: "What is separation surgery?"** Separation surgery is a modern concept combining: 1. Surgical decompression to create space between tumour and spinal cord (2-3mm gap) 2. Stabilisation with instrumentation 3. Post-operative stereotactic radiosurgery (SBRT) to the tumour Advantages: - Allows high-dose RT to tumour while protecting cord - Less extensive surgery than en bloc resection - Suitable for radioresistant tumours --- **Q: "When would you consider palliative care only?"** Indications for best supportive care: - Complete paraplegia for >48-72 hours - Expected survival <3 months - Multiple levels with extensive disease - Patient preference (after informed discussion) - Severe medical comorbidities precluding intervention - Haemodynamic instability Palliative care includes: - High-dose steroids (for symptom relief) - Optimal analgesia - Nursing care (pressure areas, catheter, bowels) - Psychological support - End-of-life planning --- **Q: "What is the role of bisphosphonates or denosumab?"** Bone-modifying agents in metastatic bone disease: - Reduce skeletal-related events (fractures, MSCC) - Zoledronic acid 4mg IV monthly OR Denosumab 120mg SC monthly - Start after acute management of MSCC - Monitor renal function (zoledronic acid) - Risk of osteonecrosis of jaw (dental review before starting) --- ## Related Topics - Spinal Instability Neoplastic Score (SINS) - Tokuhashi Score - Metastatic Bone Disease - Prostate Cancer Bone Metastases - Spinal Instrumentation Techniques - Palliative Orthopaedics