Spinal Cord Compression - Oncology
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
What is the diagnosis and what is the urgency?
What scoring systems guide management and prognosis?
What is your immediate management?
What are the treatment options for MSCC?
Describe the surgical technique for posterior decompression and stabilisation.
What factors predict neurological outcome in MSCC?
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
- Dexamethasone 16mg STAT - reduce cord oedema immediately
- MRI whole spine - multiple levels in 30% of cases
- Treat within 24-48 hours - neurological outcome depends on timing
- MDT discussion - oncology, spine surgery, radiation oncology
- SINS for stability - guides surgical decision
- Tokuhashi for prognosis - guides extent of intervention
- 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:
- Surgical decompression to create space between tumour and spinal cord (2-3mm gap)
- Stabilisation with instrumentation
- 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