Spinal Cord CompressionSpinal Cord Compression

Carol S. Viele RN MS OCNCarol S. Viele RN MS OCNClinical Nurse SpecialistClinical Nurse Specialist

Heme-Onc-BMTHeme-Onc-BMTUniversity of California San FranciscoUniversity of California San Francisco

Associate Clinical Professor Associate Clinical Professor Dept of Physiological NursingDept of Physiological Nursing

UCSF UCSF School of NursingSchool of Nursing

ObjectivesObjectives

At the completion of this presentation At the completion of this presentation the participant will be able to:the participant will be able to:– Describe the most common cancers Describe the most common cancers

associated with cord compressionassociated with cord compression

– Identify at least 2 symptoms associated Identify at least 2 symptoms associated with cord compressionwith cord compression

– Describe the most appropriate nursing Describe the most appropriate nursing interventions for cord compressioninterventions for cord compression

Definition/FrequencyDefinition/Frequency

A mass effect from the tumor with A mass effect from the tumor with associated edema which results associated edema which results in ischemia and neural damage to in ischemia and neural damage to the spinal cordthe spinal cord

10% of all patients with cancer 10% of all patients with cancer will develop this complicationwill develop this complication

OccurrenceOccurrence

The most common source of cord The most common source of cord compression is metastasis to the epidural compression is metastasis to the epidural space with or without bony involvementspace with or without bony involvement

Tumors can also through the reach the Tumors can also through the reach the epidural space by direct extension through epidural space by direct extension through the intervertebral foramenthe intervertebral foramen

Some tumors occur in the cord itselfSome tumors occur in the cord itself

EtiologyEtiologyTumor typesTumor types– Breast, (Number 1 in women)Breast, (Number 1 in women)– Lung Lung – KidneyKidney– MyelomaMyeloma– ProstateProstate– MelanomaMelanoma– Gastrointestinal tumorsGastrointestinal tumors– LynphomaLynphoma

Level of InvolvementLevel of Involvement

Cervical area 10%Cervical area 10%

Thoracic area 70%Thoracic area 70%

Lumbosacral 20%Lumbosacral 20%

SymptomsSymptoms

Back pain is usually the first symptomBack pain is usually the first symptom

95% of patients with a cord compression 95% of patients with a cord compression experience back pain experience back pain

Pain will precede other symptoms by Pain will precede other symptoms by weeks to monthsweeks to months

Early cord compression may be Early cord compression may be asymptomaticasymptomatic

ManifestationsManifestationsPain Pain – LocalizedLocalized– RadicularRadicular– SeveritySeverity– Position changesPosition changes– CoughCough– WeightbearingWeightbearing– Valsalva maneuverValsalva maneuver

ManifestationsManifestationsWeakness 75-85%Weakness 75-85%– May progress rapidlyMay progress rapidly– BilateralBilateral– Corresponds to the level of cord involvemnentCorresponds to the level of cord involvemnent

SpasticitySpasticity

HyperreflexiaHyperreflexia

Abnormal stretch reflexesAbnormal stretch reflexes

Extensor plantar responseExtensor plantar response

ManifestationsManifestations

Sensory lossSensory loss–Bowel dysfunctionBowel dysfunction

–Bladder dysfunctionBladder dysfunction

–ImpotenceImpotence

DiagnosisDiagnosisThorough physical examinationThorough physical examination– PalpationPalpation– Gentle percussion over bony areasGentle percussion over bony areas– Neurologic examNeurologic exam

Laboratory data – Increased alkaline Laboratory data – Increased alkaline phosphatase may indicate bony phosphatase may indicate bony involvementinvolvement

DiagnosisDiagnosis

Radiographs- may reveal erosion of the Radiographs- may reveal erosion of the pedicle,pedicle,– Lytic lesions of the vertebral bodyLytic lesions of the vertebral body– Collapse of the vertebral bodyCollapse of the vertebral body

Bone scan- 20% of scans reveal lesions Bone scan- 20% of scans reveal lesions missed on plain filmsmissed on plain films

CTCT– Used to determine extent of tumorUsed to determine extent of tumor

DiagnosisDiagnosis

MRI ( Tool of choice)MRI ( Tool of choice)– Able to determine prevertebral, vertebral, Able to determine prevertebral, vertebral,

extradural, intradural, extramedullary and extradural, intradural, extramedullary and intramedullary lesionsintramedullary lesions

– Provides better anatomic visualization with Provides better anatomic visualization with sagittal and axial images of the spinal cordsagittal and axial images of the spinal cord

Fine needle aspirationFine needle aspiration– May provide tissue confirmationMay provide tissue confirmation

TreatmentTreatment

Criteria: Criteria: –Primary tumor typePrimary tumor type

–Level of myelopathyLevel of myelopathy

–Degree of spinal blockDegree of spinal block

–Potential for neurologic reversibilityPotential for neurologic reversibility

TreatmentTreatment

SurgerySurgery– Radical resection if an a candidateRadical resection if an a candidate– Complete blockComplete block– Single lesion where complete removal is Single lesion where complete removal is

possiblepossible– Diagnosis is uncertainDiagnosis is uncertain– Mild deficitsMild deficits– New data supports surgery over treatment New data supports surgery over treatment

with RT if patient is a good surgical candidatewith RT if patient is a good surgical candidate

TreatmentTreatment

Radiation therapyRadiation therapy– If not a surgical candidateIf not a surgical candidate– Incomplete blockIncomplete block– Severe deficitsSevere deficits– Relapse in area of prior radiation if short Relapse in area of prior radiation if short

survival is expectedsurvival is expected

TreatmentTreatmentRadiation- often initiated as an emergency if Radiation- often initiated as an emergency if

not a surgical candidatenot a surgical candidate– TherapyTherapy

Treatment field extends 1-2 vertebral Treatment field extends 1-2 vertebral bodies above and below level of bodies above and below level of compressioncompression

3000-4000 cGy over 2-4 weeks3000-4000 cGy over 2-4 weeks

2/3 of patients remain stable or improve2/3 of patients remain stable or improve

65-75% achieve pain relief65-75% achieve pain relief

TreatmentTreatmentSteroidsSteroids– DexamethasoneDexamethasone

Bolus IV 10 mgBolus IV 10 mg

Oral 4-6 mg q 6 hours for 2 days then a slow taperOral 4-6 mg q 6 hours for 2 days then a slow taper

25% of patients with cord compression require 25% of patients with cord compression require maintenance to maintain neurologic functionmaintenance to maintain neurologic function

Steroid related side effects may occurSteroid related side effects may occur– HyperglycemiaHyperglycemia– GI bleedingGI bleeding– PsychosisPsychosis

TreatmentTreatment

ChemotherapyChemotherapy– May be given in highly sensitive tumorsMay be given in highly sensitive tumors– Always given with other modalitiesAlways given with other modalities

OutcomeOutcome

Pretreatment ambulatory ability is the Pretreatment ambulatory ability is the main determinant of post treatment main determinant of post treatment ambulatory abilityambulatory ability

90% of patients ambulatory before 90% of patients ambulatory before therapy are aftertherapy are after

Only 10% of paraplegics become Only 10% of paraplegics become ambulatory after therapyambulatory after therapy

PrognosisPrognosis

Median survival is 6 months if patient Median survival is 6 months if patient presents as a paraplegicpresents as a paraplegic

50% of patients who walk in with a cord 50% of patients who walk in with a cord compression are alive at 1 yearcompression are alive at 1 year

If patient was ambulatory prior to RT If patient was ambulatory prior to RT survival is 8-10 monthssurvival is 8-10 months

Recurrent DiseaseRecurrent Disease

OptionsOptions

– If RT given may be a surgical candidate If RT given may be a surgical candidate if survival of > 12 months predictedif survival of > 12 months predicted

– Repeat RTRepeat RT

Risks of repeat RT Risks of repeat RT

–Radiation myelopathyRadiation myelopathy

–Collateral damageCollateral damage

Nursing InterventionsNursing Interventions

Thorough assessment and early Thorough assessment and early MD/Provider notification of changes inMD/Provider notification of changes in– PainPain

– Sensory functionSensory function

– Motor functionMotor function

– Urinary functionUrinary function

– Bowel functionBowel function

Nursing InterventionsNursing Interventions

Maintenance of functional statusMaintenance of functional status

– Bowel programBowel program

– Bladder programBladder program

– Skin careSkin care

– Rehabilitation servicesRehabilitation servicesPTPT

OTOT

Nursing InterventionsNursing Interventions

EducationEducation–PatientPatient

–FamilyFamily

–Significant othersSignificant others

–Care giversCare givers

Nursing InterventionsNursing Interventions

Emotional supportEmotional support–Decrease anxietyDecrease anxiety

–ReferralsReferralsSocial workerSocial worker

PsychologistsPsychologists

PsychiatristPsychiatrist

ChaplainChaplain

Nursing InterventionsNursing Interventions

ReferralsReferrals–Care coordinationCare coordination–Case managerCase manager–Home careHome care–Rehabilitation centerRehabilitation center–Skilled nursing facilitySkilled nursing facility–HospiceHospice

ReferencesReferencesSchulmeister, L., Gatlin, C.,( 2008) Spinal cord Schulmeister, L., Gatlin, C.,( 2008) Spinal cord compression in compression in Oncology Nursing Secrets, Oncology Nursing Secrets, Gates, R. and Fink, R. (eds) Hanley and Belfus, Gates, R. and Fink, R. (eds) Hanley and Belfus, Philadelphia, 546-550Philadelphia, 546-550Quinn, J., De Angelis, L.(2000) “Neurologic Quinn, J., De Angelis, L.(2000) “Neurologic emergencies in the cancer patient”, emergencies in the cancer patient”, SeminSemin Oncol,Oncol, 27: 311- 321 27: 311- 321Tan, S. Recognition and Treatment of Oncologic Tan, S. Recognition and Treatment of Oncologic Emergencies (2002), Emergencies (2002), Journal of InfusionJournal of Infusion NursingNursing,25:3, 182-188,25:3, 182-188

ReferencesReferences

www.uptodate.com, Spinal Cord , Spinal Cord Compression, Accessed 7/9/09Compression, Accessed 7/9/09