Maliganant Spinal Cord Compression

Dr Sasikumar Sambasivam Dept. Of Palliative Medicine

Intra medullary

Intradural

Extramedullary Extradural

Compressive Myelopathy

Extramedullary

Intramedullary Late

Motor
a)UMN signs b)LMN signs Common 1or2segments at the site of wide (Ant horn cell) root compression Root pain Absent Lost Funicular pain present Preserved

Sensory
a)Pain b)Dissociated sensory loss c)Sacral sensation

d)Joint sensation
e)Lhermitte`s sign Autonomic involvement Bowel and Bladder

Lost
present Late

Late involvement
absent Early

Intradural
Mode of onset Asymmetrical , acute,rapid

Extradural
Symmetrical,slow, progressive

Vertebral

No Pain and gibbus

Pain and Gibbus

COMPRESSIVE MYELOPATHY CAUSES

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

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

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

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

Spinal Cord Syndrome

Spinal Cord Syndrome

Making the diagnosis early Imaging studies Conventional Therapy Radiation approaches Surgical techniques

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.

Symptoms of Spinal Cord Syndrome

Pain Motor Sensory Autonomic

 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.

Odds of finding epidural metastases based on symptoms in patients with bone metastases in spine

myelopathy

78%

radicular pain
back pain

61%
36%

Motor findings Weakness is present in 60 to 85 percent of patients.

o When 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. o The progression of motor findings until diagnosis typically consists of increasing weakness followed sequentially by loss of gait function and paralysis

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.

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

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

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.

MRI BONE SCAN PET SCAN

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.

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)

 Inform patients at high risk of developing bone metastases

Early Detection

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

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 patients remaining life, are not always attainable.

 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 surgery.

 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

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 painspine support---corsets or braces for the trunk, and collars or halo jackets. Internal supportvertebroplasty, kyphoplasty

 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

Radiotherapy (Level 1)
30Gy/10 fr; 20Gy/5 fr; 8 Gy /1fr based on the performace scale.

Treatments for painful spinal metastases and prevention of MSCC

No role of Prophylactic RT.

Vertebroplasty and kyphoplasty

Consider for patients who have vertebral metastases and no evidence of compression or spinal instability if they have: mechanical pain resistant to conventional analgesia, or vertebral body collapse.

Treatments for painful spinal metastases and prevention of MSCC

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.

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

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 34 hours. continue to unsupported sitting if BP is stable

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.

Care of the threatened spinal cord in patients with MSCC

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.

 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 57 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

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

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.

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

 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

 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

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. Fractionatedgood 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

 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

Recent Advances in relation to RT

Improving radiation technology from radium and cobalt to image guided IMRT / Tomotherapy and stereotactic radiosurgery (Cyberknife)

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.

Supportive care and rehabilitation

Bed rest--thigh-length graduated compression/anti-embolism stockings unless contra-indicated high risk of venous thromboembolismlow molecular weight heparin + mechanical thromboprophylaxis

 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

Tokuhashi scoring system: A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis Spine 2005, 30 (19), 21862191
General condition (performance status) Poor (PS 1040%) 0 Moderate (PS 5070%) 1 Good (PS 80100%) 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 Primary site of the cancer Lung, osteosarcoma, stomach, bladder, esophagus, pancreas 0 Liver, gall bladder, unidentified Others Kidney, uterus Rectum 4 Thyroid, breast, prostate, carcinoid tumor 5 Palsy Complete (Frankel A, B) 0 Incomplete (Frankel C, D) 1 None (Frankel E)

1 2 3

Criteria of predicted prognosis: Total Score (TS) 08 < 6 months, TS 911 6 months, TS 1215 1 year

Thank you.