Malignant spinal cord compression (Guidelines)

A MSCC is an oncological emergency that occurs when the dural sac and its contents are compressed at the level of the spinal cord or cauda equina.  This may result from direct pressure, vertebral collapse or instability caused by metastatic spread or by direct extension of a malignancy.  Urgent referral to the MSCC coordinators is essential to ensure rapid assessment, investigation and treatment in order to prevent or limit irreversible neurological damage.

MSCC should be considered in malignancy especially if there is bone involvement.  MSCC is most common in people diagnosed with myeloma, lung, breast and prostate cancers however it can also present in patients with an unknown primary cancer.

Late diagnosis due to delays in recognition can result in significant pain, permanent loss of function and significant morbidity.  

Does the patient have:

• a history of cancer and/or suspicion of metastatic cancer 
• severe unremitting or progressive back pain
• new difficulty walking 

Do not discount the MSCC pathway if there are only 2 indicators.  

The following pain characteristics are suggestive of spinal metastases:

• severe unremitting back pain
• progressive back pain
• mechanical pain (aggravated by standing, sitting or moving)
• back pain aggravated by straining (for example, coughing, sneezing or bowel movements)
• night-time back pain disturbing sleep
• localised tenderness
• claudication (muscle pain or cramping in the legs when walking or exercising).

The following pain characteristics are suggestive of cord compression:

• bladder or bowel dysfunction
• gait disturbance or difficulty walking
• limb weakness
• neurological signs of spinal cord or cauda equina compression
• numbness, paraesthesia or sensory loss
• radicular pain

Contacting your local MSCC Coordinator will ensure rapid assessment, investigation and treatment of a patient with suspicion of a MSCC.

At NHS Highland, therapeutic radiographers within the radiotherapy department at Raigmore Hospital are the MSCC coordinators.  They are supported by the on-call oncologist.  

How to contact the MSCC Coordinator at NHS Highland:

Monday-Thursday 09.00 to 17.00/Friday 09.00 to 16.30:

• MSCC Coordinator via bleep: 2134.
• Raigmore switchboard (01463 704000) and ask for the malignant spinal cord compression coordinator.

Out of Hours/Public Holidays: 

• On-call oncologist via Raigmore switchboard (01463 704000).  Between the hours of midnight and 7am if you suspect MSCC please start the patient on 16mg of dexamethasone and call the on-call oncologist at 7am when further investigations can be booked.
• If there is no local oncologist available please contact the on-call oncologist at Aberdeen Royal Infirmary (0345 456 6000)

The MSCC Coordinator will: 

• Act as a single point of contact for the triage and discussion of patient symptoms.
• Seek advice from the on-call oncologist on a patients eligibility for the MSCC pathway. 

If a patient is eligible for the pathway, they will organise a MRI scan and ward admission if applicable.  

Dexamethasone

• Administer 16mg oral dexamethasone as soon as possible.
• Consider gastro-protective cover if patient is high risk and monitor blood glucose levels.

If MRI scan negative: 

• Stop any additionally prescribed dexamethasone immediately. 

If MRI scan positive: 

Steroids should be under regular review with downward titration after radiotherapy commences or surgery.  Titration should be guided by the clinical condition of the patient.

• Titrating oral dexamethasone:
  • 8mg for 3 days from treatment date
  • 4mg for 3 days
  • 2mg for 3 days
  • Discontinue (if appropriate)
  • If residual symptoms or initial period on 16mg was longer than 1 to 2 days wean further by halving the dexamethasone dose every 2 to 3 days.

Analgesia administered as required.

Radiotherapy 

• Radiotherapy is the most common treatment option for patients with MSCC. If the patient is positive for MSCC then the on-call oncologist will make the decision on whether they will receive urgent radiotherapy.  

If mobile at presentation: 

• Local agreement in NHS Highland is to keep a mobile patient mobile.
• Advise not to carry anything.
• Seek assistance on transfer and climbing stairs.
• Refrain from driving.

If severe pain on movement: 

• May indicate spinal instability.
• Consider advising patient to lie flat until assessment / MRI has been made and log roll.

Paralysis: 

• Where paralysis is observed, patients remain on bed rest.

• OOH: out of hours
• MRI: magnetic resonance imaging
• MSCC: malignant spinal cord compression