Practical mobility considerations
on diagnosis of MSCC.
Ruth Mhlanga
What it is



Compression of the dural sac and its
contents (spinal cord and or cauda
equina) by an extradural tumour mass
(Loblaw et al 2004).
Spinal cord or cauda equina compression
by direct pressure and or induction of
vertebral collapse or instability by
metastatic spread or direct extension of
malignancy that threatens or causes
neurological disabilty(NICE 2008)
Minimum radiological evidence is
indentation of theca at level of clinical
features.
Cauda equina
How this happens
Effects



Compression causes inflammation ,
oedema, mechanical compression
which in turn leads to neural
damage, vascular impairment and
oxygen deprivation to the cord
(Meyering 2008)
Could result in infarction of cord.
Range from sensory, motor,
autonomic, severe pain to complete
paralysis (Drudge Coates and
Rajbabu 2008 pg4).
Symptoms

-
-
Spinal metastasis
Thoracic or cervical spine
Progressive lumbar spine pain
Severe unremitting lumbar spine
pain.
Worse with straining
Pain preventing sleep at night
Localised spinal tenderness.
Neurological signs and symptoms
-
Radicular pain
Limb weakness
Difficulty with mobs
Sensory loss
Bowel and bladder dysfunction
Any other signs of spine or cauda
equina involvement.
Differential diagnoses
Herniated disk
 Haematoma
 Abscess
 Primary tumour
 Extradural lesion
 Myelopathy
 Metastasis.
(London Health Sciences Centre
2004)

INFORM MSCC COORDINATIOR
WITHIN 24 HOURS
IMMEDIATE
Pain in T or L spine
Progressive C spine
pain
Pain ++ on straining
Pain preventing sleep
Neuro Sx or signs
Includes radicular pain
TREATMENT
MOBILISATION
STEROIDS
Nurse flat with spine neutral until spinal/neuro
stability ensured
Gradual sitting over 3-4 hours
Dexamethasone 16mgs until RT/surgery
Reduce over 5-7 days and stop
Increase if neuro deterioration
PAIN CONTROL
DEFINITIVE TREATMENT
Causal pathway of MSCC(Loblaw and
Lapierre1998 and 2005)
Asymptomatic
MSCC
Screening
Biologics
Biphosphonates
Chemotherapy
Symptomatic
Favourable
MSCC
Outcome
Reducing delays
Improved
Treatment
Stable or unstable




Can not always be ascertained using
radiology alone (Pease et al 2004).
Lessons learnt from osteoporosis indicate
that fracture does not equal instability.
Spinal ligaments also contribute to spinal
stability.
Images are just a snapshot in time
therefore need to complement with
clinical signs and symptoms.
Stable or unstable
Spinal Protection


Logrolling only appropriate where
disease or surgery have
compromised spinal stability.
Mobilise patients unsuited to
surgical stabilisation once risk of
causing lesion extension has been
assessed as acceptable to all parties
or where patient is enabled to make
an informed quality of life decision.
So what do we do?



If MRI unavailable and patient in
pain….nurse flat.
MRI available and consultants report no
radiological instability bed rest (not
necessarily flat) until physiotherapy
assessment.
MRI available and no plan for treatment –
bed rest. Doctors discuss with patient about
possible deterioration and if patient aware of
risks, bed rest until physiotherapy
assessment.
Consideration
MRI
Pain and other
neurological
symptoms
Mobility
Action
Not available
Flat bed rest.
Available
Stable spine - bed rest
until physio assessment.
Unstable – flat bed rest
Present
Flat bed rest or as
tolerated.
Not present
Bed rest until clearance
from consultant.
Pain worse with mobility
Reposition until symptom
reversed. Monitor, may
need re-referral to
surgeons.
Completely absent
Consultant d/w with
patient. Sit up as
tolerated
Present but with pain
Bed rest until
physiotherapy
assessment
Present with no pain
Supervised mobilisation
Mobilisation





Patients with an unstable spine to be
nursed flat.
Once stability ascertained sit up gradually
to 60 degrees over 3-4 hrs
If tolerates with all other vital signs stable
check for sitting balance and mobilise as
able.
If neurology deteriorates return to
position of reversal of symptoms,
reassess stability of spine.
If unsuitable for definitive treatment then
mobilise as able . Ensure patient aware of
risks.
Stable or unstable
Stable
 Mobile
 Pain usually eases
with steroids.
 Keep mobile
Unstable
- Can be mobile
- Pain on movt
- Stabilise spine
before mobs
Treatment outcomes



60-90% of patients get relief from
pain from radiotherapy and
steroids.
60-100% of those who are mobile
maintain their mobility status
(Helweg Larsen et al 2000/ Loblaw
et al 2004)
Survivors are at high risk of
recurrence or new compression.
NICE Guidance and Rehabilitation




Discharge planning and
rehabilitation should be initiated on
admission.
Should include patient and carers,
oncology team, surgery (where
appropriate), rehabilitation,
community, SPCT where
appropriate.
Patient centred.
Consider patients’ preferred place of
care.
Prior to discharge




Ensure family aware of what patient able to do
and support and guidance given prior to
discharge.
If patient mobile ensure patient aware of new
symptoms.? NECN MSCC patient information
leaflet.
MDT to address mobility issues including spinal
support with braces and collars as well as
handover to their colleagues where
appropriate.
Medical concerns including pain and stability
addressed prior to discharge.
References







Drudge-Coates L. and Rajbabu(2008) Diagnosis and management of
Spinal cord compression part 2. International Journal of Palliative
Nursing Vol 14. No 4
Loblaw D.A and Lapierre L.J (1998)Emergency treatment of Malignant
extradural spinal cord Compression: An evidence based guide. Journal
of clinical Oncology American Society of Clinical oncology16.1613-1624
Loblaw D.A, Perry J.,Chambers A. and Lapierre N.J. Systematic Review
of the diagnosis and management of malignant spinal cord
compression: The cancer care Ontario Practice Guidelines Initiatives
Neuro-Oncology Disease site Group.Journal of Clinical
Oncology.American Society of Clinical Oncology 23:2028-2037
London Health Sciences centre 2004.
Meyering S.M. (2008) Spinal cord compression and vertebral
metastasis diagnosed in correlation with TC-99 m H/MDP scan.
Nuclear Medicine Vol 5. No 1.
NICE guidelines.(2008) Metastatic Spinal Cord Compression Diagnosis
and management of adults at risk of and with metastatic spinal cord
compression.
Pease N.J, Harris R.J, Finlay I.G. Development and audit of a care
pathway for the management of patients with suspected malignant
spinal cord compression. Physiotherapy, 2004 Mar, vol 90, no 1, pg
27-34