Metastatic Spinal Cord Compression (MSCC)

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Spinal cord compression requires early identification and immediate treatment to prevent permanent neurological impairment.
There should be a high index of suspicion in cancer patients who have known bone and/or spinal metastases, present with back pain or sudden worsening of previously well controlled back pain.

Back pain is the most common symptom.
Neurological impairment can present as limb weakness, sensory impairment/loss, urinary and/or bowel incontinence or retention, and saddle anaesthesia.
Physical examination should include a full neurological examination including looking for lax anal tone and saddle anaesthesia.
An early MRI of the whole spine should be done within 24 hours or as soon as possible for patients with a clear neurological deficit or rapidly evolving neurology.

Confirm diagnosis and degree of cord compression with MRI spine.
Start Dexamethasone 16mg/day with gastric protection.
Ensure adequate analgesia is prescribed.
Spinal nursing until spine is deemed stable.
Good skin, urinary and bowel care are essential. This includes regular turning, regular changing of wet diapers, insert indwelling urinary catheter regular turning, indwelling catheter and routine bowel regimen.
Principle of bowel regimen is to keep bowel habit regular and stool soft (i.e. PO Senna 2 tablets Every Other Night, and Dulcolax Suppository Every Other Day after Senna is given). Avoid lactulose as it leads to watery and ‘acidic’ stools that may cause skin irritation.
Prevent pressure injury by performing regular turning and skin care, pressure-reducing devices (e.g. air mattress)
Involvement of multidisciplinary team e.g. Orthopaedics, Interventional radiologist, rehabilitation medicine, medical oncologist, speech therapist, occupational therapist, dietician, and medical social worker
If patient is deemed suitable for further specific intervention, stratification can be done according to NOMS Framework by Laufer et al (2013) (table below), and modified to local institutional practice.

Assess extent of neurological deficits. If deficits are severe and >48hours, chance of neurological recovery is very low with RT or surgery. However, RT may still be given for pain control if pain is an issue (in absence of spinal instability)
Radiotherapy is unlikely to relieve pain caused by an unstable spine. May require surgery or spinal analgesia to control such pain
A referral to Palliative Care and/or Pain team should be considered for uncontrolled symptoms

Spine Instability Neoplastic Score (SINS)

			Score
Spine Location
Junctional (occiput-C2, C7–T2, T11–L1, L5–S1)			3
Mobile spine (C3–C6, L2–L4)			2
Semi-rigid (T3–T10)			1
Rigid (S2–S5)			0
Mechanical or Postural Pain
Yes			3
No (occasional pain but not mechanical)			1
Pain-free lesion			0
Bone Lesion Quality
Lytic			2
Mixed lytic/blastic			1
Blastic			0
Radiographic spinal alignment
Subluxation/translation present			4
De novo deformity (kyphosis/scoliosis)			2
Normal alignment			0
Vertebral Body Involvement
>50% collapse			3
<50% collapse			2
No collapse with >50% of the body involved			1
None of the above			0
Posterior Involvement
Bilateral			3
Unilateral			1
None of the above			0

United Kingdom. National Institute for Health and Care Excellence. (2008). Metastatic spinal cord compression in adults: risk assessment, diagnosis and management. Clinical guideline CG75. https://www.nice.org.uk/guidance/cg75
Laufer,I., Rubin, D.G., Lis, E., Cox, B.W., Stubblefield, M.D., Yamada, Y., and Blisky, M.H. (2013). The NOMS Framework: Approach to the Treatment of Spinal Metastatic Tumours. Oncologist, 18(6): 744-751. https://doi.org/10.1643/theoncologist.2012-0293
Fisher, C.G., DiPaola, C.P., Ryken T.C., et.al. (2010). A novel classification system for spinal stability in neoplastic disease: An-evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine. 35: 1221-1229.