11/14/24, 10\:56 AM Malignant Spinal Cord Compression (MSCC)

Malignant Spinal Cord Compression (MSCC)

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Malignant spinal cord compression (MSCC)\: medical emergency due to compression of the spinal cord or cauda equina,
typically caused by tumour expansion, vertebral collapse, or instability.
Incidence\: occurs in 5-10% of cancer patients; 20% of patients with MSCC have it as the presenting feature of cancer.
Mechanisms\: direct tumour compression, vertebral collapse (most common in thoracic spine), direct extension from intra-
abdominal/thoracic malignancy, primary vertebral body malignancy, intradural spinal cord malignancies.
Risk factors\: common in prostate (20%), lung (20%), breast (17%), renal cancers, and multiple myeloma; median age at
diagnosis is 65 years.
Symptoms\: back pain (red
sensory disturbances, autonomic dysfunction, cauda equina syndrome (bladder/bowel dysfunction, saddle anaesthesia,
leg weakness).
Clinical examination\: full neurological exam;
muscle tone, clonus, upgoing plantars, reduced anal tone, and palpable distended bladder.
Investigations\: urgent MRI spine within 24 hours; CT if MRI contraindicated; further investigations include bladder scan,
baseline blood tests, bone pro
Diagnosis\: con
Initial management (suspected MSCC)\: dexamethasone 16mg OD or 8mg BD, PPI (e.g., omeprazole), thromboprophylaxis,
contact MSCC coordinator for MRI, immobilize spine if instability suspected, analgesia.
De
on patient's status, malignancy extent, comorbidities, compression level, neurological de
Rehabilitation\: ongoing rehabilitation for pain control, thromboprophylaxis, weaning dexamethasone, chest clearance
exercises, preventing contractures/spasticity, continence management, preventing pressure ulcers, communication
assistance, mobility aids, psychological care.
Complications\: pressure ulcers, autonomic dysre
contractures, psychological complications.
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A comprehensive topic overview

Introduction

Malignant spinal cord compression (MSCC) is a medical emergency caused by compression of the spinal cord or cauda
equina. It can result from direct pressure, vertebral collapse or instability due to metastatic or local spread of tumours.
It occurs in 5-10% of cancer patients and will be the presenting feature of cancer in 20% of patients with MSCC.
1

Aetiology

MSCC occurs when there is compression of the spinal cord or cauda equina related to malignancy. This can occur
through several mechanisms\:
2,3
Direct compression from tumour expansion into the epidural space\: most commonly due to metastases
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Direct compression from collapsed vertebral bodies\: most commonly due to metastases; the most common region of
bony metastases is the thoracic spine (around 70%), followed by the lumbosacral (20%) and cervical (10%)
Direct extension of an intra-abdominal or intra-thoracic primary malignancy
Direct compression from a primary malignancy of the vertebral body
Compression from intradural spinal cord malignancies
The compression leads to oedema, venous congestion and demyelination. This leads to loss of neurological function,
which is variable depending on the level of the lesion(s).

Risk factors

While any malignancy has the potential to metastasise to the spine, it is more common in certain types of cancer\:
2
Prostate cancer (20%)
Lung cancer (20%)
Breast cancer (17%)
Renal cancer (12%)
Multiple myeloma
The risk of MSCC is also related to the duration of the disease. The median age of patients at the time of MSCC diagnosis is
65.

Clinical features

History

The most common presenting complaint in MSCC is back pain, and it may have been present for several weeks before
MSCC is diagnosed.
Red
Thoracic or cervical pain
Progressive lumbar pain
Spinal pain aggravated by straining
Localised spinal tenderness
Nocturnal pain preventing sleep
Other symptoms can vary depending on the level of compression but commonly include\:
Limb weakness (e.g. the limb feeling "heavy
" or "sti
, di
Loss of coordination
Sensory disturbance
Autonomic dysfunction (e.g. urinary retention, faecal incontinence due to loss of anal tone, constipation)
Cauda equina syndrome (bladder/bowel dysfunction, saddle anaesthesia, leg weakness, gait disturbance, back pain)
Patient education
The Christie NHS Foundation Trust have produced a range of MSCC patient information resources, including alert
cards which list the red

Clinical examination

Patients with suspected MSCC should have a full neurological examination.
Clinical
level and symptoms. Additionally, over 20% of patients will have compression at multiple levels.
Typical examination
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Limb weakness or paralysis (assess using the MRC muscle power scale)
Sensory disturbance
Brisk re
Increased muscle tone
Clonus
Upgoing plantars
Reduced anal tone
Palpable, distended bladder

Investigations

Any patient with suspected MSCC should be referred for an urgent MRI of the spine within 24 hours. If an MRI is
contraindicated (e.g.pacemakers and metallic foreign bodies), the next best imaging modality is CT.
Figure 1. T12 vertebral metastasis with
spinal cord compression in a patient with
metastatic parotid squamous cell
carcinoma.
Once imaging has been obtained, further investigations can help to guide treatment.

Bedside investigations

Relevant bedside investigations include\:
Bladder scan\: to assess for urinary retention

Laboratory investigations

Relevant laboratory investigations include\:
Baseline blood tests (FBC, U&Es, LFTs)\: to assess general
Bone pro\: to assess for hypercalcaemia
Clotting and group & save\: if the patient is likely to require surgery
LDH\: higher levels are associated with poor prognosis
Myeloma screen\: if the patient does not have a known cancer diagnosis
Tumour markers\: may help with the assessment of cancer stage and suitability for treatment or diagnosis if MSCC is the
initial presentation
An up-to-date staging CT is needed to help assess the cancer stage and suitability for treatment.

Diagnosis

MSCC is diagnosed by imaging (spinal MRI or CT). The scan should also be reported within 24 hours of patient
presentation to enable rapid treatment.
If MSCC is the presenting feature, then patients will require further investigation to diagnose the primary tumour, but this
should not delay the assessment and treatment of the cord compression.
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Management

The management of MSCC can be split into initial management of suspected MSCC, de
MSCC and ongoing rehabilitation.

Initial management (suspected MSCC)

Initial management of suspected MSCC includes\:
Dexamethasone (16mg OD or 8mg BD)\: to reduce in
Omeprazole (or alternative PPI) for stomach protection
Low molecular weight heparin (or alternative) for thromboprophylaxis
Contact the local MSCC coordinator to arrange admission and MRI spine (follow local referral guidelines)
Immobilise the spine if instability is suspected
Analgesia

De

Management options for conradiotherapy, radiotherapy alone or best supportive care.
The management choice depends on various factors, including the patient's performance status, the extent of their
malignancy, other comorbidities, level(s) of compression and neurological de
paraplegia and loss of sphincter control for >48 hours, treatment is unlikely to improve neurological function.
Surgery
Surgical decompression can be considered in patients with a life expectancy >6 months, some preserved neurological
function and limited levels of compression. This would usually be followed by radiotherapy to reduce the recurrence risk.
Radiotherapy alone
Radiotherapy alone is generally the management of choice for most patients, particularly those with multiple medical
comorbidities, rapidly progressive neurological de
In these patient groups, radiotherapy is given to improve function. However, it can also be given for palliative pain relief in
those with a life expectancy of \<6 months, low-performance status and established paraplegia >24 hours.
Best supportive care
Patients who are frail, unwell or have a short life expectancy require palliative management. This focuses on managing
symptoms and considering referral to specialist palliative care teams for advice.

Rehabilitation

Ongoing rehabilitation is essential, and the patient's exact needs will vary depending on the neurological de
treatment given. Common considerations include\:
Pain control
Thromboprophylaxis
Weaning of dexamethasone
Breathing exercises and forced expiratory techniques to aid chest clearance
Prevention of contractures/spasticity
Continence management
Prevention of pressure ulcers
Communication assistance
Mobility aids
Psychological care

Complications

Complications of MSCC include\:
Pressure ulcers
Autonomic dysre
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Deep vein thrombosis
Pulmonary embolism
Falls
Urinary tract infections
Pneumonia
Muscle contractures
Psychological complications

References

Scottish Palliative Care Guidelines. M a l i g n a n t s p i n a l c o r d c o m p r e s s i o n . Published 2021. Available from\: [LINK]
BMJ Best Practice. M a l i g n a n t S p i n a l C o r d C o m p r e s s i o n . Published 2023. Available from\: [LINK]
NHS Greater Manchester, Lancashire and South Cumbria Strategic Clinical Networks. G u i d e l i n e s f o r t h e m a n a g e m e n t o f
m a l i g n a n t s p i n a l c o r d c o m p r e s s i o n . Published 2014. Available from\: [LINK]

Image references

Figure 1. Case courtesy of Andrew Murphy, Radiopaedia.org, rID\: 47515

Related notes

Anal Cancer and Anal Intraepithelial Neoplasia (AIN)
Brain Tumours
Breast Cancer
Hypercalcaemia of Malignancy
Laryngeal Cancer

Test yourself

Contents

Introduction
Aetiology
Risk factors
Clinical features
Investigations
Diagnosis
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