Management of Metastatic Spinal Cord Compression in Secondary Care: A Practice Reflection from Medway Maritime Hospital, Kent, UK

Abstract

Introduction: Malignant spinal cord compression (MSCC) is one of the most devastating complications of cancer. This event requires rapid decision-making on the part of several specialists, given the risk of permanent spinal cord injury or death. The goals of treatment in spinal metastases are pain control and improvement of neurological function. There can be challenges in delivering prompt diagnosis and treatment in a secondary care setting. We have reflected on the experience of managing MSCC in a district general setting.

Aim: Our retrospective audit identified 53 patients with suspected MSCC who entered the relevant pathway from April 2017 to March 2018 at Medway, United Kingdom (UK). Our audit standards were set out by Medway Maritime Hospital and Maidstone and Tunbridge Wells NHS Trust MSCC working group members, using a combination of published evidence and best practice.

Results: The patients with suspected MSCC were 53 and 29 of them (54.7%) had confirmed MSCC. The most common malignancies within the confirmed MSCC were lung (11 patients, 37.9%), breast (5 patients 17.2%), and renal (3 patients, 10.3%), followed by prostate, myeloma and carcinoma of unknown primary (2 patients (6.9%) each), as well as pancreatic, colorectal, lymphoma and, bladder (1 patient (3.4%) each). A magnetic resonance imaging (MRI) scan was performed in 48 patients (90.5%); the majority (31 patients, 64.6%) underwent the MRI within the first 24 h, whereas 3 patients had the investigation between 24 and 72 h from the admission. Among the 29 patients with confirmed MSCC, 6 (20.6%) were treated with surgical decompression, while 20 (69%) received radiotherapy (RT) and 3 (10.3%) best supportive care, respectively. Median time to surgery was 5 days (ranged between 2 and 8 days), whereas for RT 44.4 h (ranged between 24 and 72 h). Finally, all 3 patients that decided on symptom control were referred to a palliative care team within the first 24 h following the MRI scan.

Conclusions: MSCC is frequently presented outside tertiary care. This may cause subsequent delays in investigation, diagnosis, and treatment, which can be improved by following a fast track referral pathway.

Keywords: corticosteroids; decompressive surgery; metastatic spinal cord compression; palliative radiotherapy; pathway.

Figure 1

Distribution of the suspected malignant spinal cord compression (MSCC) cases.

Figure 2

Time from admission to magnetic resonance imaging (MRI) in hours.

Figure 3

Comparison of time of magnetic resonance imaging (MRI) from admission and suspicion of malignant spinal cord compression (MSCC).

Figure 4

Diagnosis and management of malignant spinal cord compression (MSCC). Abbreviations: MSCC: Malignant spinal cord compression; PPIs: Proton Pump Inhibitors.

Figure 5

Time from confirmed malignant spinal cord compression (MSCC) to radiotherapy (RT).

Figure 6

Medway Maritime Hospital updated malignant spinal cord compression (MSCC) guidelines. Abbreviations: MSCC: Malignant spinal cord compression; MDT: Multidisciplinary team; MRI: Magnetic resonance imaging; CT: Computerized tomography; RT: Radiotherapy.