Approach to managing malignant spinal cord compression in palliative care

Malignant spinal cord compression occurs in about 5% of patients with advanced cancer and is usually caused by vertebral metastasis extending into the epidural space. The site of compression is thoracic in most cases.

Note: Spinal cord compression is a medical emergency—urgent investigation and treatment is essential to prevent permanent neurological damage.

Spinal cord compression is a medical emergency—urgent investigation and treatment can significantly limit loss of function and maintain quality of life. For principles of managing emergencies in patients with palliative care needs, see Emergencies in palliative care.

Features of malignant spinal cord compression may be subtle and includeAl-Qurainy, 2016 Fallon, 2018:

new onset or an exacerbation of back or neck pain
sensory changes—peripheral tingling or numbness
motor changes—weakness or gait changes
autonomic changes—bladder or bowel dysfunction
Cauda equina syndrome—perianal numbness, and diminished bladder and bowel awareness.

Neurological deficit may be variable and indistinct, or initially absent. Assess reflexes, anal tone, motor weakness and for any sensory loss (eg determine a sensory level).

Request or arrange transfer for urgent magnetic resonance imaging (MRI) of the entire spine; multiple areas may be compressed. MRI is the imaging modality of choice; computed tomography (CT) is an option if MRI is not possible. A delay in diagnosis can lead to further (and irreversible) loss of function.

Corticosteroids reduce peritumour oedema and pain, and may preserve spinal cord function. The role of corticosteroid therapy depends on whether symptoms are presentGeorge, 2015 National Institute for Health and Care Excellence (NICE), 2008:

For symptomatic patients, give a corticosteroid dose as soon as spinal cord compression is suspected, even if imaging has not yet confirmed the diagnosis—see Corticosteroid therapy for emergency management of malignant spinal cord compression in palliative care.
For asymptomatic patients, the role of corticosteroid therapy is unclear; it may increase the risk of perioperative complications—seek immediate specialist advice.

Note: For patients with symptoms of malignant spinal cord compression, give a corticosteroid dose as soon as the diagnosis is suspected, even if imaging has not yet confirmed the diagnosis.

Refer patients with suspected malignant spinal cord compression for specialist advice. Definitive management options include radiotherapy or surgical decompression, depending on the potential benefits and burdens of investigations and treatment, and the patient’s prognosis, preferences and goals of care—see Principles of symptom management in palliative care. In some patients, definitive management may not be appropriate.