Early Intervention Can Help Preserve Function in Spinal Cord Compression
Spinal cord compression (SCC)—an oncologic emergency—is the initial presentation in roughly 20%–33% of patients with a malignancy, Carol S. Viele RN, MS, OCN®, of the University of California, San Francisco, School of Nursing, said during a session on Saturday, April 13, 2019, at the ONS 44th Annual Congress in Anaheim, CA (https://congress.ons.org/). Nurses can play a key role in recognizing the condition and getting patients into early treatment that may help preserve their function, she said.
Clinical Presentation
The malignancies most commonly associated with SCC are breast, lung, and prostate cancer and multiple myeloma. The most common source of SCC is metastasis to the epidural space, with or without bony involvement; however, SCC may also occur in nonmetastatic disease.
Pain is a frequent symptom and is often worse at night because of diurnal variation in endogenous corticosteroid levels. About 33%–75% of patients with SCC have progressive motor symptoms, with an initial presentation of increased weakness proceeding to loss of gait function and ultimately an inability to ambulate. New gait ataxia in the setting of back pain should elevate suspicion of SCC. Sensory symptoms occur less frequently than motor ones and may include ascending numbness and paresthesia, radicular distribution, lumbar cord compression, bilateral leg weakness, and thoracic compression.
Evaluation and Treatment
A diagnostic evaluation for SCC should include magnetic resonance imaging (MRI) of the entire spine. MRI has a sensitivity of 93% and a specificity of 97% for detecting SCC. Approximately 20%–33% of patients with SCC are found on MRI to have noncontiguous compression. For patients unable to undergo MRI (e.g., those with mechanical valves, pacemakers, paramagnetic implants, embedded metal, or severe claustrophobia), CT myelography is the recommended alternative.
Glucocorticoids are part of the standard treatment regimen for SCC as a bridge to definitive treatment and pain palliation. Pain can be managed with immediate- or sustained-release opioids, neuropathic pain adjuvants (e.g., dexamethasone, gabapentin, amitriptyline), or bone pain adjuvants (e.g., zoledronic acid, pamidronate, acetaminophen).
Criteria for selection of appropriate treatment options include primary tumor type, level of myelopathy, degree of spinal block, and potential for neurologic reversibility. Stereotactic body radiotherapy may be used for patients with radioresistant or recurrent spinal metastases who are diagnosed before high-grade cord compression has developed. Vertebroplasty, kyphoplasty, and percutaneous spinal instrumentation are more minimally invasive procedure options.
For spinal instability, bed rest should be recommended and surgical stabilization considered. Data show that surgical stabilization can reduce pain and may be preferred over radiation therapy if patients are a good surgical candidate. Patients with spinal instability are not candidates for any minimally invasive intervention.
Nursing interventions for SCC should focus on:
- Maintaining functional status by implementing bowel, bladder, and skin care programs
- Referring patients to physical and occupational therapy for rehabilitation services
- Educating patients, family members, significant others, and caregivers
Ensuring that patients receive emotional support to decrease anxiety, with referrals as appropriate to a social worker, psychologist, psychiatrist, or chaplain