Metastatic spinal cord compression

Short Text

Diagnosis and management of adults at risk of and with metastatic spinal cord compression

Introduction

Metastatic spinal cord compression (MSCC) is defined in this pathway as spinal cord or cauda equina compression by direct pressure and/or induction of vertebral collapse or instability by metastatic spread or direct extension of malignancy that threatens or causes neurological disability.
It is important to recognise the impact of an MSCC diagnosis on people with MSCC and their families and carers, and understand their needs and the support required throughout their care.
Some people with MSCC experience delays in their treatment and care and may, as a result, develop avoidable disability and die prematurely.
This pathway will help to ensure that facilities are available for early diagnosis and that treatment is coordinated, follows best practice and whenever possible prevents paralysis from adversely affecting the quality of life of people living with cancer.

Source guidance

The NICE guidance that was used to create the pathway.
Metastatic spinal cord compression. NICE clinical guideline 75 (2008)
Balloon kyphoplasty for vertebral compression fractures. NICE interventional procedure guidance 166 (2006)
Percutaneous vertebroplasty. NICE interventional procedure guidance 12 (2003)

Quality standards

Quality statements

Information about recognising the symptoms of metastatic spinal cord compression

This quality statement is taken from the metastatic spinal cord compression quality standard. The quality standard defines clinical best practice in metastatic spinal cord compression care and should be read in full.

Quality statement

Adults at high risk of developing metastatic spinal cord compression (MSCC), and their families or carers (as appropriate), are given information that describes the symptoms of MSCC and what to do if they develop symptoms.

Rationale

It is important that adults at high risk of developing MSCC, and their or carers (as appropriate), receive information about how to recognise the symptoms of MSCC so they can seek help to ensure prompt diagnosis and treatment. If people have information they are empowered to manage their condition, which can lead to early detection and improved outcomes. Healthcare professionals should carefully consider the timing of giving information, because adults with cancer receive a wide variety of supporting information about the disease. It is important to communicate information about MSCC clearly, and to emphasise the importance of being aware of the symptoms.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults at high risk of developing MSCC, and their families or carers (as appropriate), are given information that describes the symptoms of MSCC and what to do if they develop symptoms.
Data source: Local data collection. Department of Health Acute Oncology Measures 11-1E-105y (Network Information on Early Detection of MSCC) and 11-3Y-311 (Patient Information on Early Detection of MSCC) Manual for cancer services: acute oncology – including metatastic spinal cord compression measures (2011).
Process
Proportion of adults identified as at high risk of developing MSCC, or their families or carers, who receive information that describes the symptoms of MSCC and what to do if they develop symptoms.
Numerator – the number of adults in the denominator or their family member or carer who receive information when they are identified as at risk that describes the symptoms of MSCC and what to do if they develop symptoms.
Denominator – the number of adults identified as at high risk of developing MSCC.
Data source: Local data collection. NICE audit support for Metastatic spinal cord compression (NICE clinical guideline 75).

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that patient information about the symptoms of MSCC is available, and that healthcare professionals are trained to understand and explain the information and to give it to adults at high risk of developing MSCC, and their families or carers (as appropriate).
Healthcare professionals in both primary and secondary care ensure that they understand and can explain the patient information about the symptoms of MSCC, and that they give this information to adults at high risk of developing MSCC, and their families or carers (as appropriate).
Commissioners ensure that they commission services that provide patient information about the symptoms of MSCC, and that they train healthcare professionals to understand and explain the information and give it to adults at high risk of developing MSCC, and their families or carers (as appropriate).

What the quality statement means for patients, service users and carers

Adults at high risk of MSCC, and their families or carers (as appropriate), are given information that describes the symptoms to look out for, and advice on what to do if they notice any symptoms of MSCC developing.

Source guidance

  • Metastatic spinal cord compression (NICE clinical guideline 75), recommendation 1.3.1.1 (key priority for implementation).

Definitions of terms used in this quality statement

Adults at high risk of MSCC
Adults with cancer who have, or who are at high risk of developing, bone metastases, and adults with cancer who present with spinal pain. [Adapted from NICE clinical guideline 75 recommendation 1.3.1.1]
Adults at high risk of developing bone metastases
This group includes, but is not limited to, adults with known cancer of the lung, breast or prostate, or myeloma. The risk can be determined by identifying the tumour site, grade and stage at presentation. [Definition developed from expert consensus]
Information that describes the symptoms of MSCC
Information may be in the form of, for example, a leaflet, a ‘red flag’ card, or audio/visual materials. It should list the early warning symptoms of MSCC, together with clear advice on what action to take if any symptoms develop.
NICE has produced information for the public about MSCC. In addition, the full clinical guideline on MSCC includes an example of a patient information leaflet. [Definition developed from the full clinical guideline 75 appendix 2 and expert consensus]
Symptoms of MSCC
The following symptoms are suggestive of MSCC:
  • progressive pain in the spine
  • severe unremitting spinal pain
  • spinal pain aggravated by straining (for example, when passing stools, when coughing or sneezing, or when moving)
  • pain described as ‘band like’
  • localised spinal tenderness
  • nocturnal spinal pain preventing sleep
  • neurological symptoms: radicular pain, any limb weakness, difficulty in walking, sensory loss, or bladder or bowel dysfunction.
[Definition developed from NICE clinical guideline 75 recommendations 1.3.2.1 and 1.3.2.2 and expert consensus]

Equality and diversity considerations

All information given about the symptoms of MSCC and what to do if symptoms develop should be accessible to people with additional needs, such as physical, sensory or learning disabilities, and to people who do not speak or read English. Adults at high risk of developing MSCC should have access to an interpreter or advocate if needed.

Imaging and treatment plans for adults with suspected spinal metastases

This quality statement is taken from the metastatic spinal cord compression quality standard. The quality standard defines clinical best practice in metastatic spinal cord compression care and should be read in full.

Quality statement

Adults with spinal pain suggestive of spinal metastases, but with no neurological symptoms or signs, have an MRI of the whole spine and any necessary treatment plan agreed within 1 week of the suspected diagnosis.

Rationale

Adults with spinal pain suggestive of spinal metastases need timely access to imaging that will accurately identify spinal metastases. Whole-spine MRI is central to the diagnosis, staging and planning of treatment. If spinal metastases are suspected, it is essential that investigation, planning and treatment take place before any loss of neurological function occurs. To reduce the risk of avoidable disability for adults with suspected spinal metastases, it is important that an MRI is performed and that treatment is planned by senior clinical advisers, within 1 week of the suspected diagnosis.

Quality measures

Structure
Evidence of local arrangements and written protocols to ensure that adults with spinal pain suggestive of spinal metastases, but with no neurological symptoms or signs, have an MRI of the whole spine and any necessary treatment plan agreed within 1 week of the suspected diagnosis.
Data source: Local data collection.
Process
a) Proportion of adults with spinal pain suggestive of spinal metastases, but with no neurological symptoms or signs, who receive an MRI of the whole spine within 1 week of the suspected diagnosis.
Numerator – the number of adults in the denominator who receive an MRI of the whole spine within 1 week of presenting with spinal pain suggestive of spinal metastases, but with no neurological symptoms or signs.
Denominator – the number of adults who present with spinal pain suggestive of spinal metastases, but with no neurological symptoms or signs.
b) Proportion of adults with spinal metastases confirmed by MRI of the whole spine, but with no neurological symptoms or signs, who have a treatment plan agreed within 1 week of the suspected diagnosis.
Numerator – the number of adults in the denominator who have a treatment plan agreed within 1 week of presenting with spinal pain suggestive of spinal metastases, but with no neurological symptoms or signs.
Denominator – the number of adults with spinal metastases confirmed by MRI of the whole spine, but with no neurological symptoms or signs.
Data source: Local data collection. British Spine Registry Spinal tumour data (2013).
Outcome
a) Proportion of adults with spinal metastases who are able to walk within 3 months of treatment.
b) Proportion of adults with spinal metastases who are able to walk within 2 years of treatment.
c) Rates of mortality within 30 days of treatment.
Data source: Local data collection. British Spine Registry Spinal tumour data (2013).

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that adequate capacity is available for whole-spine MRI scanning and treatment planning to be undertaken within 1 week for adults with suspected spinal metastases who present with spinal pain but with no neurological symptoms or signs.
Healthcare professionals ensure that they perform an MRI of the whole spine for adults with suspected spinal metastases who present with spinal pain but with no neurological symptoms or signs, and agree any necessary treatment plan within 1 week of the suspected diagnosis.
Commissioners ensure that they commission services that can provide MRI scanning and treatment planning by senior clinical advisers within 1 week of the suspected diagnosis of spinal metastases for adults who have spinal pain but no neurological symptoms or signs.

What the quality statement means for patients, service users and carers

Adults with suspected spinal metastases (who have spinal pain only) have an MRI of their whole spine and, if necessary, have a plan for their treatment organised within 1 week of the suspected diagnosis.

Source guidance

  • Metastatic spinal cord compression (NICE clinical guideline 75), recommendation 1.4.3.3 (key priority for implementation).

Definitions of terms used in this quality statement

Symptoms of spinal metastases
The following symptoms are suggestive of spinal metastases:
  • progressive pain in the spine
  • severe unremitting spinal pain
  • localised spinal tenderness
  • nocturnal spinal pain preventing sleep.
[Definition developed from NICE clinical guideline 75 recommendation 1.3.2.1 and expert consensus]
Senior clinical advisers
Includes clinical oncologists, spinal surgeons and radiologists with experience and expertise in treating adults with spinal metastases. [Adapted from NICE clinical guideline 75 recommendation 1.1.2.4]
Treatment plan
A treatment plan for adults with spinal metastases should be agreed by senior clinical advisers, and the names of those involved in the discussion should be included in the documentation. Treatment planning should take account of:
  • spinal stability, which should be assessed both clinically and radiologically
  • the degree of neurological disability
  • the general health of the patient
  • the prognosis, which should be estimated using a validated scoring system
  • the primary site of tumour
  • the presence of other spinal and extraspinal metastases
  • the likely response of the tumour to radiotherapy or other adjuvant therapy
  • the patient’s care and treatment preferences.
[The full clinical guideline 75, section 6.1 and expert consensus]

Imaging and treatment plans for adults with suspected metastatic spinal cord compression

This quality statement is taken from the metastatic spinal cord compression quality standard. The quality standard defines clinical best practice in metastatic spinal cord compression care and should be read in full.

Quality statement

Adults with suspected metastatic spinal cord compression (MSCC) who present with neurological symptoms or signs have an MRI of the whole spine and any necessary treatment plan agreed within 24 hours of the suspected diagnosis.

Rationale

Adults with suspected MSCC who present with neurological symptoms or signs need rapid access to imaging that will accurately identify spinal cord compression. Whole spine MRI is central to the diagnosis, staging and planning of treatment. Neurological deficit at initial presentation is an important predictor of long-term functional outcome. To reduce the risk of avoidable disability for adults with suspected MSCC, it is important that both an MRI is performed and treatment is planned by senior clinical advisers, within 24 hours of the suspected diagnosis.

Quality measures

Structure
Evidence of local arrangements and written protocols to ensure that adults with suspected MSCC, who present with neurological symptoms or signs, have an MRI of the whole spine and any necessary treatment plan agreed within 24 hours of the suspected diagnosis.
Data source: Local data collection. Department of Health Acute Oncology Measures 11-1E-110y (The MSCC Case Discussion Policy) and 11-1E-111y (The Audit of Timeliness of the Investigation of MSCC) Manual for cancer services: acute oncology – including metatastic spinal cord compression measures (2011).
Process
a) Proportion of adults with suspected MSCC who present with neurological symptoms or signs who receive an MRI of the whole spine within 24 hours of the suspected diagnosis.
Numerator – the number of adults in the denominator who receive an MRI of the whole spine within 24 hours of presenting with suspected MSCC and neurological symptoms or signs.
Denominator – the number of adults with suspected MSCC who present with neurological symptoms or signs.
Data source: Local data collection. Department of Health Acute Oncology Measures 11-1E-111y (The Audit of Timeliness of the Investigation of MSCC) Manual for cancer services: acute oncology – including metatastic spinal cord compression measures (2011). British Spine Registry Spinal tumour data (2013).
b) Proportion of adults with MSCC confirmed by MRI of the whole spine, who presented with neurological symptoms or signs, who have a treatment plan agreed within 24 hours of the suspected diagnosis.
Numerator – the number of adults in the denominator who have a treatment plan agreed within 24 hours of presenting with suspected MSCC and neurological symptoms or signs.
Denominator – the number of adults with MSCC confirmed by MRI of the whole spine who presented with neurological symptoms or signs, who have a diagnosis of MSCC confirmed after an MRI of the whole spine.
Data source: Local data collection. NICE audit support for Metastatic spinal cord compression (NICE clinical guideline 75). British Spine Registry Spinal tumour data (2013).
Outcome
a) Proportion of adults with MSCC who are able to walk within 3 months of treatment.
b) Proportion of adults with MSCC who are able to walk within 2 years of treatment.
c) Rates of mortality within 30 days of treatment.
Data source: Local data collection. Department of Health Acute Oncology Measures 11-1E-113y Manual for cancer services: acute oncology – including metatastic spinal cord compression measures (2011). British Spine Registry Spinal tumour data (2013).

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that adequate capacity is available for whole-spine MRI scanning and treatment planning to be undertaken within 24 hours for adults with suspected MSCC who present with neurological symptoms or signs.
Healthcare professionals ensure that they perform an MRI of the whole spine for adults with suspected MSCC who present with neurological symptoms or signs, and that if a diagnosis of MSCC is confirmed they agree a treatment plan within 24 hours of the suspected diagnosis.
Commissioners ensure that they commission services that can provide MRI scanning and treatment planning by senior clinical advisers within 24 hours of the suspected diagnosis, for adults with suspected MSCC who present with neurological symptoms or signs.

What the quality statement means for patients, service users and carers

Adults with suspected MSCC have an MRI of their whole spine and, if a diagnosis of MSCC is confirmed by the MRI, a plan for their treatment organised within 24 hours of the suspected diagnosis.

Source guidance

  • Metastatic spinal cord compression (NICE clinical guideline 75), recommendation 1.4.3.3 (key priority for implementation).

Definitions of terms used in this quality statement

Symptoms and signs of MSCC
The following symptoms and signs are suggestive of MSCC:
  • progressive pain in the spine
  • severe unremitting spinal pain
  • spinal pain aggravated by straining (for example, at stool, when coughing or sneezing, or when moving)
  • pain described as ‘band like’
  • localised spinal tenderness
  • nocturnal spinal pain preventing sleep
  • neurological symptoms: radicular pain, any limb weakness, difficulty in walking, sensory loss, or bladder or bowel dysfunction
  • neurological signs of spinal cord or cauda equina compression.
[Definition developed from NICE clinical guideline 75 recommendations 1.3.2.1 and 1.3.2.2 and expert consensus]
Senior clinical advisers
Includes clinical oncologists, spinal surgeons and radiologists with experience and expertise in treating adults with MSCC. [NICE clinical guideline 75 recommendation 1.1.2.4]
Treatment plan
A treatment plan for adults with MSCC should be agreed by senior clinical advisers, and the names of those involved in the discussion should be included in the documentation. Treatment planning should take account of:
  • spinal stability, which should be assessed both clinically and radiologically
  • the degree of neurological disability
  • the general health of the patient
  • the prognosis, which should be estimated using a validated scoring system
  • the primary site of tumour
  • the presence of other spinal and extraspinal metastases
  • the likely response of the tumour to radiotherapy or other adjuvant therapy
  • the patient’s care and treatment preferences.
[The full clinical guideline 75, section 6.1 and expert consensus]

Coordinating investigations for adults with suspected metastatic spinal cord compression

This quality statement is taken from the metastatic spinal cord compression quality standard. The quality standard defines clinical best practice in metastatic spinal cord compression care and should be read in full.

Quality statement

Adults with suspected metastatic spinal cord compression (MSCC) who present with neurological symptoms or signs have their diagnostic investigations coordinated by an MSCC coordinator.

Rationale

Some adults with cancer who have a high risk of developing bone metastases are at high risk of developing MSCC. When people present with suspected MSCC, it is important that diagnostic investigations are undertaken promptly. The principal role of the MSCC coordinator for adults with suspected MSCC is to liaise with healthcare professionals and ensure that investigations are organised and undertaken without delay. For those with neurological symptoms or signs it is particularly important that an MSCC coordinator is available at all times to ensure that initial management for adults with MSCC is both comprehensive and timely.

Quality measures

Structure
a) Evidence of local arrangements for identifying individuals responsible for performing the role of MSCC coordinator.
b) Evidence of local arrangements to ensure that adults with suspected MSCC who present with neurological symptoms or signs have their diagnostic investigations coordinated by an MSCC coordinator.
Data source: Local data collection. Department of Health Acute Oncology Measures 11-3Y-304 Manual for cancer services: acute oncology – including metatastic spinal cord compression measures (2011).
Process
Proportion of adults with suspected MSCC who present with neurological symptoms or signs who have an assessment of their requirement for, and urgency of investigations, undertaken by an MSCC coordinator.
Numerator – the number of adults in the denominator who have an assessment of their requirement for, and urgency of investigations, undertaken by an MSCC co-ordinator.
Denominator – the number of adults with suspected MSCC who present with neurological symptoms or signs.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers ensure that an MSCC coordinator is available at all times to coordinate the diagnostic investigations for adults with suspected MSCC who present with neurological symptoms or signs.
Healthcare professionals ensure that adults with suspected MSCC who present with neurological symptoms or signs have their diagnostic investigations organised by the MSCC coordinator.
Commissioners ensure that they commission services that provide access to an MSCC coordinator, available at all times, to coordinate diagnostic investigations for adults with suspected MSCC who are referred from primary or secondary care.

What the quality statement means for patients, service users and carers

Adults with suspected MSCC who have neurological symptoms or signs have their tests and investigations arranged by a coordinator.

Source guidance

Definitions of terms used in this quality statement

Adults at high risk of MSCC
Adults with cancer who have, or who are at high risk of developing, bone metastases, and adults with cancer, who present with spinal pain. [Adapted from NICE clinical guideline 75 recommendation 1.3.1.1]
MSCC coordinator role
The role involves coordinating the ongoing care of adults with MSCC and the diagnostic investigations of people at risk of developing MSCC who present with relevant symptoms. An MSCC coordinator should be available 24 hours a day, 7 days a week, acting as a single point of contact for healthcare professionals to liaise with.
The MSCC coordinator’s responsibilities and the support they should receive are described in NICE clinical guideline 75 recommendations 1.1.2.3 and 1.1.2.5.
The Manual for cancer services: acute oncology – including metatastic spinal cord compression measures (2011; measure 11-3Y-304) lists the criteria that the MSCC coordinator service should fulfil.
Symptoms and signs of MSCC
The following symptoms and signs are suggestive of MSCC:
  • progressive pain in the spine
  • severe unremitting spinal pain
  • spinal pain aggravated by straining (for example, at stool, when coughing or sneezing, or when moving)
  • pain described as ‘band like’
  • localised spinal tenderness
  • nocturnal spinal pain preventing sleep
  • neurological symptoms: radicular pain, any limb weakness, difficulty in walking, sensory loss, or bladder or bowel dysfunction
  • neurological signs of spinal cord or cauda equina compression.
[Definition developed from NICE clinical guideline 75 recommendations 1.3.2.1 and 1.3.2.2 and expert consensus]

Coordinating care for adults with metastatic spinal cord compression

This quality statement is taken from the metastatic spinal cord compression quality standard. The quality standard defines clinical best practice in metastatic spinal cord compression care and should be read in full.

Quality statement

Adults with metastatic spinal cord compression (MSCC) have their ongoing care coordinated by an MSCC coordinator.

Rationale

The care and treatment of adults with MSCC may involve a number of specialties including oncology, surgery and radiology. It is important that the ongoing investigations and treatments are undertaken promptly because early intervention has a positive effect on MSCC outcomes. The principal role of the MSCC coordinator for adults with MSCC is to liaise with the relevant specialists and organise treatment and any ongoing investigations, ensuring that the ongoing care of adults with MSCC is both comprehensive and timely.

Quality measures

Structure
a) Evidence of local arrangements for identifying individuals responsible for performing the role of MSCC coordinator.
b) Evidence of local arrangements to ensure that adults with MSCC have their ongoing care coordinated by an MSCC coordinator.
Data source: Local data collection. Department of Health Acute Oncology Measures 11-3Y-304 (The MSCC Coordinator Service) Manual for cancer services: acute oncology – including metatastic spinal cord compression measures (2011).

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers ensure that an MSCC coordinator is available to coordinate the ongoing care for adults with MSCC.
Healthcare professionals ensure that they arrange access to the MSCC coordinator who will coordinate the ongoing care for adults with MSCC.
Commissioners ensure that they commission services that provide access to an MSCC coordinator who will coordinate the ongoing care for adults with MSCC.

What the quality statement means for patients, service users and carers

Adults with MSCC have their treatment organised by a coordinator who will oversee important aspects of care on their behalf.

Source guidance

Definitions of terms used in this quality statement

MSCC coordinator role
The role involves coordinating the ongoing care of adults with MSCC and the diagnostic investigations of people at risk of developing MSCC who present with relevant symptoms. An MSCC coordinator should be available 24 hours a day, 7 days a week, acting as a single point of contact for healthcare professionals to liaise with.
The MSCC coordinator’s responsibilities and the support they should receive are described in NICE clinical guideline 75 recommendations 1.1.2.3 and 1.1.2.5.
The Manual for cancer services: acute oncology – including metatastic spinal cord compression measures (2011; measure 11-3Y-304) lists the criteria that the MSCC coordinator service should fulfil.

Treatment of metastatic spinal cord compression

This quality statement is taken from the metastatic spinal cord compression quality standard. The quality standard defines clinical best practice in metastatic spinal cord compression care and should be read in full.

Quality statement

Adults with metastatic spinal cord compression (MSCC), who present with neurological symptoms or signs, start definitive treatment (if appropriate) within 24 hours of the confirmed diagnosis.

Rationale

Treatment while patients are still able to move or walk around is effective in maintaining their ability to walk and functional independence. Delay in treatment may have irreversible consequences, such as loss of motor and bladder functions. Starting definitive treatment as a matter of urgency is important for adults with MSCC because it can help to prevent further neurological deterioration, which may lead to paraplegia. People who develop paraplegia have a significantly impaired quality of life and shortened survival, and so it is important to identify possible ways of preventing or improving the outcome of MSCC.

Quality measures

Structure
Evidence of local arrangements and written protocols to ensure that adults with MSCC who present with neurological symptoms or signs start definitive treatment (if appropriate) within 24 hours of the confirmed diagnosis.
Data source: Local data collection. Department of Health Acute Oncology Measures 11-1E-112y (The Audit of Timeliness of Definitive Treatment of MSCC) Manual for cancer services: acute oncology – including metatastic spinal cord compression measures (2011).
Process
Proportion of adults with MSCC who present with neurological symptoms or signs who start definitive treatment (if appropriate) within 24 hours of the confirmed diagnosis.
Numerator – the number of adults in the denominator who start definitive treatment within 24 hours of the confirmed diagnosis.
Denominator – the number of adults with MSCC who present with neurological symptoms or signs for whom it is appropriate to start definitive treatment within 24 hours.
Data source: Local data collection. Department of Health Acute Oncology Measures 11-1E-112y (The Audit of Timeliness of Definitive Treatment of MSCC) Manual for cancer services: acute oncology – including metatastic spinal cord compression measures (2011).
Outcome
a) Proportion of adults with MSCC who are able to walk within 3 months of treatment.
b) Proportion of adults with MSCC who are able to walk within 2 years of treatment.
c) Rates of mortality within 30 days of treatment.
Data source: Local data collection. Department of Health Acute Oncology Measures 11-1E-113y Manual for cancer services: acute oncology – including metatastic spinal cord compression measures (2011). British Spine Registry Spinal tumour data (2013).

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers ensure that for adults with MSCC presenting with neurological symptoms or signs adequate capacity is available and that there are local protocols in place to enable healthcare professionals to start definitive treatment (if appropriate) within 24 hours of the confirmed diagnosis.
Healthcare professionals ensure that for adults with MSCC who present with neurological symptoms or signs they start definitive treatment (if appropriate) within 24 hours of the diagnosis being confirmed.
Commissioners ensure that for adults with MSCC who present with neurological symptoms or signs they commission services that can start definitive treatment (if appropriate) within 24 hours of the confirmed diagnosis.

What the quality statement means for patients, service users and carers

Adults with MSCC for whom treatment is appropriate start their treatment as quickly as possible (ideally within 24 hours of being diagnosed with MSCC).

Source guidance

Definitions of terms used in this quality statement

Definitive treatment
Definitive treatment for MSCC includes surgery and radiotherapy. [Department of Health Acute Oncology Measures (The Audit of Timeliness of Definitive Treatment of MSCC) Manual for cancer services: acute oncology – including metatastic spinal cord compression measures (2011)]
Symptoms and signs of MSCC
The following symptoms and signs are suggestive of MSCC:
  • progressive pain in the spine
  • severe unremitting spinal pain
  • spinal pain aggravated by straining (for example, at stool, when coughing or sneezing, or when moving)
  • pain described as ‘band like’
  • localised spinal tenderness
  • nocturnal spinal pain preventing sleep
  • neurological symptoms: radicular pain, any limb weakness, difficulty in walking, sensory loss, or bladder or bowel dysfunction.
  • neurological signs of spinal cord or cauda equina compression.
[Definition developed from NICE clinical guideline 75 recommendations 1.3.2.1 and 1.3.2.2 and expert consensus]

Equality and diversity considerations

Survival times for adults with MSCC vary from just a few weeks to over a decade. The person’s age should not affect the decision to undertake definitive treatment.

Supportive care and rehabilitation

This quality statement is taken from the metastatic spinal cord compression quality standard. The quality standard defines clinical best practice in metastatic spinal cord compression care and should be read in full.

Quality statement

Adults with metastatic spinal cord compression (MSCC) have a management plan that includes an assessment of ongoing care and rehabilitation needs.

Rationale

It is important that personalised management planning for adults with MSCC starts on admission because rehabilitation and supportive care are integral to the promotion of independence and quality of life for adults with MSCC. Emphasis should be on an individualised, person-centred management planning process, led by a key worker, which takes into account care relating to all existing healthcare issues the person may have, including cancer. Communication between secondary, primary and tertiary care needs to ensure a seamless transfer between services and continuity of care for patients.

Quality measures

Structure
Evidence of local arrangements and written protocols to ensure that management planning for adults with MSCC includes an assessment of ongoing care and rehabilitation needs.
Data source: Local data collection.
Process
Proportion of adults with MSCC who are discharged from hospital with a management plan that includes an assessment of ongoing care and rehabilitation needs.
Numerator – the number of adults in the denominator who have a management plan on discharge.
Denominator – the number of adults with MSCC who are admitted to hospital.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that staff are trained on how to develop management plans, including how to undertake an assessment of ongoing care and rehabilitation needs for adults with MSCC, and have protocols in place for starting management planning on admission.
Healthcare professionals involve adults with MSCC in developing management plans that include an assessment of ongoing care and rehabilitation needs for adults with MSCC when they are admitted to hospital.
Commissioners ensure that they commission services that train their staff on how to develop management plans including how to undertake an assessment of ongoing care and rehabilitation needs for adults with MSCC, and have protocols in place for starting management planning on admission.

What the quality statement means for patients, service users and carers

Adults with MSCC have a plan of the ongoing care they agree they will receive after they have been discharged from hospital, which will include plans for rehabilitation.

Source guidance

  • Metastatic spinal cord compression (NICE clinical guideline 75), recommendation 1.6.5.4 (key priority for implementation).

Definitions of terms used in this quality statement

Management planning and ongoing care
For adults with MSCC, this should start on admission and it should involve: the patient; their families and carers with the patient’s consent; their primary oncology site; surgical, specialist palliative care and rehabilitation teams and community support, including primary care, as needed. The management plan should address physical and psychological needs. Management planning should include, but not be limited to, consideration of: pressure ulcers, continence, maintenance of circulatory and respiratory functioning, psychological adjustment and location of care. [NICE clinical guideline 75 recommendation 1.6.5.4 and expert consensus]
Key worker
Person who, with the patient’s consent and agreement, takes the leading role in coordinating the patient’s care and promoting continuity, ensuring the patient knows who to access for information and advice, regardless of the patient’s location. The role may be undertaken by the MSCC coordinator or by a different named individual. Different practitioners are likely to perform this function on behalf of individual patients over time. [Adapted from the full clinical guideline 75, appendix 6, glossary; NICE cancer service guidance on Supportive and palliative care, recommendation 1.29 and expert consensus]

Equality and diversity considerations

Survival times for adults with MSCC vary from just a few weeks to over a decade. MSCC is closely associated with the end of life because of its high incidence in the late stages of advanced malignancy. The timing of discussions about ongoing care and rehabilitation should be sensitive to the emotional adjustments that the patient and carer may be experiencing.
The person’s age should not affect the content of the discharge plan or their access to rehabilitation services. Healthcare professionals should consider whether adults with MSCC who are experiencing the later stages of cancer may benefit more from readjustment rather than rehabilitation.

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Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics:

Information about the metastatic spinal cord compression quality standard

NICE has also written a document for patients and the public explaining its quality standard for metastatic spinal cord compression.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

22 April 2014 Links to the pressure ulcers pathway have been added.
26 February 2014 Quality standard on metastatic spinal cord compression added to the pathway.
23 January 2014 Minor maintenance updates.
10 September 2013 A link to the 'Urinary incontinence in women pathway' has been added.
15 February 2013 Minor maintenance updates.
30 October 2012 Minor maintenance updates.
23 October 2012 'Denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours' (NICE technology appraisal guidance 265) added to bisphosphonates and denosumab.
11 May 2012 Online educational tool added to the 'Into practice' menu.

Supporting information

Glossary

Metastatic spinal cord compression
Spinal pain that is not progressive, severe or aggravated by straining and has no accompanying neurological symptoms
Magnetic resonance imaging

Patients without a prior diagnosis of cancer, with suspicious spinal pain

Patients without a prior diagnosis of cancer, with suspicious spinal pain

Patients without a prior diagnosis of cancer, with suspicious spinal pain

Review frequently patients without a prior diagnosis of cancer who have suspicious spinal pain for:
Treat or refer patients without a prior diagnosis of cancer who have stable and mild symptoms of suspicious spinal pain, with or without neurological symptoms, by normal non-specific spinal pathways. Refer by cancer pathway if concerned.

Source guidance

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Patients with cancer

Patients with cancer

Patient information and support

Patient information and support

Patient information and support

Give patients with cancer and spinal pain, patients with bone metastases and patients at high risk of developing bone metastases information explaining what to do and who to contact if they develop symptoms of spinal metastases or MSCC or if their symptoms progress while waiting for investigation.
Ensure that communication with patients is clear and consistent, and that patients, families and carers are fully informed and involved in all decisions about treatment
NICE has written information for the public explaining the guidance on MSCC.
Offer specialist psychological and spiritual support at diagnosis, during treatment and on discharge from hospital. Explain how to access these services.

Quality standards

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Source guidance

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Patients with non-specific lumbar spinal pain

Patients with non-specific lumbar spinal pain

Patients with non-specific lumbar spinal pain

Review frequently patients with cancer who have non-specific lumbar spinal pain who have suspicious spinal pain for:
  • development of progressive pain or other symptoms suggestive of spinal metastases (contact the MSCC coordinator within 24 hours), or
  • development of neurological symptoms or signs suggestive of MSCC (contact the MSCC coordinator immediately).

Implementation tools

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Source guidance

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Symptoms suggestive of spinal metastases

Symptoms suggestive of spinal metastases

Symptoms suggestive of spinal metastases

If patients with cancer have symptoms suggestive of spinal metastases, discuss with the MSCC coordinator within 24 hours.
Symptoms suggestive of spinal metastases:
  • pain in the thoracic or cervical spine
  • progressive lumbar spinal pain
  • severe unremitting lumbar spinal pain
  • spinal pain aggravated by straining
  • localised spinal tenderness
  • nocturnal spinal pain preventing sleep.

Source guidance

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Symptoms of spinal metastases, and neurological symptoms or signs suggestive of metastatic spinal cord compression

Symptoms of spinal metastases, and neurological symptoms or signs suggestive of metastatic spinal cord compression

Symptoms of spinal metastases, and neurological symptoms or signs suggestive of metastatic spinal cord compression

If patients with cancer and symptoms suggestive of spinal metastases have neurological symptoms or signs suggestive of MSCC, discuss with the MSCC coordinator immediately and view as an emergency.
Neurological symptoms or signs suggestive of MSCC:
  • radicular pain
  • limb weakness
  • difficulty walking
  • sensory loss
  • bladder or bowel dysfunction
  • signs of spinal cord or cauda equina compression.

Source guidance

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Imaging

Imaging

Imaging

Before imaging or hospital transfer

If possible discuss patients with suspected MSCC, a poor performance status and widespread metastatic disease with their primary tumour site clinician and spinal senior clinical adviser before any urgent imaging or hospital transfer.
If possible urgently discuss patients with suspected MSCC who have been completely paraplegic or tetraplegic for more than 24 hours with their primary tumour site clinician and spinal senior clinical adviser before any imaging or hospital transfer.
Do not transfer unnecessarily patients with MSCC who are too frail or unfit for specialist treatment.

Magnetic resonance imaging

Perform MRI of the whole spine in patients with suspected MSCC, unless contraindicated.
Include sagittal T1, short T1 inversion recovery and sagittal T2 weighted sequences.
Perform supplementary axial imaging through any significant abnormality noted on the sagittal scan.
Configure lists to allow MRI at short notice. Out-of-hours MRI should be available in emergency situations if immediate treatment is planned.
If MRI is not available at the referring hospital, transfer patients with suspected MSCC to a unit with 24-hour capability.
Perform MRI in time to plan definitive treatment:
  • within 1 week in patients with symptoms suggestive of spinal metastases
  • within 24 hours in patients with symptoms suggestive of spinal metastases and neurological symptoms or signs suggestive of MSCC
  • sooner (including out-of-hours) if emergency treatment is needed.

Other imaging options

If MRI is contraindicated, contact the MSCC coordinator to determine the best imaging option.
Consider myelography if other imaging options are contraindicated or inadequate. Undertake myelography only at a neuroscience or spinal surgery centre.
Consider targeted computerised tomography to assess spinal stability and plan vertebroplasty, kyphoplasty or surgery.
Do not use plain radiographs to diagnose or exclude spinal metastases or MSCC.
Do not routinely image the spine if patients with malignancy are asymptomatic.
Serial imaging of the spine in asymptomatic patients with cancer at high risk of developing spinal metastases should only be done as part of a randomised controlled trial.

Quality standards

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Source guidance

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Service organisation

Service organisation

Service organisation

Cancer networks should:
  • have a clear care pathway for the diagnosis, treatment, rehabilitation and ongoing care of patients with MSCC
  • commission and monitor appropriate services throughout the care pathway
  • ensure that access to MRI is available within 24 hours for all patients with suspected MSCC and 24-hour availability of MRI at centres treating patients with MSCC
  • establish a network site specific group for MSCC, including representatives from primary, secondary and tertiary care. This group should have strong links to the network site specific groups for primary tumours
  • appoint a network lead for MSCC.
The network lead for MSCC should:
  • advise the network, commissioners and providers about the provision and organisation of services
  • ensure that the local care pathway is documented, agreed and consistent
  • ensure that there are appropriate points of telephone contact to an MSCC coordinator and senior clinical advisers
  • maintain a network-wide audit of the care pathway and outcomes of patients
  • arrange and chair twice-yearly meetings of the network site specific group to discuss patient outcomes and review the care pathway.
Secondary or tertiary care centres should have an identified lead healthcare professional for MSCC who:
  • represents the hospital at network level to develop the care pathway
  • implements the care pathway and disseminates information about the diagnosis and appropriate management of patients
  • ensures good communication between all healthcare professionals involved in the care of patients with MSCC
  • raises awareness of the treatment options
  • contributes to regular audits of the care pathway
  • attends and contributes to the twice-yearly network site specific group meeting.
Every centre that treats patients with MSCC should:
  • identify or appoint individuals to the role of MSCC coordinator and ensure coordinator availability at all times
  • have a single point of contact to access the MSCC coordinator to advise clinicians and coordinate the care pathway
  • ensure 24-hour availability of senior clinical advisers to advise and support the MSCC coordinator and other clinicians and undertake treatment where necessary.
The MSCC coordinator should:
  • provide the first point of contact for clinicians who suspect that a patient may be developing spinal metastases or MSCC
  • perform an initial telephone triage by assessing requirement for, and urgency of, investigations, transfer and treatment
  • advise on the immediate care of the spinal cord and spine and seek senior clinical advice, as necessary
  • gather baseline information to aid decision-making and collate data for audit purposes
  • identify the appropriate place for timely investigations and admission, if required
  • liaise with the acute receiving team and organise admission and mode of transport.
Commissioners and councils should work jointly to provide equipment and support (including nursing and rehabilitation services) to people with MSCC and their carers and families when they return home.
NICE has published cancer service guidance on:

Quality standards

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Source guidance

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Patient experience in adult NHS services pathway

View the 'Patient experience in adult NHS services overview' path

Paths in this pathway

Pathway created: January 2012 Last updated: April 2014

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

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