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Metastatic spinal cord compression
Short Text
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.
In 2011, the Department of Health published a Manual for cancer services: acute oncology – including metastatic spinal cord compression measures.
Source guidance
The NICE guidance that was used to create the pathway.
Metastatic spinal cord compression. NICE clinical guideline 75 (2008)
Denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours. NICE technology appraisal guidance 265 (2012)
Quality standards
Quality statements
Effective interventions library
Successful effective interventions library details
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.
Service improvement and audit
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
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
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 someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their 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.
Updates to this pathway
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 with spinal pain
Patients with spinal pain
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:
- 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).
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
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePatient 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.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePatients 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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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeSymptoms 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.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeSymptoms 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.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeImaging
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.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeTreatment and care
View the 'Metastatic spinal cord compression treatment and care' pathService 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:
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePaths in this pathway
- Metastatic spinal cord compression treatment and care
- Treatments for pain relief and to prevent metastatic spinal cord compression
Pathway created: January 2012 Last updated: February 2013
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