Emergencies in palliative care---Impending spinal cord compression
Author:zplhelen | Time: 2009-7-20 21:39:16A previous homework in palliative care.
1. Pathophysiology and cause
Spinal cord compression happens in about 5-10% cancer patients. The incidence depends on the type of primary cancer. The most common ones are breast cancer, prostate cancer, and lung cancer.[1]
The main pathophysiological pathway of its development in cancer patients is summarized below:[1]
A picture from The Lancet Oncology illustrates the pathway of spinal cord compression in another way (Pic. 1):[2]
Pic 1 Pathophysiology of spinal cord compression
Blue box: step in progression; Green box: outcome; Violet box: implicated molecular mechanisms; Yellow box: current therapeutic option; Orange box: experimental therapies. NSAIDS=non-steroidal anti-inflammatory drugs.
2. Assessment tools
In a study, the symptoms of spinal cord compression were assessed by performance (PS) and neurological status (NS). The Eastern Cooperative Oncology Group (ECOG) performance scale was used to assess performance status and neurological status was defined according to a neurological scale relating to functional ability. The details are listed below.[3]
I can’t find any specific assessment tools for spinal cord compression alone. I agree with above assessing ways because spinal cord compression affects patients mainly with its de-capability symptoms. So the severity of symptoms can reflect that of spinal cord compression. Pain assessment can also be included as it is a major symptom of spinal cord compression.[2]
3. Evidence-based interventions
A care pathway was developed in Cardiff, UK for management of spinal cord compression in 2004: Pic 2[4]
The goals of treatment are relief of pain, preservation of neurological function, and preservation of spinal stability. The optimal management of spinal cord compression remains controversial and the decision should be made according to the patients clinical status, their preferences for treatment and the therapeutic facilities available in the clinical settings.[5]
Interventions mainly include radiotherapy, surgery, and medications.
Surgery is quite limited in advanced cancer patients and only suitable for those with a life expectancy longer than 3 months and with favorable performance status, whose tumor is not radiosensitive. It is said that in selected patients, when compared with RT alone, surgery can improve functional outcomes, on a 2 type level of evidence.[5]Radiotherapy is the most common treatment for spinal cord compression in cancer patients. It can be used following decompression operations or used alone. The best radiotherapy regimen has not been established yet.[1] A prospective randomised trial has shown that direct decompressive surgery plus postoperative radiotherapy is better than radiotherapy alone.[6]
Corticosteroids like dexamethasone are commonly used in treating spinal cord compression. Corticosteroids have been agreed to be an effective medication for spinal cord compression, however, the optimal dose is not established and loading doses of 10mg to 100mg with single dose of 4mg to 24mg have been used.[1] Silvia et al recommended the following dosage and schedules on a type 3 level of evidence:
• dexamethasone 10–100 mg i.v. bolus followed by 16–96 mg daily orally.[5]
In another study, adapted Tomita scale was used to assess patients’ function and neurological status as in Table 1:[4]
Pic 2: Care pathway for management of spinal cord compression
Biphosphonates are indicated in patients with at least 6 months’ life expectancy. [1] Most of the clinical trials on bisphosphonates have been conducted on patients with metastatic breast cancer and multiple myeloma, but small studies on patients with other metastatic carcinomas have also demonstrated benefit.[7]
Chemotherapy is not commonly used except in patients with chemo-sensitive cancer.[1,5] First-line chemotherapy is recommended only for very young children with chemosensitive tumours in order to decrease the long-term sequelae of surgeries or spinal radiation on a type 3 level of evidence. And it is suitable for adults with chemosensitive tumours (lymphoma, myeloma, breast or germ cell tumours) who are not candidates for surgery or radiation on a type R basis only. [5]
4. Update the progress in management since 2001
D. Andrew Loblaw et al published a systematic review of treatment of malignant spinal cord compression(MSCC). It is concluded that high dose dexamethasone is an effective adjunct to RT, but may lead to serious side effects. So it is suggested that patients with good mobility should not be prescribed dexamethasone but be educated about symptoms of MSCC. Radiotherapy or surgery alone is good for selected patients, though optimal dose and fraction for RT is not established. However, It is not clear whether surgery plus radiotherapy is better than single treatment or not.[9]
The following conclusion is made: surgical management should be offered to patients with malignant spinal-cord compression when possible. Radiotherapy is an excellent adjuvant to surgery and may be used as the only management in patients who are unsuitable for surgery or when the aim is palliation.[2]
Biphosphonates seem to be a new kind of medicine used in spinal cord compression, but I can’t find any articles focus on this topic.
5. Identify other specialists for assistance
According to the care pathway above, a multidisciplinary team is helpful in managing this situation. Specialists in radiodiagnosis are needed in early diagnosing[8]. Radiologists and oncologists are needed for making radiotherapy/chemotherapy regimens. Surgeons are helpful in selecting patients for surgery. And palliative care specialists are necessary in symptom management such as pain.
In another article, the following facilities and departments are listed for assistance in diagnosing and managing spinal cord compression[5]:
Diagnostic facilities:
• Clinical departments: neurology, medical oncology or internal medicine.
• Radiological department: conventional radiology, computerized tomography (CT) scanners, magnetic resonance imaging (MRI), ultrasound (US) and medical staff skilled in neuroradiology.
• Laboratories: haematochemical, microbiological and histological tests must be available.
Therapeutic facilities:
• Department of Neurosurgery.
• Department of Radiotherapy.
• Department of Orthopedic Surgery.
• Department of Medical Oncology.
• Department of Internal Medicine.
The cooperation of the surgeon, the radiotherapist and the oncologist is strongly recommended. Unfortunately, palliative care specialists are not listed here.
6. What enhances or makes difficult the instigation in your work place?
In my clinical settings, most patients are dying and no surgeons dare do any surgery on them. Radiotherapy is unfeasible because of limited mobility of patients. Chemotherapy is neither used in such patients because they are too weak for that, and the side effects of chemotherapy may be very serious in these weak patients.
Dexamethasone is most commonly used for spinal cord compression. But the dose is relative small compared to the recommended one mentioned above: 5-10mg/d is used. The reason is the superior doctor always think Asian patients, especially Chinese patients, need smaller dose than western patients because their body mass is smaller, and dying patients with cachexia require smaller dose than other patients.
Biphosphonates are used in patients who can afford such expensive medicines. But they are also used in patients with life expectancy shorter than 6 months because of some private benefit of the superior physicians.
Reference:
1. Dirk Rades and Steven E. Schild. Spinal cord compression. European Journal of Cancer Supplements, Volume 5, Issue 5, September 2007, Pages 359-370
2. Dheerendra Prasad and David Schiff. Malignant spinal-cord compression. The Lancet Oncology, Volume 6, Issue 1, January 2005, Pages 15-24
3. Jane Cowap, Janet R. Hardy and Roger A'Hern. Outcome of Malignant Spinal Cord Compression at a Cancer Center: Implications for Palliative Care Services. Journal of Pain and Symptom Management, Volume 19, Issue 4, April 2000, Pages 257-264
4. N. J. Pease, R. J. Harris and I. G. Finlay. Development and audit of a care pathway for the management of patients with suspected malignant spinal cord compression. Physiotherapy, Volume 90, Issue 1, March 2004, Pages 27-34
5. Silvia Spinazzé, Augusto Caraceni and Dirk Schrijvers. Epidural spinal cord compression. Critical Reviews in Oncology/Hematology, Volume 56, Issue 3, December 2005, Pages 397-406
6. R. Patchell, P. Tibbs and W. Regine et al., Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial, Lancet 366 (2005), pp. 643–648.
7. Daniel M. Sciubba and Ziya L. Gokaslan. Diagnosis and management of metastatic spine disease. Surgical Oncology Volume 15, Issue 3, November 2006, Pages 141-151
8. Jane Cowap, Janet R. Hardy and Roger A'Hern. Outcome of Malignant Spinal Cord Compression at a Cancer Center: Implications for Palliative Care Services. Journal of Pain and Symptom Management, Volume 19, Issue 4, April 2000, Pages 257-264
9. D. A. Loblaw, J. Perry, et al. Systematic review of the diagnosis and management of malignant extradural spinal cord compression: the cancer care Ontario practice guidelines initiative’s neuron-oncology disease site group. Journal of Clinical Oncology 2005, 23(9): pg 2028-2037
1. Pathophysiology and cause
Spinal cord compression happens in about 5-10% cancer patients. The incidence depends on the type of primary cancer. The most common ones are breast cancer, prostate cancer, and lung cancer.[1]
The main pathophysiological pathway of its development in cancer patients is summarized below:[1]
A picture from The Lancet Oncology illustrates the pathway of spinal cord compression in another way (Pic. 1):[2]
Pic 1 Pathophysiology of spinal cord compression
Blue box: step in progression; Green box: outcome; Violet box: implicated molecular mechanisms; Yellow box: current therapeutic option; Orange box: experimental therapies. NSAIDS=non-steroidal anti-inflammatory drugs.
2. Assessment tools
In a study, the symptoms of spinal cord compression were assessed by performance (PS) and neurological status (NS). The Eastern Cooperative Oncology Group (ECOG) performance scale was used to assess performance status and neurological status was defined according to a neurological scale relating to functional ability. The details are listed below.[3]
I can’t find any specific assessment tools for spinal cord compression alone. I agree with above assessing ways because spinal cord compression affects patients mainly with its de-capability symptoms. So the severity of symptoms can reflect that of spinal cord compression. Pain assessment can also be included as it is a major symptom of spinal cord compression.[2]
3. Evidence-based interventions
A care pathway was developed in Cardiff, UK for management of spinal cord compression in 2004: Pic 2[4]
The goals of treatment are relief of pain, preservation of neurological function, and preservation of spinal stability. The optimal management of spinal cord compression remains controversial and the decision should be made according to the patients clinical status, their preferences for treatment and the therapeutic facilities available in the clinical settings.[5]
Interventions mainly include radiotherapy, surgery, and medications.
Surgery is quite limited in advanced cancer patients and only suitable for those with a life expectancy longer than 3 months and with favorable performance status, whose tumor is not radiosensitive. It is said that in selected patients, when compared with RT alone, surgery can improve functional outcomes, on a 2 type level of evidence.[5]Radiotherapy is the most common treatment for spinal cord compression in cancer patients. It can be used following decompression operations or used alone. The best radiotherapy regimen has not been established yet.[1] A prospective randomised trial has shown that direct decompressive surgery plus postoperative radiotherapy is better than radiotherapy alone.[6]
Corticosteroids like dexamethasone are commonly used in treating spinal cord compression. Corticosteroids have been agreed to be an effective medication for spinal cord compression, however, the optimal dose is not established and loading doses of 10mg to 100mg with single dose of 4mg to 24mg have been used.[1] Silvia et al recommended the following dosage and schedules on a type 3 level of evidence:
• dexamethasone 10–100 mg i.v. bolus followed by 16–96 mg daily orally.[5]
In another study, adapted Tomita scale was used to assess patients’ function and neurological status as in Table 1:[4]
Pic 2: Care pathway for management of spinal cord compression
Biphosphonates are indicated in patients with at least 6 months’ life expectancy. [1] Most of the clinical trials on bisphosphonates have been conducted on patients with metastatic breast cancer and multiple myeloma, but small studies on patients with other metastatic carcinomas have also demonstrated benefit.[7]
Chemotherapy is not commonly used except in patients with chemo-sensitive cancer.[1,5] First-line chemotherapy is recommended only for very young children with chemosensitive tumours in order to decrease the long-term sequelae of surgeries or spinal radiation on a type 3 level of evidence. And it is suitable for adults with chemosensitive tumours (lymphoma, myeloma, breast or germ cell tumours) who are not candidates for surgery or radiation on a type R basis only. [5]
4. Update the progress in management since 2001
D. Andrew Loblaw et al published a systematic review of treatment of malignant spinal cord compression(MSCC). It is concluded that high dose dexamethasone is an effective adjunct to RT, but may lead to serious side effects. So it is suggested that patients with good mobility should not be prescribed dexamethasone but be educated about symptoms of MSCC. Radiotherapy or surgery alone is good for selected patients, though optimal dose and fraction for RT is not established. However, It is not clear whether surgery plus radiotherapy is better than single treatment or not.[9]
The following conclusion is made: surgical management should be offered to patients with malignant spinal-cord compression when possible. Radiotherapy is an excellent adjuvant to surgery and may be used as the only management in patients who are unsuitable for surgery or when the aim is palliation.[2]
Biphosphonates seem to be a new kind of medicine used in spinal cord compression, but I can’t find any articles focus on this topic.
5. Identify other specialists for assistance
According to the care pathway above, a multidisciplinary team is helpful in managing this situation. Specialists in radiodiagnosis are needed in early diagnosing[8]. Radiologists and oncologists are needed for making radiotherapy/chemotherapy regimens. Surgeons are helpful in selecting patients for surgery. And palliative care specialists are necessary in symptom management such as pain.
In another article, the following facilities and departments are listed for assistance in diagnosing and managing spinal cord compression[5]:
Diagnostic facilities:
• Clinical departments: neurology, medical oncology or internal medicine.
• Radiological department: conventional radiology, computerized tomography (CT) scanners, magnetic resonance imaging (MRI), ultrasound (US) and medical staff skilled in neuroradiology.
• Laboratories: haematochemical, microbiological and histological tests must be available.
Therapeutic facilities:
• Department of Neurosurgery.
• Department of Radiotherapy.
• Department of Orthopedic Surgery.
• Department of Medical Oncology.
• Department of Internal Medicine.
The cooperation of the surgeon, the radiotherapist and the oncologist is strongly recommended. Unfortunately, palliative care specialists are not listed here.
6. What enhances or makes difficult the instigation in your work place?
In my clinical settings, most patients are dying and no surgeons dare do any surgery on them. Radiotherapy is unfeasible because of limited mobility of patients. Chemotherapy is neither used in such patients because they are too weak for that, and the side effects of chemotherapy may be very serious in these weak patients.
Dexamethasone is most commonly used for spinal cord compression. But the dose is relative small compared to the recommended one mentioned above: 5-10mg/d is used. The reason is the superior doctor always think Asian patients, especially Chinese patients, need smaller dose than western patients because their body mass is smaller, and dying patients with cachexia require smaller dose than other patients.
Biphosphonates are used in patients who can afford such expensive medicines. But they are also used in patients with life expectancy shorter than 6 months because of some private benefit of the superior physicians.
Reference:
1. Dirk Rades and Steven E. Schild. Spinal cord compression. European Journal of Cancer Supplements, Volume 5, Issue 5, September 2007, Pages 359-370
2. Dheerendra Prasad and David Schiff. Malignant spinal-cord compression. The Lancet Oncology, Volume 6, Issue 1, January 2005, Pages 15-24
3. Jane Cowap, Janet R. Hardy and Roger A'Hern. Outcome of Malignant Spinal Cord Compression at a Cancer Center: Implications for Palliative Care Services. Journal of Pain and Symptom Management, Volume 19, Issue 4, April 2000, Pages 257-264
4. N. J. Pease, R. J. Harris and I. G. Finlay. Development and audit of a care pathway for the management of patients with suspected malignant spinal cord compression. Physiotherapy, Volume 90, Issue 1, March 2004, Pages 27-34
5. Silvia Spinazzé, Augusto Caraceni and Dirk Schrijvers. Epidural spinal cord compression. Critical Reviews in Oncology/Hematology, Volume 56, Issue 3, December 2005, Pages 397-406
6. R. Patchell, P. Tibbs and W. Regine et al., Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial, Lancet 366 (2005), pp. 643–648.
7. Daniel M. Sciubba and Ziya L. Gokaslan. Diagnosis and management of metastatic spine disease. Surgical Oncology Volume 15, Issue 3, November 2006, Pages 141-151
8. Jane Cowap, Janet R. Hardy and Roger A'Hern. Outcome of Malignant Spinal Cord Compression at a Cancer Center: Implications for Palliative Care Services. Journal of Pain and Symptom Management, Volume 19, Issue 4, April 2000, Pages 257-264
9. D. A. Loblaw, J. Perry, et al. Systematic review of the diagnosis and management of malignant extradural spinal cord compression: the cancer care Ontario practice guidelines initiative’s neuron-oncology disease site group. Journal of Clinical Oncology 2005, 23(9): pg 2028-2037
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