A patient without a biopsy-confirmed cancer diagnosis in need of corticosteroid treatment presents a dilemma. Plasmacytomas, thymomas, lymphomas, multiple myeloma, germ-cell tumors are very sensitive to corticosteroid therapy in patients with MSCC.38 However, corticosteroids given before tissue samples are obtained may hinder proper diagnosis and complicate future management.39,40 In the absence of neurological deficit, corticosteroids may be withheld and emergent consultation with neurosurgery and oncology should be obtained. If there is any question regarding the nature of the lesion, tissue diagnosis must be obtained without delay.
Strict bed rest (including logroll and bedpan use) should be instituted if there is suspicion of spinal cord instability. Patients with suspected involvement of the cervical spine should have a Philadelphia collar placed until spinal stability has been confirmed. In the United Kingdom, the National Institutes for Health Care Excellence guidelines recommend all patients with suspected cord compression be nursed in a flat position.22 Other institutions, however, do not believe that strict bed rest is necessary, as it is presumed that MSCC is inherently different from that caused by trauma. Authors supporting this position contend that the increased incidence of deep vein thrombosis, infection (particularly from the urinary tract), and decubitus ulcers outweighs the benefit of bed rest. Patient preference should be taken into consideration as those with good functional status may be quite resistant to bed rest. In cases where cord compression is strongly suspected, these patients should be educated on proper bed rest. The greatest predictors of outcome are ambulatory and functional status at the time of diagnosis (generally based on an Eastern Cooperative Oncology Group scale). Patients with a good functional status, limited disease, and a life expectancy of greater than 3 to 6 months may benefit from surgery.41 However, emergent surgical evaluation is required in patients not responding to radiotherapy or who received received only limited doses of radiotherapy, as well as those with spinal instability, direct cord compression due to a bony fragment, impending sphincter dysfunction, unknown primary tumor, or no paraplegia for >48 hours.15
Unfortunately, surgery is only indicated in 10% to 15% of MSCC cases.42 In the past two decades, significant improvements regarding new aggressive surgical techniques have been made, and include circumferential decompression of the spine and staged or single stage anterior posterior surgery with stabilization. 43 Additionally, the combination of surgery with radiotherapy has improved outcomes.44
Most patients benefit from short-course radiotherapy45 even when given palliatively. 46 Longer courses of radiotherapy are highly recommended for patients with a more favorable prognosis.47 Up to 10% of patients diagnosed with spinal cord compression will require treatment for disease recurrence.42 There is a limited role for chemotherapy, and in seminomas and lymphomas, results can be quite dramatic.38
Prevention
Lu et al11 found that only 54% of patients were aware that back pain should be reported to their physician. Delays in diagnosis and treatment are common and well described in the literature.21 Patients should be instructed to call their physician within 24 hours from the development of any new or worsening back pain, and should be advised to seek immediate care if they develop any neurological symptoms. To facilitate appropriate and prompt management of MSCC, hospitals should develop diagnostic algorithms to minimize delays in referral to a comprehensive center for further treatment.
Case Conclusion
Based on this patient’s symptoms and status at presentation, the emergency team determined he was at high risk for MSCC. An initial dosage of 10 mg dexamethasone was administered intravenously (IV), followed by 4 mg IV every 6 hours prior to imaging. An MRI without contrast of the cervical, thoracic, and lumbar spine showed cord compression with mild cord edema at T4 level, along with diffused osseous metastasis.
Upon diagnosis, patient was referred to radiation oncology for radiotherapy of the T2-T6 vertebral bodies. Three days after initiation of radiation therapy, his neurological function deteriorated with paraplegia and incontinence, and he was emergently evaluated for neurosurgery. Although T4 laminectomy and decompression of the spinal cord were performed without complication, patient did not recover neurological function. His hospital course was complicated by Ogilvie syndrome and episodes of delirium, and he was discharged to a rehabilitation facility 23 days after admission; paraplegia and urinary and bowel incontinence remained unchanged.