CLINICAL FOCUS
Recognising metastatic spinal cord compression Ben Bowers
Community Cancer Nurse Specialist, Queen’s Nurse, Community Cancer Support Team, Cambridgeshire Community Services NHS Trust
ABSTRACT
Metastatic spinal cord compression (MSCC) is a potentially life changing oncological emergency. Neurological function and quality of life can be preserved if patients receive an early diagnosis and rapid access to acute interventions to prevent or reduce nerve damage. Symptoms include developing spinal pain, numbness or weakness in arms or legs, or unexplained changes in bladder and bowel function. Community nurses are well placed to pick up on the ‘red flag’ symptoms of MSCC and ensure patients access prompt, timely investigations to minimise damage.
KEY WORDS
w Oncological emergency w Metastatic spinal cord compression w Spinal metastases w Community nursing
162
Role of community nurses Community nurses are often involved in supporting people living with cancer. They may be the first health professional to recognise the ‘red flag’ symptoms of MSCC. Early recognition by community nurses will prompt timely investigation and treatment and potentially reduce the risks of patient having a permanent disability. This article identifies the early symptoms of MSCC that community nurses should be aware of and describes the pathway to early investigation and treatment.
Incidence and education With 2.5 million people living with cancer (Macmillan, 2015), and with an increasingly ageing population, the number of people at risk of developing metastatic spinal disease is increasing. It is estimated that 40% of patients with cancer go on to develop metastatic spinal disease (Klimo and Schmidt, 2004). It is estimated that 10–20% of these patients will develop symptoms of spinal cord compression.These symptoms occur when the spinal metastasis presses on the nerves in the spine. Spinal metastasis is the third most common site for the spread of primary cancer cells (Chandan and Rahmani, 2010). Any primary tumour can cause spinal metastasis; however, some cancers are more likely to metastasise to bones. The cancers that most often metastasise to the spine include breast (21%), lung (14%), prostate (8%), gastrointestinal (5%) and renal (5%) (Georgy, 2008). With advances in cancer treatments, more people are living with cancer longer (Macmillan, 2015) and there is likely to be an increase in the incidence and prevalence of spinal metastasis developing (Harel and Angelov, 2010). All patients with cancer and spinal pain, patients with known bone metastases and those considered at high risk of developing bone metastasis should be given information on what to look out for and whom to contact for urgent advice (see Box 1) (James and Brooks, 2010; NICE, 2014). In practice, Hutchinson et al (2012) found that practitioners were reluctant to give prophylactic information and there was a lack of consensus on when information should be provided. Conversely, in the same study, 86% of the patients questioned who had already developed MSCC
© 2015 MA Healthcare Ltd
M
etastatic spinal cord compression (MSCC) is a common oncological emergency that community nurses need to be aware of. It occurs when the spinal cord becomes compressed through direct tumour growth or pathological vertebral body collapse (United Kingdom Oncology Nursing Society (UKONS), 2013) (Figure 1). It is a serious and potentially life-altering complication of cancer disease progression. The condition often starts with back pain but can potentially result in irreversible paralysis and bladder and bowel incontinence (McLinton and Hutchinson, 2006). Neurological function and quality of life can be preserved if patients receive an early diagnosis and rapid access to acute interventions to prevent or reduce nerve damage (Kilbride et al, 2010). Despite the existence of a clear national clinical pathway (National Institute for Health and Care Excellence (NICE), 2014), patients with suspected MSCC can experience inappropriate delays in accessing timely acute care. This is sometimes a result of generalists not picking up on the importance of reported early symptoms, which leads to delays in referring to acute oncology services (Levack et al, 2002; Lew et al, 2010; Warnock and Tod, 2013). Patients may also fail to recognise the importance of their symptoms and not access medical advice when they have early symptoms of MSCC, such as ongoing progressive back pain (Hutchinson et al, 2012).
Email: [email protected]
British Journal of Community Nursing April 2015 Vol 20, No 4
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 3, 2015. For personal use only. No other uses without permission. . All rights res
CLINICAL FOCUS would have liked prophylactic information on what signs and symptoms to look out for.
Community nurses should be aware of local referral pathways if a patient is suspected to have MSCC. In recognising the importance of coordinated specialised care, NICE (2008) established that each secondary care team treating people with MSCC should have senior clinical advisors available 24 hours a day to give advice. In larger care centres, this is often a member of the oncology team, such as the on-call registrar. Many centres now have an established acute oncology service, which offers a 24-hour point of contact for clinicians in primary and secondary care to access timely expert guidance (UKONS, 2013). For community nurses, it is worth identifying with the local oncology team what MSCC clinical advice service is available and having the telephone number in case it is needed.
Spinal cord Vertebral body
Tumour Spinous process
© 2015 MA Healthcare Ltd
Recognising pain The symptoms of MSCC follow a similar pattern for almost all patients (McLinton and Hutchinson, 2006). The most common (and often the first) symptom is spinal pain associated with spinal metastases. Pain is present in 90–98% of MSCC cases (Levack et al, 2002; McLinton and Hutchinson, 2006; Harel and Angelov, 2010). Indeed, Kaplan (2009) suggests pain can precede other symptoms by up to 4 months and risks being misdiagnosed as back pain rather than an indication of spinal metastases that could lead to MSCC. In clinical practice, it is worth considering a diagnosis of spinal metastases in anyone who has known bone metastases or has cancer and develops spinal pain (NICE, 2008). Pain in the thoracic (middle) spine and cervical (upper) spine regions are infrequently caused by other medical conditions and should be considered a ‘red flag’ requiring rapid clinical assessment in people with a history of cancer (Kaplan, 2009). Around 70% of cases of spinal metastases occur in the thoracic spine and 10% occur in the cervical spine (Klimo and Schmidt, 2004). Pain in these areas requires prompt investigation and should be discussed with the MSCC clinical advice service within 24 hours of discovery (NICE, 2008). Another key ‘red flag’ for accessing a clinical assessment is if the person is experiencing progressive or severe unremitting lower spinal pain.This may also present as localised spinal tenderness, spinal pain aggravated by straining or nighttime spinal pain preventing sleep (NICE, 2008; Kaplan, 2009; Harel and Angelov, 2010). The lumbar (lower) spine is the site of 20% of spinal metastases (Klimo and Schmidt, 2004). It is important to rule out spinal metastases or MSCC in people at risk rather than assuming it is back pain from another cause. Symptoms need to be discussed with the MSCC clinical advice service within 24 hours of identification (NICE, 2014). NICE (2008) advise that patients with pain symptoms suggestive of spinal metastasis have magnetic resonance
British Journal of Community Nursing April 2015 Vol 20, No 4
Intervertebral disc
James Lemon
MSCC clinical coordinator
Figure 1. Compression of the spinal cord
imaging (MRI) of their whole spine so that ‘definitive treatment’ can be ‘planned within 1 week of the suspected diagnosis’. Patients may come home while they are awaiting imaging. It is crucial that they are aware of the neurological symptoms of MSCC (or any increasing pain symptoms) and have a point of contact for urgent reassessment if the symptoms develop.
Neurological symptoms If pain from spinal metastases is not investigated promptly, patients can quickly develop MSCC neurological symptoms when the spinal cord becomes compressed and damaged. If anyone experiences any such symptoms, emergency clinical interventions are required to minimise any further damage. Kaplan (2009) identifies that once symptoms start, paralysis can occur rapidly and very few people who are paraplegic on presentation ever walk again even with treatment. If someone has a known cancer and complains of spinal pain, then it is important to identify whether they have any of the following MSCC ‘red flags’ that indicate neurological involvement. It is worth noting that some patients may experience these symptoms and not have any spinal pain beforehand. Symptoms include radicular (band-like) pain; increased difficulty walking; reduced power/altered sensation to limbs; or new unexplained bladder or bowel dysfunction (NICE, 2008; Foulkes, 2010; James and Brooks, 2010). Patients may articulate these neurological changes as developing a new unsteadiness when walking, or experiencing an extreme heaviness in limbs (Harel and Angelov, 2010). If the patient has any of the above neurological symptoms, they need an immediate referral to the local
163
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 3, 2015. For personal use only. No other uses without permission. . All rights res
CLINICAL FOCUS
Patient’s name: ________ Consultant: ___________ People with cancer are at risk of the cancer spreading to other parts of their body, including the spine (this is known as ‘spinal metastases‘). Spinal metastases can be painful and, if not, treated can lead to metastatic spinal cord compression (MSCC)—this is when the spinal metastases press on the nerves in the spine. MSCC is rare, but it can cause damage to the spinal cord and can lead to permanent paralysis. This leaflet is not intended to scare you but to help you recognise the important symptoms of spinal metastases and MSCC. It is important to report your symptoms quickly as the earlier treatments are started, the better the result usually is. Symptoms to watch out for:
w Pain or tenderness in the middle or top of your back or neck. w Severe pain in your lower back that is getting worse or doesn’t go away w Pain in your back that is worse when you cough, sneeze or go to the toilet. w Back pain that stops you from sleeping w A narrow band of pain down the arm or leg or around the body w Numbness, weakness or difficulty using your arms or legs w Bladder or bowel control problems. If you have any of these symptoms: w Speak with a doctor, nurse or paramedic as soon as is practical (certainly within 24 hours)
w Tell them that you have cancer, are worried about your spine and would like to see a doctor
w Show the doctor this fact sheet. w Try to bend your back as little as possible. For the doctor or health professional:
w This patient has cancer and is therefore at risk of MSCC. w If they have any of the symptoms on the front of this card then please con-
sider MSCC as a possible diagnosis and discuss further management with the local MSCC coordinator (telephone XXXXXXX).
Source: National Institute for Health and Care Excellence (2011a)
MSCC clinical advice service to access an urgent oncology review (NICE, 2008). As with any decision-making process, it is imperative that patients and their family are involved throughout. Patients need to understand the importance of the situation (expressed in a sensitive way) so that they are able to make informed decisions (Hutchinson et al, 2012).
Acute clinical care
Some patients may be too frail for specialist treatment if they are terminally ill with cancer and want to stay at home. Acute interventions may prove too intense and burdensome in these circumstances (NICE, 2008). In these cases, it is crucial that the patient and his/her family, GP, oncology team and community nursing team agree and plan the best conservative management to ensure comfort. Individuals
164
who are terminally ill and too unwell to undergo MSCC treatment will have complex pain management needs. They are also likely to have complex psychological concerns if they have experienced dramatic changes in their functional abilities (McLinton and Hutchinson, 2006; NICE 2011b). Most patients will have an emergency assessment at hospital for suspected MSCC. The key investigation to be made is an MRI of their whole spine within 24 hours of assessment to confirm the diagnosis (NICE, 2008). Although MRI will enable a definitive diagnosis, it can be contraindicated for some patients (i.e. those with metal parts in their body). In these cases, the oncology team will look at other imaging options with the patient to enable a diagnosis and to plan treatment. Patients are offered a high-dose short course of radiotherapy or surgery depending on the site and extent of the disease and the prognosis (Harel and Angelov, 2010; NICE, 2014). It is good practice for individuals to start a daily dose of 16 mg oral dexamethasone while they await treatment (Chandan and Rahmani, 2010; NICE, 2014). Steroids should reduce pressure caused by the cord oedema, relieving pain and improving neurological symptoms (Foulkes, 2010). After surgery or commencing radiotherapy, it is recommended that steroids are reduced gradually over 5–7 days and then stopped (NICE, 2008). Occasionally patients may be discharged from hospital while on a reducing dose of steroids. Patients on high-dose steroids will require gastric protection medication (proton pump inhibitors) and have their blood glucose levels monitored for signs of steroidinduced diabetes.
Rehabilitation and post-discharge Rehabilitation is primarily focused on helping patients with realistic goals, adjusting to living with their disability and adapting the home environment (Abraham et al, 2008). For example, therapists will work with patients to build up their strength while ordering suitable equipment (such as grab rails and toilet seat raisers) to facilitate independence once back home. Subsequent care at home following discharge often needs to focus on supporting the patients and their families to have the best quality of life possible. This can include help with mobility issues; bowel and bladder incontinence; pain relief; and psychological support, including living with uncertainty (Foulkes, 2010; James and Brooks, 2010; Warnock and Tod, 2013). The development of MSCC often indicates further cancer disease progression. Prognosis is dependent on a number of factors, including the patients’ original cancer type, their current performance status and how extensive their disease is (Kaplan, 2009). Studies have identified that patients who develop MSCC have a median survival time of 3–6 months (Guo et al, 2010). In a large audit, McLinton and Hutchinson (2006) found that 74% of people died within 3 months of developing MSCC. Sensitively revisiting advanced care planning discussions after an MSCC diagnosis can be timely and beneficial in helping families to prepare (Guo et al, 2010; NICE 2011b).
© 2015 MA Healthcare Ltd
Box 1. Example patient leaflet on metastatic spinal cord compression
British Journal of Community Nursing April 2015 Vol 20, No 4
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 3, 2015. For personal use only. No other uses without permission. . All rights res
CLINICAL FOCUS
Conclusion The development of MSCC can be functionally and psychologically life changing. Community nurses caring for patients with a cancer history are often in a position to be the first health professional to recognise the ‘red flags’ of MSCC. They are well placed to prompt early referral to locally identified MSCC coordinators and ensure timely treatment, reducing the risk of permanent damage. BJCN
KEY POINTS
Accepted for publication: 13 March 2015
w Practitioners should be mindful of the key neurological symptoms that indicate MSCC
Abraham J, Banffy M, Harris M (2008) Spinal cord compression in patients with advanced metastatic cancer. JAMA 299(8): 937–46 Chandan K, Rahmani M (2010) Spinal cord compression—do we miss it? Geriatric Medicine 40: 476–9 Foulkes M (2010) Nursing management of common oncological emergencies. Nurs Stand 24(41): 49–56 Georgy B (2008) Metastatic spinal lesions: state-of-the-art treatment options and future trends. AJNR Am J Neuroradiol 29(9): 1605–11. doi: 10.3174/ajnr.A1137 Guo Y, Palmer L, Bainty J, Konzen B, Shin K, Bruera E (2010) Advanced directives and do-not-resuscitate orders in patients with cancer with metastatic spinal cord compression: advanced care planning implications. J Palliat Med 13(5): 513–7. doi: 10.1089/jpm.2009.0376 Harel R, Angelov L (2010) Spine metastasis: current treatments and future directions. Eur J Cancer 46(15): 2696–707. doi: 10.1016/j.ejca.2010.04.025 Hutchinson C, Morrison A, Rice A,Tait G, Harden S (2012) Provision of information about malignant spinal cord compression: perceptions of patients and staff. Int J Palliat Nurs 18(2): 61–8 James N, Brooks D (2010) Managing patients with metastatic spinal cord compression. Cancer Nurs Pract 9(6): 19–22 Kaplan M (2009) Back pain: is it spinal cord compression? Clin J Oncol Nurs 13(5): 592–5. doi: 10.1188/09.CJON.592-595 Kilbride L, Cox M, Kennedy C, Lee S, Grant R (2010) Metastatic spinal cord compression: a review of practice and care. J Clin Nurs 19(13–14): 1767–83 Klimo P, Schmidt M (2004) Surgical management of spinal metastases. Oncologist 9(2): 188–96 Levack P, Graham J, Collie D et al (2002) Don’t wait for a sensory level—listen to the symptoms: a prospective audit of delays in diagnosis of malignant cord compression. Clin Oncol (R Coll Radiol) 14(6): 472–80
w Metastatic spinal cord compression (MSCC) is an oncological emergency requiring prompt clinical interventions w Identify with the local oncology team what MSCC clinical advice service is available and have the telephone number in case of need w Back pain in people with known cancer can be a sign of spinal metastasis, which can lead to MSCC
Lew E, Pegrum H, Watkinson D (2010) Malignant spinal cord compression: a retrospective audit of diagnosis and management. Palliat Med 24(2): 232 Macmillan (2015) The rich picture: people living with cancer. http://bit.ly/1xA7I5M (accessed 2 February 2015) McLinton A, Hutchinson C (2006) Malignant spinal cord compression: a retrospective audit of clinical practice at a UK regional cancer centre. Br J Cancer 94(4): 486–91 National Institute for Health and Care Excellence (2008) Metastatic spinal cord compression: diagnosis and management of adults at risk of and with metastatic spinal cord compression. NICE Clinical Guideline 75. http://bit.ly/1FYyAhj (accessed 4 December 2014) National Institute for Health and Care Excellence (2011a) Metastatic spinal cord compression: local patient information leaflet. NICE, London. http://bit. ly/1wE9unV (accessed 11 February 2015) National Institute for Health and Care Excellence (2011b) Quality standard for end of life care for adults. NICE Quality Standard 13. http://bit.ly/1EaXub3 (accessed 5 December 2014) National Institute for Health and Care Excellence (2014) Metastatic spinal cord compression overview. NICE Pathways. http://bit.ly/1Cco5YT (accessed 24 November 2014) United Kingdom Oncology Nursing Society (2013) Acute oncology initial management guidelines. http://bit.ly/1Av8HkM (accessed 16 November 2014) Warnock C, Tod A (2013) A descriptive exploration of the experiences of patients with significant functional impairment following a recent diagnosis of metastatic spinal cord compression. J Adv Nurs 70(3): 564–74
Would you like to write for the British Journal of Community Nursing? © 2015 MA Healthcare Ltd
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British Journal of Community Nursing April 2015 Vol 20, No 4
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Recognising metastatic spinal cord compression Ben Bowers
Community Cancer Nurse Specialist, Queen’s Nurse, Community Cancer Support Team, Cambridgeshire Community Services NHS Trust
ABSTRACT
Metastatic spinal cord compression (MSCC) is a potentially life changing oncological emergency. Neurological function and quality of life can be preserved if patients receive an early diagnosis and rapid access to acute interventions to prevent or reduce nerve damage. Symptoms include developing spinal pain, numbness or weakness in arms or legs, or unexplained changes in bladder and bowel function. Community nurses are well placed to pick up on the ‘red flag’ symptoms of MSCC and ensure patients access prompt, timely investigations to minimise damage.
KEY WORDS
w Oncological emergency w Metastatic spinal cord compression w Spinal metastases w Community nursing
162
Role of community nurses Community nurses are often involved in supporting people living with cancer. They may be the first health professional to recognise the ‘red flag’ symptoms of MSCC. Early recognition by community nurses will prompt timely investigation and treatment and potentially reduce the risks of patient having a permanent disability. This article identifies the early symptoms of MSCC that community nurses should be aware of and describes the pathway to early investigation and treatment.
Incidence and education With 2.5 million people living with cancer (Macmillan, 2015), and with an increasingly ageing population, the number of people at risk of developing metastatic spinal disease is increasing. It is estimated that 40% of patients with cancer go on to develop metastatic spinal disease (Klimo and Schmidt, 2004). It is estimated that 10–20% of these patients will develop symptoms of spinal cord compression.These symptoms occur when the spinal metastasis presses on the nerves in the spine. Spinal metastasis is the third most common site for the spread of primary cancer cells (Chandan and Rahmani, 2010). Any primary tumour can cause spinal metastasis; however, some cancers are more likely to metastasise to bones. The cancers that most often metastasise to the spine include breast (21%), lung (14%), prostate (8%), gastrointestinal (5%) and renal (5%) (Georgy, 2008). With advances in cancer treatments, more people are living with cancer longer (Macmillan, 2015) and there is likely to be an increase in the incidence and prevalence of spinal metastasis developing (Harel and Angelov, 2010). All patients with cancer and spinal pain, patients with known bone metastases and those considered at high risk of developing bone metastasis should be given information on what to look out for and whom to contact for urgent advice (see Box 1) (James and Brooks, 2010; NICE, 2014). In practice, Hutchinson et al (2012) found that practitioners were reluctant to give prophylactic information and there was a lack of consensus on when information should be provided. Conversely, in the same study, 86% of the patients questioned who had already developed MSCC
© 2015 MA Healthcare Ltd
M
etastatic spinal cord compression (MSCC) is a common oncological emergency that community nurses need to be aware of. It occurs when the spinal cord becomes compressed through direct tumour growth or pathological vertebral body collapse (United Kingdom Oncology Nursing Society (UKONS), 2013) (Figure 1). It is a serious and potentially life-altering complication of cancer disease progression. The condition often starts with back pain but can potentially result in irreversible paralysis and bladder and bowel incontinence (McLinton and Hutchinson, 2006). Neurological function and quality of life can be preserved if patients receive an early diagnosis and rapid access to acute interventions to prevent or reduce nerve damage (Kilbride et al, 2010). Despite the existence of a clear national clinical pathway (National Institute for Health and Care Excellence (NICE), 2014), patients with suspected MSCC can experience inappropriate delays in accessing timely acute care. This is sometimes a result of generalists not picking up on the importance of reported early symptoms, which leads to delays in referring to acute oncology services (Levack et al, 2002; Lew et al, 2010; Warnock and Tod, 2013). Patients may also fail to recognise the importance of their symptoms and not access medical advice when they have early symptoms of MSCC, such as ongoing progressive back pain (Hutchinson et al, 2012).
Email: [email protected]
British Journal of Community Nursing April 2015 Vol 20, No 4
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 3, 2015. For personal use only. No other uses without permission. . All rights res
CLINICAL FOCUS would have liked prophylactic information on what signs and symptoms to look out for.
Community nurses should be aware of local referral pathways if a patient is suspected to have MSCC. In recognising the importance of coordinated specialised care, NICE (2008) established that each secondary care team treating people with MSCC should have senior clinical advisors available 24 hours a day to give advice. In larger care centres, this is often a member of the oncology team, such as the on-call registrar. Many centres now have an established acute oncology service, which offers a 24-hour point of contact for clinicians in primary and secondary care to access timely expert guidance (UKONS, 2013). For community nurses, it is worth identifying with the local oncology team what MSCC clinical advice service is available and having the telephone number in case it is needed.
Spinal cord Vertebral body
Tumour Spinous process
© 2015 MA Healthcare Ltd
Recognising pain The symptoms of MSCC follow a similar pattern for almost all patients (McLinton and Hutchinson, 2006). The most common (and often the first) symptom is spinal pain associated with spinal metastases. Pain is present in 90–98% of MSCC cases (Levack et al, 2002; McLinton and Hutchinson, 2006; Harel and Angelov, 2010). Indeed, Kaplan (2009) suggests pain can precede other symptoms by up to 4 months and risks being misdiagnosed as back pain rather than an indication of spinal metastases that could lead to MSCC. In clinical practice, it is worth considering a diagnosis of spinal metastases in anyone who has known bone metastases or has cancer and develops spinal pain (NICE, 2008). Pain in the thoracic (middle) spine and cervical (upper) spine regions are infrequently caused by other medical conditions and should be considered a ‘red flag’ requiring rapid clinical assessment in people with a history of cancer (Kaplan, 2009). Around 70% of cases of spinal metastases occur in the thoracic spine and 10% occur in the cervical spine (Klimo and Schmidt, 2004). Pain in these areas requires prompt investigation and should be discussed with the MSCC clinical advice service within 24 hours of discovery (NICE, 2008). Another key ‘red flag’ for accessing a clinical assessment is if the person is experiencing progressive or severe unremitting lower spinal pain.This may also present as localised spinal tenderness, spinal pain aggravated by straining or nighttime spinal pain preventing sleep (NICE, 2008; Kaplan, 2009; Harel and Angelov, 2010). The lumbar (lower) spine is the site of 20% of spinal metastases (Klimo and Schmidt, 2004). It is important to rule out spinal metastases or MSCC in people at risk rather than assuming it is back pain from another cause. Symptoms need to be discussed with the MSCC clinical advice service within 24 hours of identification (NICE, 2014). NICE (2008) advise that patients with pain symptoms suggestive of spinal metastasis have magnetic resonance
British Journal of Community Nursing April 2015 Vol 20, No 4
Intervertebral disc
James Lemon
MSCC clinical coordinator
Figure 1. Compression of the spinal cord
imaging (MRI) of their whole spine so that ‘definitive treatment’ can be ‘planned within 1 week of the suspected diagnosis’. Patients may come home while they are awaiting imaging. It is crucial that they are aware of the neurological symptoms of MSCC (or any increasing pain symptoms) and have a point of contact for urgent reassessment if the symptoms develop.
Neurological symptoms If pain from spinal metastases is not investigated promptly, patients can quickly develop MSCC neurological symptoms when the spinal cord becomes compressed and damaged. If anyone experiences any such symptoms, emergency clinical interventions are required to minimise any further damage. Kaplan (2009) identifies that once symptoms start, paralysis can occur rapidly and very few people who are paraplegic on presentation ever walk again even with treatment. If someone has a known cancer and complains of spinal pain, then it is important to identify whether they have any of the following MSCC ‘red flags’ that indicate neurological involvement. It is worth noting that some patients may experience these symptoms and not have any spinal pain beforehand. Symptoms include radicular (band-like) pain; increased difficulty walking; reduced power/altered sensation to limbs; or new unexplained bladder or bowel dysfunction (NICE, 2008; Foulkes, 2010; James and Brooks, 2010). Patients may articulate these neurological changes as developing a new unsteadiness when walking, or experiencing an extreme heaviness in limbs (Harel and Angelov, 2010). If the patient has any of the above neurological symptoms, they need an immediate referral to the local
163
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 3, 2015. For personal use only. No other uses without permission. . All rights res
CLINICAL FOCUS
Patient’s name: ________ Consultant: ___________ People with cancer are at risk of the cancer spreading to other parts of their body, including the spine (this is known as ‘spinal metastases‘). Spinal metastases can be painful and, if not, treated can lead to metastatic spinal cord compression (MSCC)—this is when the spinal metastases press on the nerves in the spine. MSCC is rare, but it can cause damage to the spinal cord and can lead to permanent paralysis. This leaflet is not intended to scare you but to help you recognise the important symptoms of spinal metastases and MSCC. It is important to report your symptoms quickly as the earlier treatments are started, the better the result usually is. Symptoms to watch out for:
w Pain or tenderness in the middle or top of your back or neck. w Severe pain in your lower back that is getting worse or doesn’t go away w Pain in your back that is worse when you cough, sneeze or go to the toilet. w Back pain that stops you from sleeping w A narrow band of pain down the arm or leg or around the body w Numbness, weakness or difficulty using your arms or legs w Bladder or bowel control problems. If you have any of these symptoms: w Speak with a doctor, nurse or paramedic as soon as is practical (certainly within 24 hours)
w Tell them that you have cancer, are worried about your spine and would like to see a doctor
w Show the doctor this fact sheet. w Try to bend your back as little as possible. For the doctor or health professional:
w This patient has cancer and is therefore at risk of MSCC. w If they have any of the symptoms on the front of this card then please con-
sider MSCC as a possible diagnosis and discuss further management with the local MSCC coordinator (telephone XXXXXXX).
Source: National Institute for Health and Care Excellence (2011a)
MSCC clinical advice service to access an urgent oncology review (NICE, 2008). As with any decision-making process, it is imperative that patients and their family are involved throughout. Patients need to understand the importance of the situation (expressed in a sensitive way) so that they are able to make informed decisions (Hutchinson et al, 2012).
Acute clinical care
Some patients may be too frail for specialist treatment if they are terminally ill with cancer and want to stay at home. Acute interventions may prove too intense and burdensome in these circumstances (NICE, 2008). In these cases, it is crucial that the patient and his/her family, GP, oncology team and community nursing team agree and plan the best conservative management to ensure comfort. Individuals
164
who are terminally ill and too unwell to undergo MSCC treatment will have complex pain management needs. They are also likely to have complex psychological concerns if they have experienced dramatic changes in their functional abilities (McLinton and Hutchinson, 2006; NICE 2011b). Most patients will have an emergency assessment at hospital for suspected MSCC. The key investigation to be made is an MRI of their whole spine within 24 hours of assessment to confirm the diagnosis (NICE, 2008). Although MRI will enable a definitive diagnosis, it can be contraindicated for some patients (i.e. those with metal parts in their body). In these cases, the oncology team will look at other imaging options with the patient to enable a diagnosis and to plan treatment. Patients are offered a high-dose short course of radiotherapy or surgery depending on the site and extent of the disease and the prognosis (Harel and Angelov, 2010; NICE, 2014). It is good practice for individuals to start a daily dose of 16 mg oral dexamethasone while they await treatment (Chandan and Rahmani, 2010; NICE, 2014). Steroids should reduce pressure caused by the cord oedema, relieving pain and improving neurological symptoms (Foulkes, 2010). After surgery or commencing radiotherapy, it is recommended that steroids are reduced gradually over 5–7 days and then stopped (NICE, 2008). Occasionally patients may be discharged from hospital while on a reducing dose of steroids. Patients on high-dose steroids will require gastric protection medication (proton pump inhibitors) and have their blood glucose levels monitored for signs of steroidinduced diabetes.
Rehabilitation and post-discharge Rehabilitation is primarily focused on helping patients with realistic goals, adjusting to living with their disability and adapting the home environment (Abraham et al, 2008). For example, therapists will work with patients to build up their strength while ordering suitable equipment (such as grab rails and toilet seat raisers) to facilitate independence once back home. Subsequent care at home following discharge often needs to focus on supporting the patients and their families to have the best quality of life possible. This can include help with mobility issues; bowel and bladder incontinence; pain relief; and psychological support, including living with uncertainty (Foulkes, 2010; James and Brooks, 2010; Warnock and Tod, 2013). The development of MSCC often indicates further cancer disease progression. Prognosis is dependent on a number of factors, including the patients’ original cancer type, their current performance status and how extensive their disease is (Kaplan, 2009). Studies have identified that patients who develop MSCC have a median survival time of 3–6 months (Guo et al, 2010). In a large audit, McLinton and Hutchinson (2006) found that 74% of people died within 3 months of developing MSCC. Sensitively revisiting advanced care planning discussions after an MSCC diagnosis can be timely and beneficial in helping families to prepare (Guo et al, 2010; NICE 2011b).
© 2015 MA Healthcare Ltd
Box 1. Example patient leaflet on metastatic spinal cord compression
British Journal of Community Nursing April 2015 Vol 20, No 4
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 3, 2015. For personal use only. No other uses without permission. . All rights res
CLINICAL FOCUS
Conclusion The development of MSCC can be functionally and psychologically life changing. Community nurses caring for patients with a cancer history are often in a position to be the first health professional to recognise the ‘red flags’ of MSCC. They are well placed to prompt early referral to locally identified MSCC coordinators and ensure timely treatment, reducing the risk of permanent damage. BJCN
KEY POINTS
Accepted for publication: 13 March 2015
w Practitioners should be mindful of the key neurological symptoms that indicate MSCC
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w Metastatic spinal cord compression (MSCC) is an oncological emergency requiring prompt clinical interventions w Identify with the local oncology team what MSCC clinical advice service is available and have the telephone number in case of need w Back pain in people with known cancer can be a sign of spinal metastasis, which can lead to MSCC
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