Malignant Spinal Cord Compression

Malignant spinal cord compression (MSCC) occurs when the dural sac and its contents are compressed on the cord or cauda equina. This may be as a result of direct pressure, vertebral collapse or instability caused by metastatic spread or by direct extension of malignancy.

Malignant cord compression is an oncology emergency as delay in treatment will cause irreversible neurological injury. The aim of treatment is to relieve pain and maintain patients' mobility, function and independence. 

Cancers with higher chances of having bony metastasis are more likely to develop cord compression. Examples include:

• Prostate cancer
• Lung cancer
• Breast cancer
• Hodgkin’s lymphoma
• Multiple myeloma
• Renal cancer
• Colorectal cancer
• Sarcoma

Symptoms of malignant spinal cord compression include:

• New, progressively severe back pain, with the following characteristics:
  • Mild to start with but becomes more severe
  • Spread down across a limb, or to the buttocks
  • Sensation of having a band around the chest or abdomen
  • Aggravated by coughing, straining or lying flat 
• New spinal nerve root pain (burning, shooting, numbness)
  • Numbness that may radiate down to the legs or buttocks (like sciatica)
• Weakness of the legs or unsteady gait
• Sensory impairment or altered sensation in legs or arms
• Bowel or bladder disturbance
  • Difficulty controlling the bladder or bowels (incontinence)
  • Difficulty in passing urine 
  • Constipation 
  • Loss of sphincter control, which is a late sign with poor prognosis

If symptoms appear:

If symptoms of MSCC appear, one should seek medical advice immediately.

One should contact the hospital team whom they receive cancer treatment and follow-up appointments from. If one is unable to get in touch with their own medical team, and go to the nearest Emergency Department (A&E).

What to tell the doctor:

• Tell them you have cancer and worried you may have spinal cord compression
• Describe your symptoms
• Tell them that you need to been seen straight away.

Do not wait as symptoms will worsen. The earlier the diagnosis, the sooner the treatment can begin. If left untreated, permanent and irreversible neurological deficits may occur.

The doctor will arrange an urgent scan for diagnosis. MRI is the most useful diagnostic tool. However, for patients who are unsuitable for MRI, CT scan can be an alternative.

• MRI
  • MRI is a non-invasive imaging scan with high soft tissue resolution. It can show any soft tissue extension into the spinal cord and outside the bone clearly.
  • MRI can distinguish benign and metastatic causes of vertebral-body collapse.
• CT scan
  • CT scan can be used for diagnosing of spinal cord compression and checking for soft tissues extending outside the spine.
  • CT scan may be needed for radiotherapy planning.
• Biopsy
  • If the patient presents with cord compression but has not been pathologically diagnosed, the doctor may consider performing a biopsy at the site of involvement.

Treatment should begin as soon as possible after diagnosis. The aim of treatment is to relieve pain and maintain the patient’s mobility, body function and independence. Treatment plans depend on the following factors:

• Type of cancer
• Area of the spine affected
• General fitness
• Number and severity of vertebral body involved
• Any spread to other parts of the body or internal organs
• Extent of neurological deficit

• Steroid
  • High dose steroid is usually given as soon as cord compression is suspected, e.g. Dexamethasone 4 mg for four times a day.
  • Steroid can reduce pressure and swelling around the spinal cord. It can also quickly relieve symptoms, such as pain. 
  • Steroid can be given either by injection or oral tablets.
  • The dose of steroid will be under regular review and gradually reduced by the doctor after starting radiotherapy.
    
• Radiotherapy
  • Uses high energy X-ray to destroy cancer cells.
  • Usually given in a short course, ranging from one single fractin to ten fractions in two weeks.
  • Most patients receiving radiotherapy with conventional radiotherapy technique will undergo X-ray or CT scan for radiotherapy planning. 
  • In some patients who are expected to survive longer and have limited sites of metastasis, more sophisticated radiotherapy technique (stereotactic radiotherapy (SBRT)) can be considered.
    
    
• Surgery
  • Only suitable for a small number of patients with malignant spinal cord compression. 
  • Aims to remove as much of the tumour as possible, in order to relieve pressure on the spinal cord and nerves. It also aims to fix and stabilise the bone.
  • Some indications for surgery include:
    • Direct compression in the setting of intraspinal bony fragments, which are unlikely to respond to radiation
    • An unstable spine where direct fixation and stabilisation is the only way to preserve ambulation
    • Tumour that is not responsive to radiotherapy
    • Spinal cord that had received dosages of radiotherapy up to a certain tolerance. Further radiotherapy cannot be given.
  • Types of surgery:

• laminectomy – a section is removed from one of the spinal bones to relieve pressure on the spinal cord and nerves.

• Decompression and debulking of tumour – The diseased vertebral body and the tumour mass are removed, then the diseased vertebral body is stabilised by replacement with cement and various fixation devices.

Radiotherapy is usually given after surgery.

• Medical treatment
  • Painkillers are usually given for pain relief.
  • Depending on the type of cancer, anti-cancer treatment is usually given. For example, hormonal therapy can be used in patients with metastatic prostate cancer.
  • Bone modifying agents, such as denosumab and bisphosphonates may be used to strengthen the bones.

It can be difficult to cope with effects of malignant spinal cord compression. Some complications may arise if you are not able to move about as normal.

Preventive measures 

Canadian Cancer Society: Spinal cord compression

Special thanks to Mr. Joshua Tang and Dr. Wendy Wing-Lok Chan, Department of Clinical Oncology, the University of Hong Kong for authoring and editing this article.

Last updated on 1 Nov 2021.