Malignant spinal cord compression (MSCC)
Malignant spinal cord compression (MSCC) is an uncommon condition that affects people with certain cancers that have spread to the bones in the spine, or have started in the spine.
What is malignant spinal cord compression?
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Malignant spinal cord compression (MSCC) happens when cancer cells grow in, or near to, the spine and press on the spinal cord and nerves. This causes swelling and a reduction in the blood supply to the spinal cord and nerve roots. The symptoms of spinal cord compression are caused by the increasing pressure (compression) on the spinal cord and nerves.
Any type of cancer can spread to the bones of the spine (vertebrae), which may lead to spinal cord compression. It is more common in certain cancers including breast, lung or prostate and people who have lymphoma or myeloma.
If your doctor has said that you are at risk of MSCC or you think you might be, let your doctor know immediately if you have any of the following symptoms:
Back or neck pain - the first symptom is usually any unexplained back or neck pain, which may be mild to begin with but becomes severe. The pain may feel like a ’band’ around the chest or abdomen and can radiate over the lower back, into the buttocks or legs. The pain can also spread down the arms. Quite often this pain is worse when lying down and it may affect sleeping.
Numbness or pins and needles in toes and fingers, or over the buttocks.
A new feeling of being unsteady on your feet, having difficulty climbing stairs or walking, or your legs giving way.
Difficulty controlling your bladder, passing very little urine or passing none at all.
Constipation or problems controlling your bowels.
These symptoms can also be caused by a number of other conditions. It is very important to let your doctor know if you have any of these symptoms so that they can be investigated.
The earlier MSCC is diagnosed, the better the chances are of treatment being effective.
Before your doctor can be sure whether these symptoms are caused by spinal cord compression, a number of tests will have to be done. These may include the following:
MRI (magnetic resonance imaging) scan
This scan uses magnetism instead of x-rays to build up a detailed picture of areas of your body. The scanner is a powerful magnet, so you may be asked to complete and sign a checklist to make sure it’s safe for you.
Before having the scan, you’ll be asked to remove any metal belongings including jewellery. Some people are given an injection of dye into a vein in the arm. This is called a contrast medium and can help the images from the scan to show up more clearly. During the test, you will be asked to lie very still on a couch inside a long cylinder (tube) for about 30 minutes. Some people feel a bit claustrophobic during the scan. It’s also noisy but you’ll be given earplugs or headphones.
CT (computerised tomography) scan
A CT scan takes a series of x-rays, which build up a three-dimensional picture of the inside of the body. The scan takes 10-30 minutes. CT scans use small amounts of radiation, which is unlikely to harm you or anyone you come into contact with.
You may be asked not to eat or drink for at least four hours before the scan.
You may be given a drink or injection of a dye, which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. It’s important to let your doctor know if you’re allergic to iodine or have asthma, because you could have a more serious reaction to the injection.
Having an MRI or CT scan is painless; however, you may find lying on a hard surface for a long time uncomfortable. Ask for a painkiller before your scan if you need one.
This scan does not diagnose MSCC but may be done to check if there are any abnormal areas inside the bone.
Rarely, MSCC is the first symptom of cancer. Your doctor may recommend a biopsy of the spine to give an exact diagnosis.
Treatment should be started as soon as possible after diagnosis, with the aim of minimising permanent damage to the spinal cord. Treatment will also help to reduce pain by shrinking the tumour and relieving the pressure on the nerves. The damage to the spinal cord means that some people will have some paralysis at the time of diagnosis. This may be permanent in some people.
The choice of treatment depends on several factors including the type of cancer, the area of the spine affected and your general fitness. The most common treatment is radiotherapy, although surgery and chemotherapy are also sometimes used.
There are some risks associated with treatment to the spine, which your doctor will discuss with you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent.
You are free to choose not to have the treatment and the staff will explain what may happen if you do not have it. Although you don’t have to give a reason for not wanting to have treatment, it can be helpful to let the staff know your concerns so they can give you the best advice.
Treatment usually involves a combination of the following:
Your doctor will usually advise you to lie flat on your back until tests have shown whether you have a spinal cord compression or not. This is to reduce movement of the affected area of the spine and to prevent an increase in symptoms.
If the tests confirm that you have spinal cord compression, your doctor and physiotherapist will decide what movement is safe for you. They will let you know what you can and can’t do.
During and after treatment, you will have regular physical examinations by your doctor and physiotherapist where they will carry out a detailed check of your nervous system. This will include examining your range of movement, muscle strength, co-ordination and sensation to touch. This helps them to see any improvement in your symptoms.
Collars and braces
Some people may be given a collar or brace to wear that can help to support their neck or spine. Your physiotherapist will discuss this with you.
Steroids are chemicals naturally produced in the body that help control and regulate how the body works. High doses of a steroid called dexamethasone are usually started immediately if spinal cord compression is suspected. The steroid helps reduce pressure and swelling around the spinal cord, and can quickly relieve symptoms such as pain. The dose is gradually reduced over time and then stopped depending on the improvement of symptoms, and after starting other treatment such as radiotherapy and surgery.
Radiotherapy is the use of high-energy rays to destroy cancer cells. It is the most common way to treat spinal cord compression. It's usually used on its own, or occasionally alongside other treatments such as surgery. It is given by directing radiotherapy rays at the tumour from outside the body - known as external radiotherapy. Radiotherapy is usually given as a short course of treatment. This can range from one single treatment to one treatment a day for two weeks. It may be given for up to four weeks for myeloma and lymphoma. Radiotherapy will be started as soon as possible after MSCC is diagnosed.
Surgery is only suitable to treat a small number of people for their spinal cord compression. This will depend on several factors, including the type of tumour, where it is situated and how unstable the spine may be.
The aim of surgery is to remove as much of the tumour as possible and relieve pressure within the spinal canal.
Surgery may involve removing several parts of the vertebrae, as well as removing as much of the tumour as possible, without weakening the spine. The common surgical techniques used in this situation are called anterior stabilisation and debulking of tumour, or decompression laminectomy.
This surgery may also involve stabilising the spine further by using metal rods or bone grafts. Your doctor or nurse will explain the operation in more detail if surgery is appropriate for you.
If some of the tumour cannot be removed by surgery, or if the tumour comes back after initial treatment, radiotherapy is sometimes given.
Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. It’s occasionally used to treat spinal cord compression. It may be used for tumours that are sensitive to chemotherapy, such as lymphoma or small cell lung cancer.
Chemotherapy and hormonal therapy can also be used after radiotherapy/surgery for certain cancers, such as breast and prostate cancers.
If you’re experiencing pain, your doctor or nurse will discuss ways of controlling this with you. You may be given different drugs to help with pain and these will be assessed regularly to make sure they are effective. Bisphosphonate drugs can be used to treat pain and weakened vertebrae in breast cancer and myeloma. They can also be used in prostate cancer if painkillers are ineffective.
Loss of mobility
Your mobility may be affected by changes in your muscle strength and your ability to feel and control the movement in your muscles. Your physiotherapist will help you to adjust to these changes. An occupational therapist can give practical advice and supply aids to help you. This can help you to be as independent as possible.
Your doctor and nurse will monitor how well your bladder is working. If you’re having problems passing urine, a thin flexible tube (catheter) may be used to help drain urine from the bladder.
You may be given medication to help with constipation or if you’re having difficulty controlling your bowels.
After treatment has finished
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Spinal cord compression can affect people differently. The care you need after treatment will depend on the result of treatment and your level of mobility. Before you leave the hospital, the staff should organise any care you will need while at home.
Some people who have lost the ability to walk or have lost movement before treatment, may not get this back. Further care may be available at your cancer centre, local hospital or hospice. This will involve a team of healthcare professionals who will work closely with you and your family to organise a plan of care and rehabilitation to suit your needs.
If you have any questions about your care you should discuss this with your doctor, nurse or radiographer. You can also speak to one of our cancer support specialists.
This section has been compiled using information from a number of reliable sources, including:
De Vita et al. Cancer: Principles & Practice of Oncology. 9th edition. 2011. Lippincott Williams and Wilkins.
Dougherty L, Lister S. Moving and positioning of the patient with spinal cord compression. The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8th edition. 2011. Wiley-Blackwell Publishing Limited. Oxford.
National Institute for Health and Clinical Excellence (NICE). Metastatic spinal cord compression: Diagnosis and management of patients at risk of or with metastatic spinal cord compression. 2008.
Schiff et al. Treatment and prognosis of neoplastic epidural spinal cord compression, including cauda equina syndrome. 2013. www.uptodate.com (accessed March 2014)
Thanks to Dr Carrie Featherstone, Consultant Clinical Oncologist, and the people affected by cancer who reviewed this edition.
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