Spinal Cord Compression (SCC)
Spinal cord compression (SCC) is a true oncologic emergency as delays in diagnosis can cause severe, irreversible neurologic compromise, decline in functional status, and impaired quality of life. SCC affects roughly 3% to 5% of all patients with cancer. The majority of cases result from spine metastases with extension into the epidural space. It is the second most frequent neurologic complication of cancer after brain metastases. The median overall survival of patients with SCC ranges from 3 to 16 months and most die of systemic tumor progression.
*Bethesda Handbook of Oncology
Causes
Although all cancers capable of hematogenous spread can cause malignant SCC, the most common underlying cancer diagnoses associated with this complication are:
- breast
- prostate
- lung
- multiple myeloma
- lymphoma
Hematogenous seeding of tumor to the vertebral bodies is the most common cause of spinal metastases, followed by direct extension and cerebrospinal fluid spread.
Nearly 66% of the cases with SCC have involvement of the thoracic spine and 20% have involvement of the lumbar spine. Colon and prostate malignancies more commonly spread to the lumbosacral spine, while lung and breast cancers frequently affect the thoracic spine. The cervical and sacral spines are rarely involved (less than 10% for each region).
The median time interval between cancer diagnosis and manifestation of SCC is approximately 6 to 12.5 months. Malignant SCC is rarely the primary manifestation of a malignancy. (but with the difficulty in accessing a primary care physician, this is more common in 2024)
*Bethesda Handbook of Oncology
Clinical
The most common presenting symptom of malignant SCC is back pain. The complaint of back pain in a cancer patient, specifically with a malignancy that frequently seeds the spine, should be considered metastatic in origin until proven otherwise. The characteristic back pain that is described is often:
- worst in the recumbent position, thus resulting in maximal intensity upon morning awakening. As time progresses, the back pain can become radicular in nature.
Other symptoms of malignant SCC are primarily dependent on the region of the spine that is affected.
- Cervical spine involvement generally presents with headache, arm/shoulder/neck pain, breathing difficulties, loss of sensation, and weakness/paralysis in the upper extremities.
- Thoracic and lumbosacral spine involvement can present with pain in the back or chest, loss of sensation below the level of tumor, increased sensation above the level of tumor, positive Babinski sign, bladder/bowel retention, and/or sexual dysfunction.
A thorough physical examination should be performed including evaluation for motor and sensory deficits including pinprick testing, straight leg raise, and a rectal examination to assess sphincter tone.
The most important prognostic factor for regaining ambulatory function after treatment of SCC is pretreatment neurologic status, making the physical examination a vital component of overall prognosis. Generally speaking, the quicker the neurologic deficit evolves, the lower the chance of recovery after treatment.
*Bethesda Handbook of Oncology
Diagnosis
- As back pain is a common complaint and the differential remains broad, having a high clinical suspicion is crucial.
- Red flags for SCC should include pain in the thoracic spine, persistence of symptoms despite conservative measures, and exacerbation of pain in the supine position.
- MRI
- CT
- PET
*Bethesda Handbook of Oncology
Treatment
- Primary goals of treatment include:
- pain control,
- preservation/recovery of neurologic function
- prevention of complications secondary to tumor growth.
- Dexamethasone: loading dose of 10 mg IV dexamethasone followed by 16 mg divided over the course of the day
- Immediate consultations to surgery (neurosurgery) and radiation oncology are required after diagnosis
- Patients with radiosensitive tumors (breast, lymphoma, myeloma, prostate cancer) have a higher chance of regaining/preserving motor function than those with less radiosensitive tumors (NSCLC, melanoma, and renal cell carcinoma).
- Systemic chemotherapy is most appropriate as a primary treatment modality only for patients with SCC caused by highly chemosensitive tumors such as Hodgkin and non-Hodgkin lymphoma, SCLC, breast cancers, and prostate cancers. It can also be used in those who are not candidates for radiation or surgery.
*Bethesda Handbook of Oncology
Other resources
- Watch This Space
