Management

This is a neurological emergency and requires immediate referral for specialist review.

• treatment requires specialist advice but includes:
  • analgesia
    • ensure adequate pain relief is provided promptly for people with suspected or confirmed spinal metastases or metastatic spinal cord compression (MSCC), including while the person is waiting for investigations or treatment
  • bisphosphonates
    • indicated if vertebral involvement from myeloma or breast cancer bisphosphonates to reduce pain and the risk of vertebral fracture/collapse
    • bisphosphonates should not be used to treat spinal pain in patients with vertebral involvement from tumour types other than myeloma, breast cancer or prostate cancer (if conventional analgesia fails) or with the intention of preventing MSCC, except as part of a randomised controlled trial
  • denosumab
    • is recommended as an option for preventing skeletal-related events (pathological fracture, radiation to bone, spinal cord compression or surgery to bone) in adults with bone metastases from breast cancer and from solid tumours other than prostate if:
      • bisphosphonates would otherwise be prescribed and
      • the manufacturer provides denosumab with the discount agreed in the patient access scheme
    • is not recommended for preventing skeletal-related events in adults with bone metastases from prostate cancer
  • radiotherapy
    • asymptomatic spinale metastases
      • consider radiotherapy only if:
        • part of a randomised controlled trial with the intention of preventing MSCC or
        • part of a treatment strategy for oligometastases with spinal involvement or
        • there are radiologica lsigns of impending cord compression by an epidural or intradural tumour
    • spinal metastases with non-mechanical pain
      • offer 8 Gy single fraction radiotherapy,even if the person is paralysed or
      • consider stereotactic ablative body radiotherapy for people with a good overall prognosis oroligometastases with spinal involvement
    • radiotherapy if MSCC and surgical intervention is not suitable
      • offer urgent radiotherapy as soon as possible and within 24 hours, unless:
        • they have complete tetraplegia or paraplegia for 2 weeks or longer and painis well controlled or
        • overall prognosis is considered poor
          
          
  • interventions to treat spinal metastases with MSCC
    • for people with spinal metastases with MSCC then the following should be considered:
    • surgical decompression of the spinal cord
    • surgical stabilisation of the spine
    • evidence shows that the survival of MSCC patients can be improved with palliative decompression before motor deficits occur (3)
      • after motor deficit onset, survival can still be improved with surgery within 7 days
      • overall survival was better in patients aged <= 55 years (3)
  • corticosteroids
    • for people with neurological symptoms or signs of MSCC:
      • offer 16 mg of oral dexamethasone (or equivalent parenteral dose) as soon as possible.
      • after the initial dose, continue 16 mg of oral dexamethasone (or equivalent parenteral dose) daily for people awaiting surgery or radiotherapy.
      • after surgery or at the start of radiotherapy, reduce the dose gradually until stopped
    • if dexamethasone is given before imaging, and spinal metastases and MSCC are subsequently ruled out, discontinue it
    • consider giving corticosteroids as part of initial management to people with spinal metastases or MSCC who do not have neurological symptoms or signs, if they have:
      • severe pain or
      • a haematological malignancy
    • for people with confirmed haematological malignancy with spinal metastases (with or without neurological symptoms or signs):
      • offer 16 mg of oral dexamethasone (or equivalent parenteral dose) as soon as possible
      • after the initial dose, offer further corticosteroid treatment in discussion with the haematology multidisciplinary team
    • seek specialist haematological advice before starting corticosteroid treatment for people presenting with radiologically suspected lymphoma or myeloma with spinal metastases without neurological symptoms or signs
    • for people taking corticosteroid treatment:
      • monitor blood glucose levels and
      • offer proton pump inhibitor acid suppression
  • interventions for thromboprophylaxis
    • if with suspected MSCC then use thigh-length graduated compression/anti-embolism stockings unless contraindicated, and/or intermittent pneumatic compression or foot impulse devices
      • offer patients with MSCC who are at high risk of venous thromboembolism (including those treated surgically and judged safe for anticoagulation) subcutaneous thromboprophylactic low molecular weight heparin in addition to mechanical thromboprophylaxis
      • for patients with MSCC, individually assess the duration of thromboprophylactic treatment, based on the presence of ongoing risk factors, overall clinical condition and return to mobility

Notes (2):

• if a patient with suspected MSCC is considered fit for investigation and treatment an urgent MRI of the whole spine is the investigation of choice
• corticosteroid use and withdrawal in MSCC
  • give a loading dose of 16 mg of dexamethasone as soon as possible after assessment, followed by a short course of 16 mg dexamethasone daily while treatment is being planned
  • continue dexamethasone 16 mg daily in patients awaiting surgery or radiotherapy for MSCC. After surgery or the start of radiotherapy the dose should be reduced gradually over 5-7 days and stopped. If neurological function deteriorates at any time the dose should be increased temporarily
  • reduce gradually and stop dexamethasone 16 mg daily in patients with MSCC who do not proceed to surgery or radiotherapy after planning. If neurological function
    deteriorates at any time the dose should be reconsidered.
  • monitor blood glucose levels in all patients receiving corticosteroids
  • Gastroprotection should be considered whilst patient is on steroids

Reference:

• 1. NICE (September 2023). Spinal metastases and metastatic spinal cord compression
• 2. West Midlands Palliative Care Physicians (2023). Palliative care - guidelines for the use of drugs in symptom control.
• 3. Lo W-Y. Metastatic spinal cord compression (MSCC) treated with palliative decompression: Surgical timing and survival rate. PLoS 2017; 12(12): e0190342.