30th December 2024

Management of MSCC

Swift action is required when MSCC is suspected, to prevent further neurological decline. Treatment involves high-dose corticosteroids, ensuring spinal stability, and definitive treatment with surgery or radiotherapy (Table 10).

Corticosteroids

Immediate treatment with high-dose corticosteroids reduces perilesional oedema and should be initiated prior to confirmation of MSCC with imaging.  The steroid of choice is dexamethasone, initially 16 mg stat. Ongoing dosing may be 16 mg OD (once daily) or 8 mg BD (twice daily) (8am and noon).

Thought should be given to co-prescription of gastroprotection (e.g. proton pump inhibitors such as omeprazole) and, in the longer term, bone protection with bisphosphonates and calcium supplementation. In breast cancer and myeloma with vertebral deposits, bisphosphonates should be started empirically to help with pain and stability.

Spinal surgery versus radiotherapy

Urgent discussion with the clinical oncology MSCC coordinator and neurosurgical team should follow. In confirmed MSCC, the optimal treatment is surgery (decompression of the cord and spinal fixation/stabilisation) followed by postoperative radiotherapy after surgical healing is complete.

Suitability for surgery depends on the following:

• The patient being fit enough for surgery
• An operation being technically possible
• Predicted prognosis from the underlying tumour likely to outlast operative recovery
• Prospect of neurological recovery; good chance if paralysis is acute onset (< 24-48 hours)
• In cases where MSCC is the presenting complaint, resection may provide a biopsy for tissue diagnosis
• Radioresistant tumour type or progression or relapse of MSCC after previous radiotherapy
• Patient choice or preference

Where spinal surgery is not possible, the patient should be considered for urgent (within 24 hours) radiotherapy.

After surgery and radiotherapy, high-dose dexamethasone can be weaned slowly.

Spinal stability

Spinal stability must also be considered; tumour burden, vertebral fractures and bone retropulsion may cause further cord compression with spinal movement. Until stability is confirmed, the patient should be nursed with full spinal precautions with flat bed rest and log-roll technique when repositioning.

If the spine is deemed unstable and spinal fixation is not appropriate or the patient is experiencing significant pain, the neurosurgical team may advise the use of external supports, collars or braces.

Supportive treatment

If there is pain, appropriate analgesia should be provided.

Patients are at high risk of venous thromboembolism due to malignancy and immobility, and appropriate prophylaxis should be prescribed – ideally prophylactic-dose low molecular weight heparin and compression stockings.

Bowel and bladder function should be monitored, with urgent catheterisation for urinary retention and bowel management systems considered for faecal incontinence. Prevent pressure sores with regular repositioning.

If there is significant neurological impairment, rehabilitation and appropriate discharge planning are paramount.