My work at Christie Hospital involves caring for patients with malignancies, from those who are newly diagnosed, to…
VOL: 100, ISSUE: 49, PAGE NO: 41
Emma Halkyard BN, RN, is E-grade staff nurse, Christie Hospital NHS Trust, Manchester
My work at Christie Hospital involves caring for patients with malignancies, from those who are newly diagnosed, to those in the last days of their life. It is not uncommon for me to nurse a patient with compression of the spinal cord, which is why I chose to reflect on this article.
The presenting signs of malignant spinal cord compression (MSCC) vary, although pain is often the earliest symptom and is usually localised in the affected vertebra. Motor loss then follows, often presenting as limb weakness or heaviness, and progressing to paralysis with sensory loss. Changes to bowel and bladder function are signs of autonomic dysfunction and are usually late presenting signs.
A thorough clinical examination is required for patients who are known to be at increased risk of MSCC, for example those with malignancies of the lung, breast or prostate, or who present with such symptoms. Urgent magnetic resonance imaging (MRI) may be indicated.
The spinal cord, which is located within the vertebral column, begins as an extension of the medulla oblongata and extends to attach inferiorly at the coccyx as fibrous tissue. Compression of the cord occurs through various mechanisms, whether through primary spinal cord tumour, or as a result of metastatic disease in the vertebrae.
Symptoms can be explained to the patient in terms of the compression causing a reduction in the neurological messages being carried to and from the brain, rather as a kink in a garden hose interferes with the flow of water from the tap. Purdue (2004) stresses the importance of open and sensitive communication with the patient, and the need for honesty when discussing recovery from MSCC. Health care professionals must avoid giving false hope and fostering unrealistic expectations in patients.
I found the most significant point of the article is that a positive outcome for the patient depends on early diagnosis and prompt treatment. MSCC is an oncological emergency, which could potentially lead to permanent paralysis. Neurological status at the start of treatment is the main prognostic indicator, so those patients with a moderate degree of mobility are likely to have a more complete recovery, while only a small percentage of those who present with paraplegia are likely to regain their mobility.
Of the patients I care for who have MSCC, the majority already have, or are suspected of having, a definitive diagnosis of compression, and are being treated accordingly.
After reflecting on this article I was particularly struck by the subtlety of symptoms involved in spinal cord compression. Patient statements may be along the lines of ‘I need to rest more’, or they may report sensory changes, such as ‘pins and needles’ in the legs.
The presentation of MSCC may vary depending on the degree and site of the compression. There are signs and symptoms that could easily be dismissed by health care professionals as side-effects, primarily of the disease, such as general malaise, or of the treatment, for example peripheral neuropathy associated with some chemotherapy. Because of this potential for confusion there is a possibility of patients ‘slipping through the net’.
The article highlights the point that although positive outcome depends on early diagnosis and treatment, there are often unacceptable delays at all stages in the delivery of care. As a result of reading this article I will be more vigilant in my assessment of patients, particularly those at risk of MSCC who describe such symptoms, in an effort to ensure the best outcome for this patient group.