Fiona Haas, BSc, RGN, is a practice nurse, Fitzalan Medical Centre, Littlehampton.
Spinal cord compression is a complication of malignant disease that can result in irreversible paralysis. The condition may be reversible if it is identified early and treatment started quickly, but because most patients are not admitted to an oncology unit until there is some neurological damage (Falk and Fallon, 1997) the chances of a good outcome are reduced. This is because the degree of neurological impairment at the start of treatment is the key factor determining the level of expected recovery (Falk and Fallon, 1997). Spinal cord compression is therefore a medical emergency (Brigden, 2001).
Some of the delay in diagnosis and treatment is caused by failure to recognise the condition and its serious nature, together with limited awareness of the importance of fast treatment to prevent permanent damage.
Malignant spinal cord compression is damage caused by a tumour of the vertebral column, the spinal meninges or the spinal cord, or by pressure from collapsed vertebrae after a pathological fracture (Edwards et al, 1995). Most commonly the tumour is a secondary cancer and is usually outside the dura of the spinal cord (Held and Peahota, 1993).
Tumours can cause compression by direct pressure on a nerve, or they can affect the blood supply. While venous obstruction will cause oedema, affecting function, arterial obstruction will cause ischaemia followed by necrosis of the spinal cord (Edwards et al, 1995).
Spinal cord compression is found in up to 5 per cent of cancer patients (Falk and Fallon, 1997). The most common malignancies causing it are those that tend to produce distant metastases. These include lung, breast, prostate and kidney cancers, lymphomas, myelomas and sarcomas (Kramer, 1992), but other malignancies can be involved. Spinal cord compression gives the first suspicion of a malignancy in some patients. The primary cancer is not always known (Kramer, 1992).
Signs of spinal cord compression
There are several symptoms that should alert a medical professional to the possibility of cord compression (Box 1). In 90 per cent of cases one of the first signs is pain in the back or neck (Held and Peahota, 1993). The pain is often in the thoracic region and may be described as a tight band around the chest or upper abdomen. It tends to be unremitting and often becomes worse when lying flat (Kramer, 1992). However, 10 per cent of patients do not experience pain (Kaye, 1992) and there are other symptoms that should alert patients and health care professionals; for example, changes in mobility and sensation. These include limb weakness and sensory changes with numbness or tingling in the limbs. Another symptom is reversal of the plantar reflexes to become up-going. Also, the legs become weak and start to give way under the patient before paralysis sets in. Sphincter disturbance, including urinary hesitancy and retention, occur late, leading to incontinence or constipation (Kaye, 1992). Numbness around the peri-anal region may indicate a cauda equina (lower end of spinal cord) compression of the nerve roots (Kaye, 1992).
Spinal cord compression is difficult to diagnose if pain is the only symptom (Kramer, 1992) but the importance of pain cannot be over-emphasised. Ingham et al (1993) maintain that pain, and its distinct nature, is often ignored, which results in weakness being the first symptom noted in many patients with a developing malignant cord compression. As weakness usually occurs late, Ingham et al (1993) suggest that more notice should be taken of pain as a symptom (Kramer, 1992).
Factors affecting likely outcome
The amount of neurological damage that has occurred by the time treatment is started is the most important element in the degree of recovery to be expected. Once paralysis begins to set in, the neurological problems seem to advance quickly over a few hours, with increasingly less likelihood of the damage from the cord being reversed (Kramer, 1992). If patients are still mobile at the start of treatment there is a 70 per cent chance of recovering motor function (Kaye, 1992). After the onset of paraplegia, the possibilities of reversing it become as low as 5 per cent (Kaye, 1992). Ingham et al (1993) found that if patients were left for 48 hours after the start of weakness there was only a 7 per cent chance of their becoming mobile again.
Other factors influencing treatment outcomes are the degree of spinal cord block, the radiation dose and the radiosensitivity of the tumour (Kramer, 1992). Lymphomas, myelomas and metastases caused by breast, renal and prostate primaries are radiosensitive, whereas lung secondaries are unlikely to be very responsive (Kramer, 1992). Once the pressure affects the circulation to the cord, and the cord starts to become ischaemic, the situation is grave (Regnard and Tempest, 1998).
Survival may be prolonged following a cord compression. This is most likely to be a possibility with breast, prostate and haematological malignancies (Kramer, 1992). Aabo and Walbom-Jørgensen (1986) made a study of patients with Hodgkin’s disease and non-Hodgkin’s lymphoma and found that, in those who presented with spinal cord compression at diagnosis, median survival was not reached by five years. One patient was still alive after 10 years.
The expense to the state of nursing care for a paralysed individual may amount to tens of thousands of pounds but the cost to the victim is the loss of mobility, sexuality, independence and freedom. It is imperative that everything possible is done to prevent paralysis, as some patients can expect several years with prolonged remission from the primary disease.
Investigations include X-rays, CT scans, myelograms and magnetic resonance imaging (MRI scans). X-rays will be useful in only 85 per cent of patients (Kramer, 1992). An MRI scan is the preferred investigation but is not available everywhere.
The nurse’s role in recognising symptoms Nurses are the health professionals who are in continuous contact with patients in hospital and who must alert doctors to new medical emergencies. Continuous back pain in a patient with a possible malignancy is usually the first sign of cord compression. The symptoms that give cause for alarm include numbness, tingling, cold, weakness, paralysis or up-going plantar reflexes. Bowel and bladder dysfunction should also be checked.
Patients considered at risk need regular assessment, and nurses could be helped in providing this by having specific guidelines and a plan of action if malignant cord compression is suspected. It would be useful if such information were included in doctors’ handbooks on dealing with medical emergencies as this might improve the possibility of rapid treatment being offered.
Care for patients with developing paralysis
Nurses are expected to provide the basic physical care for patients with progressive paralysis (Box 2). Patients need a safe environment (Held and Peahota, 1993) and will be kept in bed to prevent falls and further damage to a potentially unstable spine. Cot-sides will probably be necessary and may give the patient, who might feel off balance, a sense of security. The combination of sudden immobility and lack of sensation means that there is a high risk of pressure sores developing. In addition, good pain relief must be instituted.
The patient will probably be very anxious and frightened by any sudden loss of mobility and independence. This may be a new illness, which means that the person is probably going to be newly diagnosed as having cancer. Alternatively, it could be the first sign that cancer has spread. Being confronted with the prospect of an incurable and possibly advanced disease can be very frightening, and patients may, as a consequence, have concerns about dying. In addition, they may be faced with a complete change of body image (Jones and Davidson, 1988) with multiple losses, including control of body functions, mobility and independent living (Held and Peahota, 1993). Consideration should be given to the support that may be needed at this difficult time; the involvement of someone close to the patient may be helpful.
Investigations should proceed as quickly as possible. If there is any neurological impairment, treatment should be started before the diagnosis is confirmed (Brigden 2001). Referrals must be made and often an urgent transfer to another hospital arranged. There can be a wait before an MRI scan and then further delays before transfer to a bed at a specialist radiotherapy or neurosurgical unit.
Initial treatment and possible referral
Dexamethasone is given initially to reduce swelling and to give temporary relief of the pressure (Kramer, 1992). This corticosteroid crosses the blood-brain barrier, reduces the inflammation and swelling, and should relieve the pressure for a few hours until radiotherapy or surgery are possible. Experts have not agreed on the optimum dose but Abrahm (1999) suggests starting with 100mg intravenously, then 24mg orally four times a day for three days followed by reducing doses. She recommends the higher doses for a rapidly progressing cord compression and believes better results are obtained with these. Lower doses are less likely to give serious side-effects but will not be as effective (Abrahm, 1999). Brigden (2001) advises 10-100mg intravenously followed by 4-10mg orally or intravenously, every 4-6 hours. Kaye (1994) recommends only 16mg intravenously but expects radiotherapy to be started the same day. Intravenous dexamethasone must be given slowly (Regnard and Tempest, 1998), to avoid sensations of perineal burning.
Radiotherapy, if appropriate, should be started as soon as possible and certainly within 48 hours. Radiation is likely to be of benefit if the disease is secondary to myeloma, lymphoma, breast or prostate primaries (Abrahm, 1999). Surgery may be indicated if there is no diagnosis, or if the spine is unstable (Kaye, 1992).
Causes of delay
Husband (1998) found that 79 per cent of patients at district general hospitals waited more than 24 hours for treatment. There are many factors that can cause delays in diagnosis and treatment (Box 3). One of the initial reasons is lack of awareness of the seriousness of the condition on the part of patients, nurses and doctors (Husband, 1998). For instance, because the patient may already be unwell, and be accepting any changes in mobility as ‘what to expect’, any symptoms might not be mentioned for several days (Falk and Fallon, 1997).
Another reason for delay in treatment is that because the nurses are not aware of the dangers of cord compression they dismiss leg weakness as part of the patient’s general condition and therefore do not inform the doctors immediately.
There may also be delays if doctors do not identify the need for urgent action. Although this is a medical emergency, unless the compression is high and giving a risk of respiratory failure, spinal cord compression is not usually life-threatening (Held and Peahota, 1993). This means that doctors may not view the patient with spinal cord compression as being a very high priority. The patient’s history may be the only cause for suspicion because the suspected diagnosis may not even have been confirmed by an X-ray (Kaye, 1992).
Patients who are in the final stages of their disease or who are very unwell may not benefit from aggressive treatment, although radiotherapy may be indicated purely for pain relief (Hicks, 1993). This means that urgent discussion with the patient or carers is needed if the treatment is likely further to weaken and distress a very ill patient (Falk and Fallon, 1997).
Ways of speeding up access to treatment
Husband (1998) recommends more education for health professionals so that they are able to identify the condition and understand the need for urgent treatment.
Patients who have malignancies that may put them at risk of spinal cord compression could be taught the signs and symptoms, warned not to ignore back pain (Held and Peahota, 1993) and to report any changes early (Kramer, 1992). Husband (1998) goes so far as to advocate increased self-referral by at-risk patients who are already under the care of an oncology unit.
It may be useful if nurses are made aware of the condition during their training and taught what to do if confronted with a patient who is developing a cord compression. In practice, it could be helpful to have a set of guidelines for doctors and nurses, listing the responsibilities of each.
Educational sessions for junior doctors on how to manage patients developing a cord compression may also be useful. They could be reminded regularly of the seriousness of the condition and that early cord compression needs urgent treatment.
Because beds at radiotherapy units are normally full with a long waiting list it could be helpful if more centres were able to reserve beds for oncological emergencies (Husband, 1998).
Treatment for patients with malignant spinal cord compression is more likely to be successful if it is started before the patient loses any mobility. This means that early diagnosis is needed if permanent damage is to be avoided. Unfortunately, delays in treatment are so common that many patients have some neurological damage before they start treatment.
Educating patients, nurses and doctors on the early signs of the development of cord compression could help reduce delays. Guidelines on the action to be taken could prove useful if a spinal cord compression is thought to be occurring.
Treatment could be instigated more quickly if there were less pressure on beds in specialist units or if oncology units were able to keep a bed open for such emergencies. The risks of lifelong paralysis make it essential that everything is done to ensure treatment is given at the right time. Raising awareness of the seriousness of cord compression and educating patients, doctors and nurses on the need for immediate treatment is one way of reducing the occurrence of this devastating complication of malignancy.