Spinal cord compression happens when there is pressure on the spinal cord, which may be caused by cancer. The pressure may be caused by a cancer growing into, or spreading in, the bones of the spine. About 5 out of 100 people (5%) with advanced cancer develop spinal cord compression. (1)
Pressure on the spinal cord stops the nerves working normally and causes symptoms. The symptoms you have depend on which part of the spinal cord is compressed. Spinal cord compression is clearly a serious problem that needs to be treated as soon as possible.
When spinal cord compression is caused by a cancer, doctors call it malignant spinal cord compression (MSCC). If it is caused by a cancer that has spread from another place into the spinal bones (secondary cancer) they call it metastatic spinal cord compression. Evidence suggests that there are approximately 4000 cases each year in England and Wales, or more than 100 cases per cancer network each year. (2)
You are at risk of developing spinal cord compression if you have a cancer that is at high risk of spreading to the bones, such as breast, lung or prostate cancer. You may also have a cancer that started in the spine.
The National Institute for Health and Clinical Excellence (NICE) has produced spinal cord compression guidelines (3). The guidelines say that your doctor should tell you if you are at risk of spinal cord compression. They should also tell you what symptoms to look out for. Treating spinal cord compression as soon as possible helps to reduce the risk of permanent damage to the spinal cord.
An audit in Scotland (2) showed that there were unfortunately significant delays from the time that patients first developed symptoms to when GPs and hospital doctors recognise the possibility of MSCC and make an appropriate referral. The average time taken from the onset of back pain and nerve root pain to referral were 3 months and 9 weeks, respectively.
Nearly half of all patients with MSCC were unable to walk at the time of diagnosis and of these, the majority (67%) had recovered no function after 1 month. Of those who could walk unaided at the time of diagnosis, 81% were able to walk (either alone or with aid) at 1 month.
Initial symptoms of spinal cord compression depend on where the pressure is on the spinal cord. The first symptom is usually pain. More than 9 out of 10 people (90%) with spinal cord compression have pain. As the compression gets worse it causes other symptoms. These can mean that some people have difficulty walking, a change in sensation, or problems with their bladder or bowel, or in men there are erection problems. (1)
If you have cancer and any of the symptoms of spinal cord compression you should contact your doctor or specialist cancer nurse straight away. Don’t wait to see if it gets better and don’t worry if it is an inconvenient time. You need to speak to your doctor as soon as possible. Explain what your symptoms are and tell them that you are worried you may have spinal cord compression.
If it is possible that you could have spinal cord compression you will have an MRI scan. The scan will show whether you have a cancer affecting the spine. It will also show which part of the spinal cord is compressed. The NICE guidelines recommend that you should have a scan within a week of telling your doctor about your symptoms. But you should have a scan within 24 hours if you have changes in sensation or weakness in your arms or legs.
If you can’t have an MRI scan you may have other types of scans, such as a CT scan.
The type of treatment that you receive will depend on your symptoms. Anyone who has metastatic spinal cord compression should be seen by the local specialist care coordinator for metastatic spinal cord compression. Treatment for spinal cord compression as a result of cancer usually includes one or more of the following -
- Lying flat
- Pain control
Treatment should start as soon as possible. The National Institute for Health and Care Excellence (NICE) guidelines on metastatic spinal cord compression recommend that you should start treatment within 24 hours of being diagnosed.
The aim of treatment depends on your symptoms. Some people have pain. Other people have nerve symptoms, such as numbness or tingling, or difficulty walking. Your doctor will talk to you about what the treatment aims to do. Treatment aims to get you back to normal as far as possible and as soon as possible. Unfortunately treatment may not always be able to help some people walk again.
Steroids are drugs that help to reduce swelling and can help to relieve pressure on the spinal cord. They are usually the first treatment your doctor recommends. You may have steroids to reduce swelling before radiotherapy treatment.
Doctors usually treat spinal cord compression with radiotherapy. Radiotherapy destroys cancer cells, which can help to reduce pressure on the spinal cord. You may have a single radiotherapy treatment to help reduce pain when you are first diagnosed. Or you may have a number of treatments over a few days.
The SCORAD 3 trial is comparing a single radiotherapy treatment with a course of radiotherapy for treatment of spinal cord compression. At the moment doctors are not sure how many radiotherapy doses (fractions) it is best to give. The aim of the trial is to compare the treatments to see how well they work, and the side effects.(1)
If you have surgery, you may also have radiotherapy after your wound has healed. Surgery can help to relieve pressure on your spinal cord and strengthen the spine. It involves having a general anaesthetic. If a tumour is causing pressure on the spine, your surgeon will try to remove the tumour and any bone that is pressing on the spinal cord. They will use a special cement to fill any gaps. To stabilise or strengthen the spine your doctor may put steel rods into your spine.
At present, relatively few patients with MSCC in the UK receive surgery for the condition. However, research suggests that early surgery may be more effective than radiotherapy at maintaining mobility in some patients.(3)
If you have myeloma, breast cancer, or prostate cancer you may have bisphosphonate medication to help to control pain and strengthen the bones in your spine. It is not known how well bisphosphonates work for other types of cancer. If you have a different type, you may have bisphosphonates as part of a clinical trial.
Sometimes chemotherapy may be the first treatment given for spinal cord compression. This is most likely if you have lymphoma or small cell lung cancer.
As well as giving treatments to control pain and reduce the pressure on your spinal cord your doctors and nurses will plan for you to go home.
Cancer is a less common cause of spinal cord injury, however the possibility of compression of the spinal cord should be considered carefully by those specialists treating cancer patients. Patients should be advised on what symptoms to look for to ensure that if it does develop, it is treated in the best way, and as quickly as possible.