Metastatic spinal cord compression (MSCC) is the compression of the spinal cord or cauda equina, by direct pressure and/or vertebral collapse because of metastatic spread, that compromises the function of the spinal cord and may cause neurological deficit and paralysis (NICE [208]).

The spinal cord is about 45 cm in length and extends from the base of the brain, surrounded by the vertebrae, to the pelvis. Nerves situated within the spinal cord, called upper motor neurones, carry the messages between the brain and spinal nerves along the spinal tract. Spinal nerves are classified as lower motor neurones. Spinal nerves branch out from the spinal cord at each vertebral level to communicate with specific areas of the body (Harrison [105]).

MSCC is caused by the following (Loblaw et al. [150]):

The damage to the spinal cord causes ‘spinal shock’ which is a temporary suppression of spinal cord activity caused by swelling at and below the level of the lesion in spinal cord injury. Within the confines of the vertebral canal, the oedematous cord is compressed against the surrounding bone. A complex series of physiological and biochemical reactions occur due to the resulting oedema and vascular damage. Circulation of blood and oxygen is disrupted; ischaemic tissue necrosis follows with an immediate cessation of conductivity within the spinal cord neurones. This can persist for 2–6 weeks (Harrison [105]).

MSCC is one of the most serious and devastating complications of cancer. Unnecessary delays in diagnosis and treatment impact on patients’ quality of life and prognosis. However, with prompt diagnosis and treatment many patients can retain good levels of function and independence. MSCC can occur in virtually all types of malignancy, but myeloma, lung, prostate and breast cancer are the most common (Bach et al. [11]).

Most MSCC cases occur in patients with a pre‐existing cancer diagnosis; however, in around 20% of patients it is their first cancer presentation (Bucholtz [26]). A patient with a cancer diagnosis and confirmed vertebral metastases is at high risk of developing MSCC and it can have catastrophic consequences if diagnosis is delayed. It is important that these patients are educated about the risks of developing MSCC, how to identify the symptoms, what to do and who to contact.

It is reported that 30% of patients after diagnosis of MSCC may survive for 1 year (L'Esperance et al. [137]). Of patients that were ambulant on presentation 70% will retain function, but only 5% who presented paraplegic will regain some function (Loblaw et al. [150]). The predominant poor prognostic indicator with regards to regaining function is loss of sphincter function at presentation.

The true incidence of MSCC is unknown due to current restrictions in detection rate and coding systems in the UK (NICE [208]). Post mortem evidence indicates that it is present in 5–10% of patients with advanced cancer.

New back pain in patients with cancer suggests epidural spinal cord compression. Pain that worsens when the patient is lying down or with percussion of vertebral bodies is characteristic of this condition (Quint [239]). Late neurological signs such as incontinence and loss of sensory function are associated with permanent paraplegia (Newton [199]). The most common cause is extradural deposits due to the vertebral body extending into the anterior epidural space.

By recognizing symptoms that manifest early, such as back pain, a sensation of leg weakness or vague sensory changes, maximum functionality can be retained. Late signs such as profound weakness, a defined sensory level or sphincter disturbance are associated with a poor prognosis and the compression being less reversible.

Common symptoms include (NICE [208]):

Whole spine magnetic resonance imaging (MRI) is the investigation of choice; however, if MRI is absolutely contraindicated, spinal CT is an alternative (Levack et al. [144]). Imaging must be performed within 24 hours of presentation for any patient with spinal pain suggestive of spinal metastases and with neurological signs or symptoms suggestive of MSCC (NCAT [198], NICE [208]). Imaging must be performed more urgently if there is clear neurological deficit or deterioration. In these situations, if out‐of‐hours MRI is not available, investigations must not be delayed. Instead, the patient should be transferred to the relevant regional MSCC treatment centre.

For patients with pain suggestive of spinal metastases but no neurological signs or symptoms, imaging should be performed as an outpatient within 1 week of presentation. An up‐to‐date CT of brain, chest, abdomen and pelvis must be considered as this assists surgical planning with regard to bone strength, structural integrity and ensuring that surgery is used appropriately (NICE [208]).

A full neurological assessment including per rectum examination and a respiratory assessment will be undertaken by the healthcare professional (NICE [208]). The nurse should undertake baseline observations (blood pressure, pulse, respiratory rate, temperature, oxygen saturations) as well as blood tests (FBC, U&Es, LFTs and bone profile).

Patients with severe pain suggestive of spinal instability, or any neurological signs or symptoms suggestive of MSCC, should be nursed flat with neutral spine alignment (including ‘log rolling’ and use of a slipper bed pan) until bony and neurological stability are ensured (Levack et al. [144]). Healthcare professionals must assume that the spine is unstable until clearly documented in the medical notes. For cervical lesions, immobilization must be ensured with a hard collar.

If the patient is walking with minimal weakness or sensory change then there is a one in three chance of regaining leg strength, and initial management is:

All patients with radiologically confirmed MSCC must be discussed urgently with a consultant clinical oncologist, consultant neuro‐ or spinal surgeon and, where possible, the treating oncology consultant prior to definitive treatment decisions. Decisions regarding the role of surgery or radiotherapy should be made bearing in mind the cancer diagnosis, characteristics of the MSCC, functional level of the patient (neurological and performance status), overall disease status and likely prognosis. It may be appropriate to manage patients with MSCC palliatively, without surgery or radiotherapy; however, this decision should be made by a consultant oncologist, neurosurgeon or palliative medicine physician, usually following joint discussion. Although palliative radiotherapy is the main treatment modality, for a certain group of patients surgical decompression is appropriate (Rades et al. [240]).

MSCC co‐ordinators must be contactable 24 hours a day for:

If there is a neurological deficit, the patient must immediately be discussed with the local MSCC co‐ordinator and managed as an emergency. Assessment and investigation must not be delayed due to lack of local out‐of‐hours services. If these are not available, the local MSCC co‐ordinator must be contacted to arrange urgent transfer to the regional MSCC treatment centre (NICE [208]).

Initial nursing management is associated with maintaining spinal alignment and monitoring sensory and pain levels as well as baseline observations. Whilst waiting for a clear clinical management plan, the role of the nurse is to support the patient with analgesia, ensure that steroids are given and that the patient and their family understand the need to maintain bedrest, and supporting the patient with their activities in daily living (NICE [208]). The cancer nurse needs to understand the principles of moving and handling a patient with possible spinal instability to ensure that no further damage occurs. This is explored in greater detail later in this section.

Good nursing care remains the cornerstone of patient management. Throughout all of this the nurse must be able to recognize promptly the signs of the deteriorating patient with regards to back pain, leg weakness, sensory and functionality changes. This includes being able to prioritize patients and their management and know when to escalate and an awareness of the main side‐effects of the treatment modalities being used. Patients with urinary retention should be catheterized. The hydration and nutritional status of patients should be assessed and appropriately managed. Measures should be instituted to reduce the risk of pressure sores and thromboembolic events. The pain status of the patient should be assessed and controlled with appropriate analgesia. Care should be taken that patients do not become constipated, and where necessary laxatives should be prescribed. Patients should be encouraged to mobilize as soon as spinal stability has been documented as this will aid their rehabilitation and reduce the risk of pressure sores, chest infections and thromboembolic events (Walji et al. [301]).

Further principles are dependent upon whether the patient has a stable or unstable spine.

Prior to moving and handling a patient with MSCC, the nurse should determine whether the patient is able to assist with moving, positioning and transfers. This is dependent on:

The nurse should not attempt to move a patient without fully appraising the clinical situation and reviewing the clinical notes.