Metastatic Spinal Cord Compression

Dr Sally Hall

Dr Hannah Gunn

on behalf of MSCC group

Overview

Background to the MSCC audit March 2012 audit Recommendations and what might be

changing

Background

>100 cases per cancer network per year

Patients present acutely via different specialties

Diagnosis frequently delayed Time matters for neurological

recovery

Background

NICE Metastatic Spinal Cord Compression guidelines 2008Early detectionImagingTreatmentSupportive care & rehabCoordination of the service

Background Local audits NUTH/JCUH 2009 and 2011

using NICE standardsPatient education Chaotic pathway & delays (particularly for

patients from other trusts)Poor documentation & use of NCCC

pathwayPoor communication between specialtiesDifficulty capturing all patients

2012

New MSCC pathway document to be piloted soon across specialtieslocal then regionalpathway would move with the patientshould streamline patient journey named coordinators

MSCC group suggested a further audit whilst document being finalised

Case identification- March

16 patients with confirmed MSCC (bone mets/ vertebral collapse/ direct tumour involvement /invasion)

3 excluded: notes unavailable& insufficient information on Diadem/ PACS

Patient location 13 patients

9 referred to NUTH with ? MSCC from another hospital

0

0.5

1

1.5

2

2.5

3

3.5

North T

ynes

ide

Wan

sbec

k

Sunder

land

QEH

UHND

Darlin

gton

NCCC

RVI A&E G

P

Number of patients

Primary tumour site and metastatic disease

2

4

3

2

1

1

Breast

Lung

Prostate

Lymphoma

Myeloma

Extra-Skeletal EwS

3

6

6 New cancerdiagnosis

New diagnosis ofbone mets

Bone mets alreadyknown about

Did the patient exhibit signs and/or symptoms suggestive of spinal metastases?

Symptom Number of patients

Percentage

Pain in thoracic or cervical spine 7 54%

Progressive lumbar spinal pain 3 23%

Severe unremitting lower spinal pain 1 8%

Spinal pain aggravated by straining 0 0%

Localised spinal tenderness 4 31%

Nocturnal pain preventing sleep 0 0%

Neurological symptoms 13 92%

Neurological signs 9 69%

MSCC Coordinator

Neurosurgery = 5 patients Oncology = 8 patients

none had the old NCCC pathway document one NCCC ward no longer has copies (!)

Difficult to know when the coordinator was contacted, especially for patients being transferred from a peripheral hospital ranges from same day to 5 days telephone/ email/ MDT

MRI scanning

Whole spine imaging is the gold standard

Should be done to allow definitive treatment planning within 1 week of suspected MSCC for spinal pain or 24hours for neurological signs/symptoms suggestive of MSCC

92 % (12 patients) had whole spines done remaining patient underwent

CT

MRI diagnosis times

0

1

2

3

4

5

6

NUTH OUTSIDE NUTH

<24hrs

>24hrs

Unknown

Once MSCC confirmed…

All patients documented as receiving steroids but varying doses

VTE assessments documented in 53% (7 patients)

No documentation about being nursed flat/ stability of spine

Mobility on discharge not documented Discussions between Neurosurgery and

Oncology commented on in 46% (6 patients)

Definitive Treatment

One surgical candidate (subsequent radiotherapy)

everyone else treated with radiotherapy

? why delay from diagnosis to DXT treatment times 0

1

2

3

4

5

6

7

<24hrs unknown

numberofpatients

>48hrs

Summary

QUALITY STANDARD NCCC 2009 JCUH 2011 NCCC 2011 NCCC 2012

Whole spine MRI 100% 70% 80% 85% 92%

SPINAL PAIN

Definitive rx planning 1 week

100% unclear 18.5% 38% 63%

NEURO SX

Definitive rx planning 24hrs

100% unclear 51.6% 62% 54%

Limitations

• Retrospective for March• Unable to include 3 sets of patients

• 2 of these were surgical candidates• Number of patients that had surgery

suspiciously low ? not capturing all patients

• Referring hospital notes not always available

Recommendations & future planning

Introduction of new standardised MSCC pathway document

Should help improve standards and aid future audit

Role of MSCC coordinators Education locally, then regionally&

across specialties and grades