Back and Neck Pain in Patients with Metastatic Disease: Assessing and Managing Potential Spinal Cord Compression Mara Lu

1. Back and Neck Pain in Patients with Metastatic Disease: Assessing and Managing Potential Spinal Cord Compression Mara Lugassy MD Hospice Medical Director MJHS Hospice and Palliative Care

2. Objectives • Describe the epidemiology of malignant cord compression • Recognize characteristic signs and symptoms of cord compression • Describe immediate interventions for suspected cord compression • Identify prognostic indicators for recovery of neurologic function

3. Potential Cord Compression: A Palliative Care Emergency • Impacts quality of life • Intervention available • Time sensitive • Easily missed

4. Cord Compression: Epidemiology • Approximately 2-5% of cancer patients • 20% of cases: the initial manifestation of malignancy • Especially common in lung and hematologic malignancies Schiff D et al, Neurology 1997;49:452.

5. Who Gets it? • Metastatic disease from ANY primary site • Most common diagnosis: • Solid Tumors: Lung, Breast, Prostate Cancer • Hematologic: non-Hodgkin Lymphoma, Multiple Myeloma • Highest Incidence Rates: • Based on population based series of >15,000 cases • Multiple Myeloma (15%), Lymphoma (13.9%), Prostate Cancer (5%) Mak et al, Int J Radiat Oncol Biol Phys 2011;80:824

6. Cord Compression versus Normal Structure Univeristy of Alabama, Dept of Pathology

7. Cord Compression: How it Occurs • Approximately 90% of cases due to metastasis in vertebral bodies (anterior to cord) • Tumor expands into epidural space around thecal sac • Obstruction of epidural venous plexus -> vasogenic edema in white matter and grey matter -> spinal cord infarction

8. Characteristics • Thoracic Spine 60% • Lumbosacral Spine 30% • Cervical Spine 10% • Multilevel involvement: 30% Cole and Patchell, Lancet Neurol 2008; 7:459

9. Pain • Usually the earliest symptom • Present in around 95% of cases at diagnosis • Precedes other symptoms on average by 1-2 months

10. Pain • Severe • Localized • Progressing over time • Sudden worsening: possible compression fracture • Pain with movement: potential spinal instability • Tender to palpation

11. Pain ***Worse with LYING DOWN***

12. Pain • Can progress to radicular pain • Commonly bilateral • Thoracic: band like, wrapping around chest • Lumbosacral: radiating down legs • Cervical: radiating down arms • Worsened by coughing, sneezing, or Valsalva

13. Pain Referred Pain: C7: refers to interscapular region L1: refers to iliac crests, hips, sacroiliac region Furnicular Pain: compression of dorsal columns and spinothalamic tract – pain distant to compression site eg. cervical or high thoracic compression resulting in “sciatic” pain or pseudoclaudication pain in legs

14. Motor Symptoms • Weakness: 60-85% of cases at diagnosis • Ranges from mild to paraplegia • Ataxia • Importance of baseline exam

15. Motor Signs • Hyperreflexia below the lesion • Extensor plantar responses • Clonus

16. Sensory • Rarely the initial symptom • Occurs in approximately 60% at time of diagnosis • numbness and paresthesias • Sensory level usually 1-5 levels below level of lesion • Saddle anesthesia: cauda equina syndrome • Lhermitte phenomenon: cervical and upper thoracic cord compression

17. Autonomic Dysfunction • A LATE finding • Constipation • Urinary retention • Patient may be unaware due to sensory loss • Sexual dysfunction • Incontinence

18. What Next? Immediate management/symptom control Formulate goals of care Imaging Definitive Therapies

19. Treatment Goals • Maintain quality of life • Maintain neurologic function • Control pain • Prevent complications • Treatment usually has no impact on survival

20. Immediate Management: Steroids • Reduce tumor and spinal cord edema • Can improve or stabilize neurologic deficits • Analgesia against bone pain • Preferred agent: dexamethasone • Reduced mineralocorticoid effect

21. Dexamethasone • 57 patients with cord compression randomized to dexamethasone/+radiation therapy or radiation alone • 96 mg dexamethasone IV, then 24 mg qid, then 10 day taper • Higher percentage in dexamethasone group remained ambulatory at conclusion of therapy and at six months (59 vs 33%) Sorensen et al, Eur J Cancer 1994;30A:22.

22. Dexamethasone Dosing • 20 patient undergoing RT randomized to either 96 or 16 mg dexamethasone daily x 2 days with 10 day taper • No advantage for pain control or one month ambulation • Higher adverse events in high dose group • 37 patients randomized to 10 or 100 mg bolus followed by 16 mg PO daily • No difference in pain control or neurologic outcome Vecht et al,Neurology 1989 39:1255; Graham et al, Clin Oncol 2006 18:70

23. Supportive Care • Analgesia • Most require standing and prn opioid dosing • Necessary to tolerate imaging • GI prophylaxis • In setting of high dose steroids

24. Supportive Care • Urinary Retention • Patient may be unaware • Check post void residual, institute intermittent catheterization if residual >100 ml • Constipation • Requires aggressive management • Exacerbated by opioid use • Pressure Ulcers • Increased risk with weakness and sensory loss

25. Imaging • Should be done emergently -Need to image the entire spine • MRI: study of choice • CT Myelography: alternative study

26. Definitive Therapies - Radiation • Benefits in pain control and preservation of neurologic function • Response depends on: • Radiosensitivity of tumor • Performance status at diagnosis • Speed of development of neurologic deficits

27. Definitive Therapies - Prognosis • 67-72% of patient who are ambulatory at time of treatment remain ambulatory • 1/3 of nonambulatory patients (paraparesis) regain ability to walk • 2-6% with paraplegia regain ability to walk • Higher likelihood of walking again if motor deficits develop more slowly (weeks) or if treatment begins <12 hours after loss of ambulation • Among patients requiring catheter, 20-40% become catheter free Maranzano et al, J Radiat Oncol Biol Phys 1995; 32:959; Zaidat and Ruff, Neurology 2002, 58:1360.

28. Definitive Therapies - Surgery Tumor debulking and stabilization followed by radiation therapy Randomized trial: patients with single level cord compression, excluded for paraplegia>48 hours Surgical decompression within 24 hours of diagnosis and RT 2 weeks later versus RT within 24 hours of diagnosis Patchell et al, Lancet 2005;366(9486)643-648

29. Definitive Therapies - Surgery • Primary end point: ambulatory rate after treatment • Surgical group • significantly better ambulatory rate (84 vs 57%) • Ambulated for longer period (122 days vs 13 days) • Non-ambulatory patients more likely to regain ability to walk (62 vs 19%)

30. Surgery - Indications • Unknown primary tumor • Recurrent cord compression in previously radiated area • Spinal instability or bony impingement of cord • Primary modality with: • Radio-insensitive tumors • No paraplegia >48 hours • One level cord compression • No other contraindications • Limited systemic tumor

31. Conclusions • Careful history is key to identification • Recovery depends on early diagnosis and action • Multiple interventions available to improve and maintain quality of life