Spinal Cord Compression

Home , Dermatome (anatomy), Lumbar, Spinal cord compression

Oncology Emergency Series Understanding spinal cord compression

By Roberta Kaplow, PhD, APRN-CCNS, AOCNS, CCRN, and Karen Iyere, MSN, RN

SPINAL CORD COMPRESSION (SCC) is a life-threatening complication of primary and metastatic cancer that can significantly impact a patient’s quality of life. Prompt diagnosis and treatment are critically important. Identified by the Oncology Nursing Society as a structural oncologic emergency, SCC occurs when a tumor puts pressure on the spinal cord. This article, the first of a three-part series on oncology emergencies, describes signs and symptoms of SCC and the diagnosis, treatment, and nursing care for patients with SCC.

Anatomy and pathophysiology The spinal cord is the third most likely site where cancer cells metastasize.1 Although the exact incidence of SCC isn’t known, it’s estimated to affect 5% of patients with cancer; the incidence is reported at 10% in patients with spinal metastases.2,3 The spinal cord is composed of nerves that transmit messages to and from the brain. A tumor growing on or adjacent to the spinal cord can compress the thecal sac and the cauda equina. The thecal sac, which surrounds the spinal col-

umn, contains cerebrospinal fluid that circulates around the spinal cord and the TOCK S nerve roots. The cauda equina at the distal end of the spinal cord is a collection

4 HUTTER of nerve roots resembling a horse’s tail, hence its name. /S The spine is composed of vertebrae and the spinal cord. (See Looking at the AULITZKI

vertebral column.) Thirty-one pairs of spinal nerves connect the spinal cord to K muscles through vertebral openings. The fibers innervate different parts of EBASTIAN the body. The spinal cord conducts two types of signals. Sensory signals are S

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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. transmitted via afferent nerve fibers Each nerve is a cell and if it’s SCC can also occur when cancer to the spinal cord. Motor responses compressed, as it is with SCC, the spreads within the epidural space; are transmitted via efferent fibers signal will be inhibited; nerve dam- this typically happens in the latter from the spinal cord to the muscles. age due to compression can be part of the metastatic disease A mnemonic used to remember this temporary or permanent. Compres- trajectory.5 is SAME: Sensory (Afferent) signals sion may also inhibit blood flow to Most cases of SCC affect the tho- go to the spinal cord; Motor (Effer- the spinal cord, which can cause racic area, but a few affect the lumbo- ent) signals leave the spinal cord. nerve cell ischemia or infarction. sacral area. Cases affecting the cervical For example, if someone touches a When SCC develops, depending spine are even more unusual. hot surface, sensory signals go to the on the level of the compression, it Metastatic disease can appear in spinal cord via the afferent pathway can cause loss of function to the af- more than one area of the spinal and to the brain, creating the pain fected nerves and those distal to the column.5 Depending on the com- sensation. The reflex is to pull the site of the compression. Not only do pression’s location, signs and symp- hand away quickly via the motor sensory and motor deficits result, but toms may develop gradually or (efferent) pathway. the autonomic nervous system can be abruptly. affected. When this occurs, bowel, Although SCC can occur in pa- bladder, and sexual function may be tients with any cancer involving Looking at the lost. (See Breaking down the nervous bone, some cancers are more likely vertebral column system.) to spread to the spine than others. The vertebral column, which protects Although tumors may affect any (See Cancers that raise the risk of the spinal cord, consists of 7 cervical, area of the spinal cord, most cases of SCC.) SCC may also occur due 12 thoracic, 5 lumbar, 5 sacral, and SCC involve metastasis to the verte- to primary tumors that affect the 4 coccygeal vertebrae. bral body. Tumors can also invade paravertebral area (the area on the epidural space, the area between either side of the vertebral column) Atlas (C1) Axis (C2) the vertebrae and the dura or outer- and spread to the vertebrae. Gastro- most layer of the spinal column, and intestinal and pelvic cancers typi-

, 2009. compress the thecal sac. cally impact the lumbosacral Cervical vertebrae

EALTH C7 Compression or constriction af- spine while the thoracic spine is H T1 fects signal conduction and blood typically involved with lung or 5 LUWER supply to the spinal cord. It also breast cancer. K increases vascular permeability, re- OLTERS sulting in interstitial edema, which Recognizing SCC : W

Thoracic impedes blood flow to arterioles In some patients, SCC is the pre- vertebrae

ALTIMORE and stops capillary blood flow to senting sign of cancer; about 20% of . B the area. Decreased blood flow to patients with SCC have an undiag- 6 DITION the spinal cord can lead to a life- nosed malignancy. Back pain, the E

TH threatening emergency: infarction or most common first symptom of , 11 collapse of affected vertebrae. If not SCC, is reported in 90% to 98% of Intervertebral disc ISEASE T12 1

D recognized and treated promptly, cases. L1 AND this can cause permanent paresis, Three types of pain are associated Inferior vertebral notch

EALTH paraplegia or quadriplegia, loss of with SCC: Intervertebral

H foramen

IN •

bowel and bladder control, and Local pain is typically described as a Lumbar Superior vertebrae

ODY 5 vertebral notch sexual dysfunction. dull ache that increases in intensity B Superior articular as the day passes. The pain is located

UMAN process

H Where does SCC appear? within one or two spinal divisions of HE L5 T S ’ SCC may develop from tumors the compression.

Spinous tubercle Sacral promontory within the spinal cord (intramedul- • Radicular pain is described as a EMMLER lary), outside the spinal cord (extra- dull ache that’s difficult to localize. It

JJ. M Auricular surface medullary), intradural (within the can also be a sharp, shooting pain AYLOR

Coccygeal cornu dura mater), or extradural (outside that occurs with spinal movement. (horn) BJ, T Vertebral Column (Right Lateral View) the dura mater); however, intra- Radicular pain spreads in a bandlike OHEN

C medullary SCC is unusual. Rarely, manner (back to front in the chest or

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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. abdomen). It can also radiate along 13 an affected dermatome. Breaking down the nervous system • Referred pain is difficult to localize The nervous system is divided into two main divisions and several subdivisions. because it’s referred from one site to The central nervous system (CNS) consists of the brain and the spinal cord. The another, may affect multiple derma- peripheral nervous system (PNS) consists of nerve tissue outside the brain and tomes, and is felt in an area away spinal cord. The PNS comprises the somatic nervous system and the autonomic from the compression.5 An example nervous system. The somatic nervous system is responsible for sensory and mo- of referred pain is someone who has tor innervation of the CNS and PNS except for the viscera, smooth muscle, and right upper quadrant pain due to glands. Motor innervation for the viscera, smooth muscles, the heart, and the glands is the responsibility of the autonomic nervous system. acute cholecystitis. Often the pain is Now consider the difference between sensory (afferent) nerves and motor referred to the right shoulder. (efferent) nerves. Sensory (afferent) nerves carry impulses from the periphery to Typically, signs and symptoms the central nervous system for processing. The motor (efferent) nerves carry a of SCC progress in a similar pattern: response to the affected organ, smooth muscle, or gland. The two pathways for Symptoms begin with motor symp- the motor response are the somatic nervous system and the autonomic nervous toms, followed by sensory symptoms, system. In the somatic nervous system, the motor nerves innervate an organ. and finally autonomic symptoms. The motor neurons of the autonomic system take the response to the smooth (See Clinical manifestations of SCC.) muscle, heart, or glands. The autonomic nervous system is responsible for involuntary responses, such Diagnosing SCC as regulating body temperature, digestion, elimination, pupillary constriction, Early recognition of signs and symp- blood flow to organs, and even BP. The autonomic nervous system is divided into the sympathetic and parasympathetic branches. The sympathetic branch upregu- toms and prompt diagnosis of SCC lates the body systems (fight or flight) while the parasympathetic branch down- are essential to prevent permanent regulates the body systems (rest and digest). The three neurotransmitters in the 6 disability. For instance, if the patient autonomic nervous system are acetylcholine, epinephrine, and norepinephrine. who had ovarian cancer begins to complain of back pain, the healthcare provider should be suspicious the pain is in the lumbar area, the are ambulatory on presentation will of metastasis to the spine. patient likely has a SCC of the lum- retain that ability. Patients who can’t To diagnose SCC, several assess- bar area. Assess the location, type of ambulate before treatment probably ments and diagnostic studies should pain (such as acute or chronic), se- won’t regain this ability. Data suggest be performed. The first step is to verity, and characteristics of the pain that patients who can’t ambulate complete a comprehensive history (for example, dull or sharp, radiat- after radiation therapy to treat and physical assessment. ing or local).5,6 Ask what causes pain SCC will have a poor prognosis for • History. The history of the symp- to start and what, if anything, brings survival.5 toms and disease process will help relief. Ask about the pain’s intensity, To assess the sensory system, be- determine if the patient is experienc- location, duration, and aggravating gin most distally and move proxi- ing autonomic dysfunction. For in- and alleviating factors. Perform the mally to determine the highest level stance, ask about bowel and bladder same maneuver using the opposite of intact sensory function. Assess habit changes, incontinence, and leg. light touch with a fine wisp of cot- changes in sexual function. History Assess motor function by observ- ton. With the patent’s eyes closed, and duration of any neurologic find- ing the patient’s posture, balance, touch the patient’s skin lightly and ings as well as relief measures and gait while he or she walks across ask the patient to respond whenever should be ascertained.6 the room, turns, and walks back. a touch is felt. Compare one side of • Physical assessment. The patient Test muscle strength by asking the the body to the other. Use a pin- should have a thorough neurologic patient to actively resist your move- prick to assess pain sensation. Eval- assessment. Patients should be ment. Assess and grade deep tendon uate proprioception by grasping the evaluated for pain as well as other reflexes, including the plantar patient’s big toe, pulling it away sensory, motor, and autonomic (Babinski) response.5,6 (See Evaluat- from the other toes, and demon- dysfunction.6 ing the Babinski response.) strating “up” and “down” as you To assess for back pain, ask the The patient’s ability to ambulate is move the patient’s toe. Then with patient to raise one leg and flex the a gauge of the patient’s baseline neu- the patient’s eyes closed, ask the pa- neck. The pain’s location may indi- rologic status and helps determine tient to state if you’re moving the cate the level of SCC. For instance, if prognosis. In general, patients who toe up or down.6 www.Nursing2016.com September l Nursing2016 l 47

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. Assess the anal reflex by using a causes such as degenerative joint cotton swab or other dull object to disease. Cancers that raise the stroke outward from the anus in • Myelography. This is generally risk of SCC2,6 four quadrants while you observe used only when a patient can’t un- • multiple myeloma for reflex contraction of the anal dergo CT or MRI. A myelogram also • lymphoma 6 musculature. permits cerebrospinal fluid analysis. • lung cancer • Upon initial assessment of signs Electromyography (EMG). EMG • breast cancer and symptoms related to SCC, im- is typically used for patients who • prostate cancer mediately notify the healthcare pro- report weakness, pain, or paresthe- • renal cell carcinoma vider and prepare the patient for sias. During an EMG, electrical ac- • gastrointestinal cancer diagnostic testing. Continue to tivity of muscle fibers is evaluated • melanoma closely monitor the patient for individually and collectively by as- • sarcoma any deterioration in neurologic sessing the degree muscles can re- • gliomas 7 functioning, such as progressive spond to stimuli. • astrocytomas • weakness or development of auto- Nerve conduction velocity test- • ependymomas nomic neuropathy. ing. This test assesses how quickly • oligodendrogliomas electrical signals travel through a • hemangioblastomas. Diagnostic studies nerve. The conduction velocity • Magnetic resonance imaging along the nerve depends on the (MRI) and computed tomography state of myelination. This test is • Corticosteroids. Patients with (CT). The healthcare provider will often performed at the same time SCC are treated initially with I.V. obtain one or more imaging studies, as EMG.8 corticosteroids to reduce edema such as X-rays of the spine, MRI, or Diagnosis of SCC is based on the around the cord or involving the CT scan. MRI of the spine is the presence of risk factors, including a cord itself, alleviate pain, and im- diagnostic study of choice for SCC tumor or metastasis in the spinal prove neurologic function. Dexa- because it provides the best visual- cord, and presenting signs and methasone is the steroid of choice ization of spinal lesions and allows symptoms along with diagnostic for SCC. Acute adverse reactions the healthcare provider to evaluate study results. associated with corticosteroid the complete spine for multiple met- therapy include nausea, vomiting, astatic sites. An MRI can be used to Treatment strategies increased appetite, weight gain, flu- distinguish between a lesion and To treat SCC and manage signs id retention, heartburn, headache, other causes of signs and symp- and symptoms, the healthcare difficulty sleeping, and facial puffi- toms.5 Other diagnostic studies may provider may prescribe the following ness. Long-term adverse reactions be performed to help rule out other therapies. may include hypertension, hyper- glycemia, immunosuppression, os- teoporosis, cataracts, peptic ulcers, 5,12 Clinical manifestations of SCC and depression or other mood 5 Motor symptoms Sensory symptoms Autonomic symptoms changes. • • fatigue • numbness • urinary retention Radiation therapy (RT). Begun soon after the diagnosis of SCC and • hyporeflexia • paresthesia • urinary hesitancy the initiation of corticosteroid treat- • • • decreased muscle loss of thermal sensation frequent small voids ment, RT relieves SCC by decreasing tone • loss of proprioception • urinary incontinence tumor size. Immediate RT is re- • spasticity • loss of deep pressure and • loss of bowel control quired in patients who aren’t surgi- • gait disturbance vibration sensations • constipation cal candidates; they should receive • • leg weakness progressive lower • decreased ability to therapy within 24 hours of SCC 2 (lumbar) spinal pain bear down diagnosis. • • Analgesia. Pain management is pain in the middle • impotence (thoracic) or upper vital to both acute and chronic (cervical) spine treatment. Patient self-report is the • other pain most valid and reliable measure of pain. If patients can, they should be

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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. asked to rate their pain intensity using a numeric rating scale (or Evaluating the Babinski response equivalent) ranging from 0 (no The Babinski or plantar response is assessed by stroking the lateral aspect of the pain) to 10 (the worst pain imagin- patient’s sole from the heel to the ball of the foot, curving medially across the ball. able) per hospital policy. If patients Use an object such as a key or opposite end of a reflex hammer and use the can’t quantify their pain, use an- lightest stimulus that will evoke a response. Note movement of the big toe, which other valid and reliable tool recom- is normally plantar flexion as shown in the picture at left. mended by the facility. Use the same Dorsiflexion of the big toe and fanning out of the other toes is a positive Babinski response, as shown in the picture at right. pain intensity rating scale for subse- quent assessments. The first-line treatment for severe pain in patients with SCC is opioids. Nonsteroidal anti-inflammatory drugs may also be used if pain isn’t severe. Adjuvant therapies, including antidepressants, antiepileptic drugs, or steroids, may be prescribed to augment the effects of analgesics. Note and document efficacy. Com- plementary therapies, if available and not contraindicated, may also be of- fered. These therapies may include acupuncture, massage therapy, exter- 2003 nal Qigong therapy, capsaicin cream,

ILKINS hydrotherapy, or any combination of 4,5 & W these. Patients may need a vertebroplas- • Surgery. To decompress the spi- made brace may be created and ILLIAMS 5,6 W ty or kyphoplasty to decrease com- nal cord, the entire tumor or a seg- worn for 6 to 10 weeks. pression and chronic pain. For a ment of the tumor can be removed

IPPINCOTT vertebroplasty, a balloon is inflated via laminectomy. Surgical treat- Nursing interventions : L in the compressed vertebral space ment is used to improve mobility, Nurses play a vital role in the man- to alleviate the compression. In a decrease pain, and improve quality agement of SCC. After diagnosis of HILADELPHIA

. P kyphoplasty, special cement is of life. To make it more effective, this oncologic emergency, the nurse D E used to keep the vertebral body surgical treatment may be com- will assist with stabilizing the TH

, 8 from collapsing back onto the bined with RT. Surgical treatment patient’s clinical status and work to

AKING spinal cord. is typically appropriate for patients prevent further complications. Nurs- T • Bisphosphonates. Zoledronic with: es are responsible for the following ISTORY

H acid, pamidronate, or other bisphos- • a life expectancy of more than 4 steps. AND phonates are used to help manage months. • Tumors located in the cervical signs and symptoms associated with • rapidly progressing paraplegia. spine may alter pulmonary function, • XAMINATION bone metastases, including bone pathologic fracture with disloca- necessitating emergency endotra- E pain and pathologic fractures. tion of bone fragments. cheal intubation; therefore, closely

HYSICAL Bisphosphonates help reinforce • intractable pain. assess the the patient’s airway and P TO bones and prevent them from break- • recurrence after RT (radioresistant respiratory status.

UIDE ing down. They also can help pre- tumors). • Perform a thorough neurologic ’ G

ATES vent certain complications of cancer One of the main objectives of sur- assessment including vital signs and

, P. B , P. therapy such as hypercalcemia of gical intervention is to stabilize the evaluation for presence of clinical malignancy.9 Bisphosphonates may spine. Postoperative spinal stabiliza- manifestations at least every 2 hours. ZILAGYI

S reduce the risk of SCC and related tion may be accomplished with a • Optimize patient mobility and mit- AND signs and symptoms and can be brace until any stabilization devices igate sequelae of immobility. Patients , LS used to prevent further bone inserted in the OR or grafts heal and with spinal instability diagnosed by ICKLEY

B metastasis. the spine is strengthened. A custom- MRI should be maintained on bed

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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. rest, lying flat to prevent further neu- infection such as urinary frequency rologic damage. For patients with and dysuria. spinal instability, use log-rolling tech- • Decreased mobilization and RT nique when changing position. As increase the risk of skin breakdown. symptoms improve, gradually assist Perform a thorough assessment of the patient to a sitting position. If the skin and risk for pressure ulcer symptoms worsen, return the patient development using a valid and reli- to the most comfortable position. able tool each shift and as needed. Perform range-of-motion exercises, Initiate preventive strategies such as tolerated. Collaborate with the as turning and repositioning physical therapist to optimize func- every 2 hours, using pressure- tion. Obtain equipment to maintain relieving devices, and maintaining alignment, augment patient mobility, adequate nutrition.10,11 and promote spine stabilization. Initiate and maintain venous throm- Patient education and support boembolism (VTE) prophylaxis, Besides providing clinical care, such as intermittent compression nurses must also be attentive to devices, graduated compression the patient’s psychosocial needs. stockings, or low-molecular-weight Nurses must provide education to heparin or unfractionated heparin. help patients and families under- • Although constipation is usually a stand the reason for signs and result of loss of voluntary control of The spinal cord is the symptoms and what to expect the anal sphincter, it’s also an ad- during treatment. verse reaction to opioid therapy. third most likely site To achieve optimal outcomes Collaborate with the provider to where cancer cells from the education sessions, nurses i nitiate a bowel regimen, including metastasize. should first identify patients’ and administration of stool softeners, their families’ readiness to learn laxatives, and suppositories every and determine which methods are 1 to 2 days as needed for bowel most effective for each learner. elimination. urinary catheter is inserted, imple- Consider what environment and • Collaborate with the healthcare ment the catheter-associated uri- timing will be most conducive to provider to determine the need for nary tract infection prevention learning. (See Patient and family intermittent or indwelling urinary bundle and monitor for signs education topics.) catheterization. If an indwelling and symptoms of urinary tract Patients and their families may experience significant psychologi- 4-6 cal stress after SCC is diagnosed. Patient and family education topics Patients may feel hopeless and Topics to include during the acute phase: unable to cope with their new diag- • signs and symptoms to report nosis. Because quality of life can be • importance of reporting pain significantly decreased in patients • importance of reporting changes in sensory and motor function with SCC, it’s imperative to identify • specific preparation for diagnostic testing ways to improve outcomes. Support- • specific treatment modalities ive care and rehabilitation should • importance of VTE prevention. include consultation with psychiatry, Topics to include when preparing for discharge: social work, and spiritual support. • importance of rehabilitation Families may benefit from support • specific discharge medications services to help them care for their • importance of following instructions to taper steroids instead of stopping 4,5 them abruptly loved ones. • self-catheterization • bowel regimen Nursing’s critical role • pressure ulcer prevention. Clinical manifestations can be devas- tating and significantly impact a

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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. patient’s quality of life, but meticu- ed. Pittsburgh, PA: Oncology Nursing Society; www.uptodate.com/contents/clinical-features- lous nursing care can help to opti- 2012:337-384. and-diagnosis-of-neoplastic-epidural-spinal- 6. Flaherty AM. Spinal cord compression. In: cord-compression-including-cauda-equina- mize outcomes. This includes using Yarbro CH, Wujcik D, Gobel BH, eds. Cancer syndrome. critical thinking, evidence-informed Nursing: Principles and Practice. 7th ed. Sudbury, 13. Porth CM. Essentials of Pathophysiology: clinical decision making, and caring MA: Jones & Bartlett; 2011:979-993. Concepts of Altered Health States. 3rd ed. 7. Campellone JV. Electromyography. 2014. Philadelphia, PA: Wolters Kluwer Health/ practices. ■ https://www.nlm.nih.gov/medlineplus/ency/ Lippincott Williams and Wilkins; 2011. article/003929.htm.

REFERENCES 8. Jasmin L. Nerve conduction velocity. 2015. https://www.nlm.nih.gov/medlineplus/ency/ RESOURCE 1. Bowers B. Recognising metastatic spinal cord article/003927.htm. National Guideline Clearinghouse. Metastatic compression. Br J Community Nurs. 2015;20(4): 9. Coleman R. The use of bisphosphonates spinal cord compression. Diagnosis and 162-165. in cancer treatment. Ann N Y Acad Sci. management of adults at risk of and with 2. Robson P. Metastatic spinal cord compression: 2011;1218(1):3-14. metastatic spinal cord compression. 2008; a rare but important complication of cancer. Clin reaffirmed 2012. www.guideline.gov/content. 10. Warren D. Spinal lesions causing cord Med (Lond). 2014;14(5):542-545. aspx?id=14326. compression: a practice-related evaluation of care. 3. Gabriel J. Acute oncological emergencies. Nurs Br J Neurosci Nurs. 2011;7(3):536-540. Stand. 2012;27(4):35-41. Roberta Kaplow is an oncology clinical nurse special- 11. Warnock C, Hodson S, Tod A, et al. ist at Emory University Hospital in Atlanta, Ga. Karen 4. Colangelo J. Care considerations for patients Improving care of patients with metastatic Iyere is a staff nurse at Veterans Administration with spinal cord injuries. Radiol Technol. 2014; spinal cord compression. Br J Nurs. 2014; Medical Center in Decatur, Ga. 86(1):33-54. 23(4):S14-S18. 5. Kaplan M. Spinal cord compression. In: The authors and planners have disclosed no poten- 12. Schiff D. Clinical features and diagnosis tial conflicts of interest, financial or otherwise. Kaplan M, ed. Understanding and Managing of neoplastic epidural spinal cord compression, Oncologic Emergencies: A Resource for Nurses. 2nd including cauda equine syndrome. 2015. DOI-10.1097/01.NURSE.0000490208.81425.19