Eur J Orthop Surg Traumatol DOI 10.1007/s00590-014-1438-8


Management of metastatic spinal cord compression: awareness of NICE guidance F. M. Brooks • Ameet Ghatahora • M. C. Brooks • Hazel Warren • Laura Price • Pranter Brahmabhatt • Saik De Vauvert • Cerys John Elizabeth Farnworth • Erwina Sulaiman • Sashin Ahuja

Received: 20 November 2013 / Accepted: 25 February 2014 Ó Springer-Verlag France 2014

Abstract Objective The spine is the most common site for bony metastases. It can lead to the development of significant complications and morbidity if appropriate treatment is not provided. National Institute for Health and Clinical Excellence (NICE) issued new guidance in 2008 with regard to the management of patient with metastatic spinal cord compression (MSCC) to assess the awareness of the NICE guidelines for MSCC. Methods We contacted doctors in oncology, trauma and orthopaedics, palliative care and general medicine and assessed their knowledge of MSCC using a questionnaire based on the salient points of the NICE guidance. This was a UK-wide questionnaire. Results We contacted 96 trainee doctors (oncology, palliative care, general medicine and orthopaedics) and found that 74 % felt adequately informed to diagnose metastatic cord compression although only 11 % considered a sensory level as a potential sign of cord compression. Neurological symptoms (91 %) were the main reason for referral to a tertiary spinal service. MRI was the investigation of choice. There was a poor knowledge of metastatic scoring systems and only 8 % would consider assessing the patient’s fitness for surgery. Most of the respondents felt that they had been poorly taught at undergraduate and postgraduate level on MSSC. F. M. Brooks (&)  A. Ghatahora  H. Warren  L. Price  P. Brahmabhatt  S. De Vauvert  C. John  E. Farnworth  E. Sulaiman  S. Ahuja University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK e-mail: [email protected] M. C. Brooks Ninewells Hospital and Medical School, Dundee DD1 9SY, UK

Conclusion Our audit shows that MSCC is poorly understood in general and that greater understanding of the NICE guidance is required to allow for better management of these patients and more prompt referral for appropriate surgical assessment. Keyword Metastatic spinal cord compression  Spinal  Cord compression  Oncology

Introduction The spine represents the most common site for skeletal metastases from malignant disease. Patients often present with a variety of symptoms requiring emergent treatment to preserve function. Some patients present with cord compression without a history of previous known malignancy. In these circumstances, it is important for the managing clinician to stage the disease and get a diagnosis with regard to the primary disease. Metastatic spread to the spine is commonly by haematogenous spread. Most metastases cause symptoms due to direct involvement of the vertebra causing pain and, secondarily, due to the collapse of the vertebra causing spinal cord compression. Metastatic cord compression is estimated to occur in 5–10 % of patients with cancer and 40 % of patients with pre-existing bone metastases [1]. Some of the common features include pain from instability, pathological fractures and neurological symptoms. For 23 % of patients who present with cord compression, this is the first presentation of the tumour [2]. In 2008, National Institute for Health and Clinical Excellence (NICE) ( CG75NICEguideline.pdf) issued guidance on the management of metastatic spinal cord compression (MSCC). The


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guidance provides the clinician with a stratified method for investigation and promotes referral for surgical opinion. There has been a rise in the number of patients presenting with MSCC, and this is mainly thought to be secondary to improved survival rates. Emphasis is made on early detection and appropriate imaging so that treatment can be initiated as soon as possible. One of the key recommendations from this guidance is that every cancer network has a metastatic cord compression coordinator. This is to ensure good service organisation and 24-h service provision of expertise in dealing with patients suffering from MSCC. The NICE guidelines highlight the fact that 50 % of patients are unable to walk at time of diagnosis, a startling statistic when the ability to walk at diagnosis is significantly related to overall survival [3]. Survival following presentation with MSCC is poor with only 10 % of patients surviving for 18 months postpresentation [1]. Tumour scoring symptoms, such as Tokuhashi and the modified Bauer score, aid the surgeon in deciding whether surgery is appropriate [4]. These scores have been shown to have the best prognostic factor in a review of prognostic scores in 2008 [5]. It is improving the early detection of signs and symptoms of MSCC; however, that remains the key step in improving the treatment of the disease. Our study attempts to assess the current level of trainee knowledge in the UK regarding the management of MSCC and the recently published NICE guidelines.

Methods We performed a UK-wide, telephonic survey. We spoke to medical, oncology, orthopaedic and palliative care trainees and asked about their understanding of NICE guidance about MSCC. We asked them questions based around the recommendations in the NICE guidance. The full questions asked are provided in ‘‘Appendix’’. The questions in ‘‘Appendix’’, were aimed at giving an insight into a doctor’s confidence or competence in dealing with MSCC. Doctors were asked an open question, to ascertain what signs or symptoms they considered to be important to diagnose MSCC. The doctor was then presented with the list of symptoms suggestive of spinal metastases as laid out in the guidelines. If a patient presents with these symptoms alone, the doctor should contact their MSCC coordinator within 24 h. If there were also neurological symptoms, such as those listed in Key Priorities section of the NICE guidelines, then the referring doctor is to discuss this with the MSCC coordinator immediately, and the case treated as an emergency. The doctors were asked how quickly they would make a referral, depending


on the symptoms the patient had. There is clearly guidance from NICE regarding escalation of care [3]. The doctors were then asked about imaging. The NICE guidelines clearly state that MRI is the imaging of choice. If MRI is contraindicated, then the MSCC coordinator needs to be contacted to ascertain the best form of imaging. As there are various steps within the NICE guidelines, which require discussion with the MSCC coordinator, doctors were polled to see whether they knew who their MSCC coordinator was. The NICE guidelines clearly outline how the service should be set up, and the referring doctor should have some knowledge of this [3]. The final question, although not relating to the NICE guidelines, helps to analyse how competent doctors within these four specialities feel.

Results We contacted 96 trainees who deal with patients presenting with MSCC at centres across the UK. These included trainees in orthopaedics, oncology and palliative care. 74 % of respondents felt adequately informed to make a diagnosis of MSCC (Fig. 1). Despite this, only 11 % felt that they had received enough education at an undergraduate level and 43 % felt that they had received enough at a postgraduate level. When looking at the patient’s symptoms, there was a variation in what respondents would consider as an oncological emergency (Fig. 2). A total of 90 % would refer patients with evidence of cord compression within 24 h, but only 70 % would consider this an oncological emergency. In terms of image modality used, all would use MRI scan as the image modality of choice, but few knew which sequence was best (Fig. 3). Another area which raises

Fig. 1 A chart showing the % of participants reporting adequate training for a diagnosis of MSCC

Eur J Orthop Surg Traumatol Fig. 2 Bar chart showing the positive response against cluster symptoms suggestive of MSCC

Fig. 3 Graph showing the radiological imaging thought to be appropriate for investigation of suspected MSCC

concerns was that only 15 % knew who their MSCC coordinator was or if there was one.

Discussion MSCC is increasing in frequency with a reported 7 % of patients with cancer at risk of MSCC [6]. The increase in incidence has been down to improvements in detection and treatment of cancers and improved life expectancy following treatment [7]. There is a need for doctors to be aware of the issues surrounding MSCC and vigilance amongst those treating cancer patients. Our study shows that the knowledge of NICE guidelines is variable amongst the different specialities treating patients with cancer.

The NICE guidelines aim to improve awareness of the risk of MSCC and aim to put the patient at the centre of any treatment pathway with a view to preserving function and neurology in this cohort of patients. Despite walking ability being key to the NICE guidelines, it was surprising that 20 % of the respondents would assess the patient’s ability to walk. Walking allows patients to have on-going independence, and loss of walking ability has devastating effects on the patient’s physical and psychological function. A retrospective audit performed by Sui et al. [8] found that at a regional oncology centre, there was marked variance in the management of MSCC. They concluded that education of doctors was required to improve compliance to the NICE guidelines. Our results would echo the findings


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of this study. We found that, like their study, there were issues with imaging. Kelly et al. [9] highlighted the lack of provision for out of hour imaging for spinal tumours in Ireland. Similar studies have been performed in the NHS framework which have highlighted the importance of out of hour imaging [9, 10]. Our study shows that 20 % of respondents would still be happy to wait for more than 24 h for an MRI, and this may reflect a similarly poor access to MRI imaging out of hours. A study by Patchell et al. [11] showed that, in carefully selected patients, early surgery and radiotherapy was superior to just radiotherapy in the ability of patients to maintain the ability to walk. These results are supported by studies which show that early surgery and decompression in MSCC help to maintain ambulation function and improve survival [12, 13]. Quan et al.’s [14] recent study has shown that early surgery can improve and restore function in patients with MSCC. Numerous scoring systems exist to guide surgeons and oncologists on those patients who might benefit from surgical intervention for their MSSC. These scoring systems were often devised in the early 1990s and the question exists whether they are still clinically relevant or not. The Tokuashi score and the modified Bauer scores have been shown to have the best prognostic factor in a review of prognostic scores in 2008 [15]. Our survey shows that prognostic scores were only known by 14 % of the respondents. It is important to understand that these scoring systems may be dated due to advances in the medical management of many of these diseases. Our study shows that the symptoms of MSCC are still poorly understood. White et al. [16] have previously shown that 50 % of patient present with the inability to walk despite symptoms been present for 2 months or more. The ability to walk at the time of diagnosis has been shown to be a significant predictor of outcome in terms of survival. Numerous studies have shown a significant association between the ability to walk pre- and post-treatment [17, 18]. Our study shows that people accept that neurological change is an emergency but for those with symptoms suggestive of instability such as back pain are still treated less aggressively than they should be. The assessment of the patients fitness to undergo surgery was something we felt was found to be poor in this study with the American Society of Anaesthesiologists grading system (ASA) being used in only 8 % of those responding to our survey [19]. This and other methods such as the Karnofsky score are available to assess patient’s fitness for surgery [20]. The Karnofsky score assesses a patient’s function as a general status of health. Its use as a prognostic indicator has been incorporated in the Van der Linden score [21]. Some find these scores use limited, as most patients with neurological compromise will present with a


low Karnofsky score [22]. A long-term study from Hannover concluded that in 740 patients who underwent palliative surgery the outcome following surgery was related to patients general health and surgery should be tailored around this and their prognosis [23]. Our study demonstrates that both MSCC and the relevant NICE guidelines are generally poorly understood amongst doctors in the UK. Knowledge base is variable across specialties, but it is evident that trainees require further teaching both at under and postgraduate level to improve their understanding. Efforts should be made to make patients with cancer more aware of the signs and symptoms of MSCC given their relative risks of developing it to improve early detection. Conflict of interest There is no conflict of interests for the authors to declare.

Appendix: Metastatic spinal questionnaire Current post: Have you previously undertaken rotations specific to: T&O Oncology Neurology Spinal surgery Do you feel adequately informed to make a presumptive diagnosis of MSCC What do you consider to be symptoms and signs of MSCC? Are you aware of who is your currently MSCC coordinator? How would you get in contact with your current MSCC coordinator? Clinical features With the following clinical features how quickly would you make a referral Pain in the middle (thoracic) or upper (cervical)spine: Severe unremitting lower spinal pain: Spinal pain aggravated by straining (e.g. at stool, coughing or sneezing). Localised spinal tenderness. Nocturnal spinal pain preventing sleep. Neurological symptoms including radiculopathy, limb weakness, sensory loss or bladder or bowel dysfunction. In assessing the patient would you typically consider: Examining the patient’s gait. Tokuhashi scoring system. American Society of Anaesthetists grading. Imaging What imaging should the patient receive in an ideal situation according to NICE guidance.

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What time frame is appropriate for radiological imaging to be performed in a patient suspected of MSCC according to NICE guidelines? Treatment A patient has a confirmed diagnosis of MSCC, over what time frame is treatment ideally initiated according to NICE? Teaching Do you feel enough teaching has been provided in the area of MSCC? Undergraduate Postgraduate

References 1. Quraishi NA, Esler C (2011) Metastatic spinal cord compression. BMJ 342:d2402 2. Levack P (2001) A prospective audit of the diagnosis, management and outcome of malignant cord compression (CRAG 97/08). CRAG, Edinburgh 3. Nice guideline 75 CG75NICEguideline.pdf 4. Tokuhashi Y, Matsuzaki H, Oda H et al (2005) A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine 30(19):2186–2191 5. Loblaw DA, Laperriere NJ, Mackillop WJ (2003) A populationbased study of malignant spinal cord compression in Ontario. Clin Oncol 15(4):211–217 6. Bailar JC III, Gornik HL (1997) Cancer undefeated. N Eng J Med 336:1569–1574 7. Heary RF, Bono CM (2001) Metastatic spinal tumours. Neurosurg Focus 11(6):e1 8. Sui J, Fleming JS, Kehoe M (2011) An audit of current practice and management of metastatic spinal cord compression at a regional cancer centre. Ir Med J 104(4):111–114 9. Kelly JC, O’Briain DE, Kelly GA et al (2012) Imaging the spine for tumour and trauma—a national audit of practice in Irish hospitals. Surgeon 10(2):80–83

10. Thangarajah T, O’Donoghue D, Pillay R (2011) Today or tomorrow? A retrospective analysis of the clinical indications used to request urgent magnetic resonance imaging of the spine. Ann R Coll Surg Engl 93(1):76–80 11. Patchell RA, Tibbs PA, Pegine WF et al (2005) Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer; a randomised trial. Lancet 366:643–648 12. Hirabayashi H, Ebara S, Kinoshita T et al (2003) Clinical outcome and survival after palliative surgery for spinal metastases: palliative surgery in spinal metastases. Cancer 97(2):476–484 13. Jansson KA, Buer HC (2006) Survival complications and outcome in 282 patients operated for neurological deficit due to thoracic or lumbar spinal metastases. Eur Spine J 15(2):196–202 14. Quan GM, Vital JM, Aurouer N et al (2011) Surgery improves pain, function and quality of life in patients with spinal metastases: a prospective study on 118 patients. Eur Spine J 20(11):1970–1978 15. Leithner A, Radl R, Gruber G et al (2008) Predictive value of seven preoperative prognostic scoring systems for spinal metastases. Eur Spine J 17:1488–1495 16. White BD, Stiring AJ, Paterson E et al (2008) Guideline development group. Diagnosis and management of patients at risk o or with metastatic spinal cord compression: summary of NICE guidance. BMJ 337:a2538 17. Brown PD, Stafford SL, Schild SE et al (1999) Metastatic Spinal cord compression in patients with colorectal cancer. J Neurooncol 44(4):175–180 18. Husband DJ (1998) Malignant spinal cord compression: prospective study of delays in referral and treatment. BMJ 317:18–21 19. Dripps RD (1963) New classification of physical status. Anesthesiology 24:111 20. Karnofsky DA (1967) Clinical evaluation of anticancer drugs. GANN Monogr 2:223–231 21. Van der Linden YM, Dijkstra SP, Vonk EJ et al (2005) Prediction of survival in patients with metastases in the spinal column: results based on a randomized trial of radiotherapy. Cancer 103:320–328 22. Tomita K, Kawahara N, Kobayashi T et al (2001) Surgical strategy for spinal metastases. Spine 26:298–306 23. Kleklamp J, Samii H (1998) Surgical results for spinal metastases. Acta Neurochir 140(9):957–967


Management of metastatic spinal cord compression: awareness of NICE guidance.

The spine is the most common site for bony metastases. It can lead to the development of significant complications and morbidity if appropriate treatm...
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