Makindo Medical Notes

Related Subjects: | Osteoporosis

⚠️ Malignant Spinal Cord Compression (MSCC) is a medical, oncological, and surgical emergency. ⏱️ Immediate treatment is crucial to prevent paralysis and sphincter dysfunction. 💊 Dexamethasone 16 mg should be given immediately if MSCC is suspected (unless contraindicated).

ℹ️ About

• 🚨 MSCC = emergency requiring urgent diagnosis + treatment.
• 🧠 Spinal cord ends at L1 → lesions above cause UMN signs; Cauda equina below L1 causes LMN signs.
• 🎯 Goal = preserve mobility, bladder/bowel function, and quality of life.

🧾 Causes

• 💥 Trauma with fracture fragments.
• 🩸 Epidural haematoma (trauma, anticoagulation).
• 🦠 Epidural abscess (staph aureus common).
• 💿 Central disc prolapse (massive herniation).
• 🎗️ Metastases (prostate, breast, lung, lymphoma, myeloma, melanoma, renal cell carcinoma).

🩺 Clinical Features

• 💢 Severe back or radicular pain (often nocturnal, not relieved by rest).
• 🦵 UMN signs: sensory level, spasticity, hyperreflexia, Babinski sign.
• 🧤 Radiculopathy: asymmetric numbness, tingling, root pain.
• 🚽 Sphincter symptoms: retention, incontinence, loss of anal tone.
• 🍑 Cauda equina syndrome: saddle anaesthesia, LMN leg weakness, areflexia.
• 🎗️ Often background of malignancy (prostate, breast, lung, myeloma).

🔎 Investigations

• 🧪 Bloods: FBC, U&E, LFTs, ESR/CRP, ALP, PSA, paraproteins, Bence-Jones protein.
• 🖥️ Imaging:
  • 🎯 MRI whole spine within 24h (gold standard).
  • 🩻 CT if MRI contraindicated/unavailable.
  • 🫁 CT chest/abdomen/pelvis for staging.
  • 👩 Mammogram if breast primary suspected.

💊 General Management

• 📞 Immediate referral to neurosurgery & oncology.
• 🛏️ Bed rest & log-rolling until stability confirmed.
• 💊 Adequate analgesia (often opioids) + laxatives.
• 🚽 Bladder: catheterisation / ISC training if retention.
• 🍽️ Bowel care: – Above T12/L1 → spastic bowel (reflex intact). – Below T12/L1 → flaccid bowel (manual evacuation often required).
• 💉 VTE prophylaxis: very high risk.

🎗️ Specific MSCC Management

• 💊 Dexamethasone 16 mg OD (or 8 mg BD) + PPI cover.
• ☢️ Radiotherapy: first-line for most, especially radiosensitive tumours (myeloma, lymphoma, breast, prostate, small-cell lung).
• 🔪 Surgery: urgent decompression ± fixation if fit, single level, or unstable spine.
• 💉 Chemotherapy: chemosensitive tumours (lymphoma, germ cell, neuroblastoma).
• 🩺 Palliative care: if prognosis very poor or paraplegic >24h without pain.

🦴 Spinal Stability Factors

• 📍 Site: cervical least stable; thoracic more stable (rib support).
• 📉 Extent of vertebral body involvement → risk of collapse.
• ⚖️ Comorbidity: osteoporosis, steroids, frailty → weaker bones.
• 🔪 Surgery: decompression may destabilise, fixation often needed.

📊 Prognosis (Median Survival after MSCC)

• 🫁 Lung cancer – ~32 days.
• 🍏 Prostate cancer – ~114 days.
• 🎗️ Breast cancer – ~74 days.
• 🧬 Lymphoma – ~226 days.
• 🦴 Myeloma – ~374 days.
• ❓ Unknown primary – ~41 days.

📝 Exam / OSCE Pearls

• 🧠 Distinguish UMN (cord) vs LMN (cauda equina).
• 💊 Dexamethasone 16 mg = first step in suspected MSCC.
• ⏱️ Always mention urgent MRI whole spine within 24h.
• ☢️ Radiotherapy is mainstay; surgery if instability or single lesion.
• 📌 Ask about red-flag symptoms: saddle anaesthesia, sphincter disturbance, progressive weakness.

📚 References

• SWBH MSCC Guidelines
• Recognition & Treatment of MSCC