Red Flags in metastatic spinal cord compression
Cancer is the second most common cause of death in the United Kingdom. Metastases to the spinal column occur in 3–5% of all patients with cancer, most commonly those with breast, prostate and lung cancer, in whom the incidence may be as high as 19%. In total, there are +/- 4000 cases of metastatic spinal cord compression (MSCC) in England and Wales each year.
Pathological vertebral body collapse or direct tumour growth cause compression of the spinal cord, leading to irreversible neurological damage. In addition to the agonising pain and spinal instability, compression on the spinal cord can also lead to paraplegia or quadriplegia and double incontinence.
At diagnosis, 82% of patients with MSCC are unable to walk or only able to do so with help. The development of paraplegia and loss of control of bladder and bowel function have a devastating effect on the quality of life that remains and considerably reduce life expectancy.
Early diagnosis, urgent onward referral for further investigation and prompt treatment (initiation of steroid therapy, MRI, pain management, emergency radiotherapy and/or surgery).
An extensive consensus-building proces was started between physiotherapists, oncologists, palliative care specialists, a GPSI and an orthopaedic surgeon.
This credit card includes 3 key statements about MSCC
- Past medical history of cancer;
- Early diagnosis is essential (as the prognosis is severely impaired once paralysis occurs);
- A combination of Red Flags increases suspicion (the more red flags, the higher the risk and greater urgency).
Moreover, it features signposting to key sources of additional information (see below) and a user-friendly list of Red Flags which has been developed into an 8-item Red Flag acronym:
R eferred pain that is multi-segmental or band like
E scalating pain which is poorly responsive to treatment (incl medication)
D ifferent character or site to previous symptoms
F unny feelings, odd sensations or heavy legs (multi-segmental)
L ying flat increases back pain
A gonising pain causing anguish or despair
G ait disturbance, unsteadiness, especially on stairs (not just a limp)
S leep grossly disturbed due to pain being worse at night
A user-friendly guideline to identify a complex complication of cancer was developed. The cards are very simple, but they have a very significant and well-thought out message, and in our opinion the Red Flag mnemonic is easy to remember. Evaluation of the effects of the card (changes in clinical knowledge, earlier recognition) is planned.
Want to read deeper into this topic? You can access clinical guideline on Metastatic spinall cord compression in adults here!
> From: Turnpenney et al., Prim Health Care Res Dev. 16 (2015) 14-20 (Epub ahead of print). All rights reserved to Cambridge University Press. Click here for the online summary.