Management: Spinal Cord Compression

Goals of Therapy The goal of therapy for spinal cord compression includes pain control avoidance of complications preserving or improving neurologic functions, or reversing impaired neurologic functions.

Treatment usually involves treatment of the underlying tumor. For most patients with cancer-induced compression, radiation therapy is the treatment of choice. surgical decompression if radiation therapy is unavailable or if neurologic signs worsen despite medical therapyshould be performed. also indicated when a biopsy is needed when the spine is unstable when tumors have recurred after radiation therapy abscess is present. chemotherapy

Pharmacologic Management

Symptomatic Therapy Constipation, spinal instability, pain, and psychological and social distress Constipation arises in these patients from autonomic dysfunction, inactivity, and opioids Must be treated aggressively because the pain of cord compression increases with a Valsalva maneuver, such as straining at stool Osmotic agents, such as polyethylene glycol 3350 (MiraLax), are often needed in addition to stool softeners and stimulants to promote regular, soft stools

Control of pain: opioids and adjuvants for nerve and bone pain Corticosteroids are effective adjuvants NSAIDs for those unable to take corticosteroids

Corticosteroids Used most commonly in patients that develop spinal cord compression with neurologic deficits Glucocorticoids with antioxidant or antioxidant-like activity (such as methylprednisolone) Reduce the release of total free fatty acids (including arachidonic acid) and prostanoids and prevent lipid hydrolysis and peroxidation, thereby reducing injury from traumatic spinal cord injury Dexamethasone I Inhibits PGE2 and VEGF production and activity and, as a consequence, decreases ischemic edema, which is partially mediated by increased levels of PGE2 and VEGF

High doses of corticosteroids better than low doses in reversing edema and improving neurologic function Loading dose of 10 to 100 mg is administered, followed by a 16- to 96-mg/day maintenance dose High doses have been recommended (100 mg loading dose followed by 24 mg every 6 hours × 3 days) to quickly restore ambulation, although may increase the incidence of serious adverse effects Adverse effects of steroids insomnia, increased appetite, edema, hyperglycemia, leukocytosis, increased risk of infection, and gastrointestinal bleeding

Analgesics Opioid and non-opioid Mild pain Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are Acetaminophen-preferred in patients with thrombocytopenia, renal dysfunction, those receiving nephrotoxic agents, or at risk for gastrointestinal bleeds In patients with liver dysfunction, NSAIDs are preferred for mild pain

Analgesics Moderate to severe pain Opioid analgesics begin with low doses of immediate release agents (typically 5-15 mg per os morphine or 2-4 mg intravenous morphine) Reassess patient every 1 to 2 hours for effect After 24 hours of pain control on a short-acting regimen, patients should be converted to a long-acting agent (morphine, oxycodone, fentanyl, or methadone).

“ Radiation therapy is also the standard of care “ Radiation therapy is also the standard of care. Radiotherapy is delivered to the site of disease and to one or two levels above and below. It is typically given as 3,000 cGy in 10 300-Gy fractions. With this regimen, 50% of patients are able to walk again, Dr. Wen noted” management of spinal cord compression, journal of supportive oncology, volume 6, 2008

Non-Pharmacologic Management

Rehabilitation Spinal Orthotics – stabilize patients spine and decrease spinal pain by limiting motion Prophylactic fixation of upper extremity lesions to aid mobility and weight bearing

Psychologic Interventions Patient preparation Patient may complain of issues such as loss of independence Emotional support Family participation