1. Management: Spinal Cord Compression

2. 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.

3. 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

4. Pharmacologic Management

5. 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

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

7. 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

8. 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

9. 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

10. 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).

11. “ 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 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

12. Non-Pharmacologic Management

13. 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

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