Key priorities for implementation

Key priorities for implementation

Service configuration and urgency of treatment

  • Every cancer network should ensure that appropriate services are commissioned and in place for the efficient and effective diagnosis, treatment, rehabilitation and ongoing care of patients with MSCC. These services should be monitored regularly through prospective audit of the care pathway.

Early detection

  • Inform patients at high risk of developing bone metastases, patients with diagnosed bone metastases, or patients with cancer who present with spinal pain about the symptoms of MSCC. Offer information (for example, in the form of a leaflet) to patients and their families and carers which explains the symptoms of MSCC, and advises them (and their healthcare professionals) what to do if they develop these symptoms.

  • Contact the MSCC coordinator urgently (within 24 hours) to discuss the care of patients with cancer and any of the following symptoms suggestive of spinal metastases:

    • pain in the middle (thoracic) or upper (cervical) spine

    • progressive lower (lumbar) spinal pain

    • severe unremitting lower spinal pain

    • spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing)

    • localised spinal tenderness

    • nocturnal spinal pain preventing sleep.

  • Contact the MSCC coordinator immediately to discuss the care of patients with cancer and symptoms suggestive of spinal metastases who have any of the following neurological symptoms or signs suggestive of MSCC, and view them as an oncological emergency:

    • neurological symptoms including radicular pain, any limb weakness, difficulty in walking, sensory loss or bladder or bowel dysfunction

    • neurological signs of spinal cord or cauda equina compression.

Imaging

  • Perform MRI of the whole spine in patients with suspected MSCC, unless there is a specific contraindication. This should be done in time to allow definitive treatment to be planned within 1 week of the suspected diagnosis in the case of spinal pain suggestive of spinal metastases, and within 24 hours in the case of spinal pain suggestive of spinal metastases and neurological symptoms or signs suggestive of MSCC, and occasionally sooner if there is a pressing clinical need for emergency surgery.

Treatment of spinal metastases and MSCC

  • Patients with severe mechanical pain suggestive of spinal instability, or any neurological symptoms or signs suggestive of MSCC, should be nursed flat with neutral spine alignment (including 'log rolling' or turning beds, with use of a slipper pan for toilet) until bony and neurological stability are ensured and cautious remobilisation may begin.

  • Start definitive treatment, if appropriate, before any further neurological deterioration and ideally within 24 hours of the confirmed diagnosis of MSCC.

  • Carefully plan surgery to maximise the probability of preserving spinal cord function without undue risk to the patient, taking into account their overall fitness, prognosis and preferences.

  • Ensure urgent (within 24 hours) access to and availability of radiotherapy and simulator facilities in daytime sessions, 7 days a week for patients with MSCC requiring definitive treatment or who are unsuitable for surgery.

Supportive care and rehabilitation

  • Discharge planning and ongoing care, including rehabilitation for patients with MSCC, should start on admission and be led by a named individual from within the responsible clinical team. It should involve the patient and their families and carers, their primary oncology site team, rehabilitation team and community support, including primary care and specialist palliative care, as required.

  • National Institute for Health and Care Excellence (NICE)