Spinal metastases and metastatic spinal cord compression

Service configuration

Topic experts highlighted changes to the structure and naming of cancer services. The term 'cancer networks' is out of date and does not accurately reflect the current service set up and recommendations in this section should be updated.

Topic experts commented that the care pathways for managing MSCC patients remain unclear. Specifically, the management of patients transferred from 1 hospital to another and the lack of communication to determine treatment outcomes. There is potential to amend recommendations in the service configuration and MSCC coordinator sections of the guideline to clarify the need for communication between services.

Comments from topic experts also suggested that there is national variation in the provision of services. The GIRFT report on spinal surgery is due to publish in 2019 and topic experts highlighted that it will contain data on national variations which may impact current recommendations. It was highlighted that the GIRFT report will likely impact sections in the guideline on service configuration, diagnosis, and treatment. Topic experts also commented that the report may indicate the difficulties of implementing the guideline. Liaison with the GIRFT team will support the proposed update of the guideline.

Imaging

Topic experts highlighted evidence (Fisher et al. 2014) that CT scanning could be used to calculate the Spinal Instability Score (SINS) to assess patients' suitability for surgery. The guideline does not currently contain recommendations on the use of SINS. Topic experts and stakeholders also suggested that evidence comparing MRI with CT should be reviewed. Although the guideline primarily advises to use MRI for diagnosis, it does also consider CT scans to assess spinal stability when planning surgery. Topic experts suggest that the use of MRI should be reconsidered due to the increased costs.

Radiotherapy

Current recommendations advise fractionated therapy but topic experts highlighted an ongoing study that contradicts the current recommendations and supports the use of single dose radiotherapy. The publication of this study is being monitored and may be considered as part of the guideline update.

Surgery

Surgical interventions for this population have progressed since publication of the guideline (Choi et al. 2015, Verlaan et al. 2016 and Choi et al. 2016). Topic experts suggest that there is new evidence for the management of vertebral collapse following vertebroplasty and kyphoplasty as well as other minimal intervention surgical stabilisation techniques that are not currently covered by the recommendations. Although studies were not provided by topic experts, NICE has produced interventional procedures guidance on percutaneous vertebroplasty and balloon kyphoplasty for vertebral compression fractures. Two studies (Quraishi et al. 2013 and Fan et al. 2016) were provided by topic experts that support the recommendations to offer surgical treatment without delay.

Comments from topic experts also suggested the need to review recommendations in section 1.5.4 regarding the technical factors of surgery. This includes reviewing the role of embolisation and the use of salvaged blood transfusion.

Corticosteroids

Topic experts highlighted concerns that the recommendations advise incorrect use of corticosteroids. Patients awaiting surgery with asymptomatic radiological MSCC or without neurological deficit should not be prescribed corticosteroids as this may increase the risk of preoperative complications. In addition, topic experts also suggested that the use of corticosteroids in patients with suspected MSCC could reduce the chance of a positive biopsy.

Mobilisation

Topic experts highlighted the need for further detailed guidance on the correct mobilisation techniques for MSCC patients. Specifically, which patients should be nursed flat, advice for gradual sitting and the symptoms to look out for on reassessment.

Scoring systems

Topic experts commented that new scoring systems have been validated and used in services other than the Tokuhashi score as advised in the recommendations. They suggested that evidence should be reviewed to determine the comparative prognostic values of the newly available scoring systems.

Resource and costs

A topic expert commented that longer survival times following treatments for the primary cancer may potentially lead to increased costs of further treatment. However, cost-effectiveness studies addressing this issue were not identified and so we could not determine whether there would be an impact on recommendations.

Imaging

Stakeholders commented that the use of MRI scanners for acute conditions needs to be justified with an evaluation of cost effectiveness. The surveillance review proposal for a full update will cover evidence in this area.

Treatment

Stakeholders suggested that the World Health Organisation (WHO) 3-step pain ladder referenced in the recommendations is now obsolete and its use may be dangerous. It is suggested that the use of the WHO ladder is inappropriate in patients with MSCC as it was not designed for this population. Stakeholders also commented that recommendations on the use of non-steroidal anti-inflammatory drugs (NSAIDs) should contain notes of caution due to the risk of provoking acute kidney injury in multiple myeloma patients. There is also a potential caution in the use of NSAIDs without gastric protection especially in older patients.

Stakeholders were concerned that the current recommendations do not adequately address the need for patients to be reviewed and intervention provided by pain medicine specialists or anaesthetists. A further concern identified is that recommendations to use escalating doses may lead to potentially toxic doses of opioids when prescribed by inexperienced clinicians.

Stakeholders also highlighted the ongoing study on the use of single compared to multifraction radiotherapy as a treatment option. This has the potential to change recommendations in this area and should be reviewed as part of the full update.

Stakeholder comments suggested the need to review evidence on case selection for treatments. The suggestion was that age and other patient factors may be indicators of the effectiveness of surgery and radiotherapy (Amelot et al. 2017). The current recommendations on case selection may need to be updated to take into account the patient factors identified within the new evidence.

See appendix A for full details of stakeholders' comments and our responses.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.