Quality statement 3: Imaging and treatment plans for adults with suspected metastatic spinal cord compression

Quality statement

Adults with suspected metastatic spinal cord compression (MSCC) who present with neurological symptoms or signs have an MRI of the whole spine and any necessary treatment plan agreed within 24 hours of the suspected diagnosis.

Rationale

Adults with suspected MSCC who present with neurological symptoms or signs need rapid access to imaging that will accurately identify spinal cord compression. Whole‑spine MRI is central to the diagnosis, staging and planning of treatment. Neurological deficit at initial presentation is an important predictor of long-term functional outcome. To reduce the risk of avoidable disability for adults with suspected MSCC, it is important that both an MRI is performed and treatment is planned by senior clinical advisers, within 24 hours of the suspected diagnosis.

Quality measures

Structure

Evidence of local arrangements and written protocols to ensure that adults with suspected MSCC, who present with neurological symptoms or signs, have an MRI of the whole spine and any necessary treatment plan agreed within 24 hours of the suspected diagnosis.

Data source: Local data collection. Department of Health Acute Oncology Measures 11‑1E‑110y (The MSCC Case Discussion Policy) and 11‑1E‑111y (The Audit of Timeliness of the Investigation of MSCC) Manual for cancer services: acute oncology – including metatastic spinal cord compression measures (2011).

Process

a) Proportion of adults with suspected MSCC who present with neurological symptoms or signs who receive an MRI of the whole spine within 24 hours of the suspected diagnosis.

Numerator – the number of adults in the denominator who receive an MRI of the whole spine within 24 hours of presenting with suspected MSCC and neurological symptoms or signs.

Denominator – the number of adults with suspected MSCC who present with neurological symptoms or signs.

Data source: Local data collection. Department of Health Acute Oncology Measures 11‑1E‑111y (The Audit of Timeliness of the Investigation of MSCC) Manual for cancer services: acute oncology – including metatastic spinal cord compression measures (2011). British Spine Registry Spinal tumour data (2013).

b) Proportion of adults with MSCC confirmed by MRI of the whole spine, who presented with neurological symptoms or signs, who have a treatment plan agreed within 24 hours of the suspected diagnosis.

Numerator – the number of adults in the denominator who have a treatment plan agreed within 24 hours of presenting with suspected MSCC and neurological symptoms or signs.

Denominator – the number of adults with MSCC confirmed by MRI of the whole spine who presented with neurological symptoms or signs, who have a diagnosis of MSCC confirmed after an MRI of the whole spine.

Data source: Local data collection. NICE audit support for Metastatic spinal cord compression (NICE clinical guideline 75). British Spine Registry Spinal tumour data (2013).

Outcome

a) Proportion of adults with MSCC who are able to walk within 3 months of treatment.

b) Proportion of adults with MSCC who are able to walk within 2 years of treatment.

c) Rates of mortality within 30 days of treatment.

Data source: Local data collection. Department of Health Acute Oncology Measures 11‑1E‑113y Manual for cancer services: acute oncology – including metatastic spinal cord compression measures (2011). British Spine Registry Spinal tumour data (2013).

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that adequate capacity is available for whole-spine MRI scanning and treatment planning to be undertaken within 24 hours for adults with suspected MSCC who present with neurological symptoms or signs.

Healthcare professionals ensure that they perform an MRI of the whole spine for adults with suspected MSCC who present with neurological symptoms or signs, and that if a diagnosis of MSCC is confirmed they agree a treatment plan within 24 hours of the suspected diagnosis.

Commissioners ensure that they commission services that can provide MRI scanning and treatment planning by senior clinical advisers within 24 hours of the suspected diagnosis, for adults with suspected MSCC who present with neurological symptoms or signs.

What the quality statement means for patients, service users and carers

Adults with suspected MSCC have an MRI of their whole spine and, if a diagnosis of MSCC is confirmed by the MRI, a plan for their treatment organised within 24 hours of the suspected diagnosis.

Source guidance

  • Metastatic spinal cord compression (NICE clinical guideline 75), recommendation 1.4.3.3 (key priority for implementation).

Definitions of terms used in this quality statement

Symptoms and signs of MSCC

The following symptoms and signs are suggestive of MSCC:

  • progressive pain in the spine

  • severe unremitting spinal pain

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

  • pain described as 'band like'

  • localised spinal tenderness

  • nocturnal spinal pain preventing sleep

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

  • neurological signs of spinal cord or cauda equina compression.

[Definition developed from NICE clinical guideline 75 recommendations 1.3.2.1 and 1.3.2.2 and expert consensus]

Senior clinical advisers

Includes clinical oncologists, spinal surgeons and radiologists with experience and expertise in treating adults with MSCC. [NICE clinical guideline 75 recommendation 1.1.2.4]

Treatment plan

A treatment plan for adults with MSCC should be agreed by senior clinical advisers, and the names of those involved in the discussion should be included in the documentation. Treatment planning should take account of:

  • spinal stability, which should be assessed both clinically and radiologically

  • the degree of neurological disability

  • the general health of the patient

  • the prognosis, which should be estimated using a validated scoring system

  • the primary site of tumour

  • the presence of other spinal and extraspinal metastases

  • the likely response of the tumour to radiotherapy or other adjuvant therapy

  • the patient's care and treatment preferences.

[The full clinical guideline 75, section 6.1 and expert consensus]